Racism in medicine: An 'open secret'
Jacqueline Howard CNN | 10/26/2016, 6:09 p.m.
(CNN) -- What happened on a hot summer day two years ago still shakes Dr. Emily Whitgob to the core.
The Palo Alto, California-based pediatrician had just started supervising interns at Lucile Packard Children's Hospital Stanford. She was sitting in the doctors' workroom, listening to one of her interns describe a young patient in the emergency department.
"By the way," the intern said, "the dad just looked at my name tag and asked, 'Oh, is that a Jewish last name? I don't want a Jewish doctor.' "
Whitgob said that she was surprised -- and not prepared -- to hear that. After all, though it turned out that the intern isn't Jewish, Whitgob is.
"For the rest of the night, I think we both felt a little bit uncomfortable," Whitgob said. "I realized that I was a supervising resident and yet didn't have the tools to fully support my intern. Furthermore, our faculty attending also lacked the skills to debrief it."
As it weighed heavily on her mind, Whitgob mentioned the incident in an educational conference the following week.
"I would say there were 20 to 30 people in the room, and half of them were in tears by the end," she said, because they had either faced or witnessed similar discrimination when attempting to treat a patient.
"That right there made me think, 'Wow, we have to talk a lot more about this,' " said Whitgob, a research fellow in developmental-behavioral pediatrics at Stanford University. She decided to gather qualitative data and conduct a small survey on what physicians can do when they face discrimination by patients.
Now, the survey results and a call for strategies on how to effectively respond to discrimination have been published in a paper in the journal Academic Medicine.
The research, published Wednesday, comes on the heels of a doctor discrimination claim that went viral and the launch of the hashtag #WhatADoctorLooksLike.
'Go back to India'
About 15% of pediatric residents personally experienced prejudice by patients or their families, according to the survey, which involved all Stanford pediatric residents last year.
The issue of discrimination, especially against doctors, has not been adequately addressed in medical schools or residency training programs, said Dr. Sachin Jain, president of CareMore Health System in Cerritos, California, and a consulting professor of medicine at Stanford School of Medicine, who was not involved in the new paper.
"I applaud the authors' effort to give tools to faculty who train medical students and residents who are the subject of discrimination and abuse," Jain said, adding that he knows what it feels like to face racial prejudice as a physician.
When Jain was a third-year resident training in Boston, an angry patient told him to "go back to India."
"I am of Indian origin but was born in New York and raised in New Jersey. It was a very vivid and disturbing moment that cut deeply," Jain said.
"I regrettably reacted angrily towards the patient but was a bit disappointed when my colleagues minimized what had happened, taking the approach that it 'comes with the territory' of treating patients as a minority physician in America. Health care institutions have an obligation to set standards not only for how their staff interact with patients but also the reverse," he said. "Unfortunately, I think mistreatment and discrimination by patients is too common."
In the new paper, the researchers recommended that discussions about discrimination should be introduced early in medical training, and institutions should develop procedures for how discrimination should be addressed at trainee, faculty, staff and hospital administration levels.
Task forces could be developed to create institutional policies on how to interact with patients who discriminate against providers, the researchers recommended.
"Because these things come up in the heat of the moment, we really need to prepare people so they're ready to handle it no matter what the situation may be," said Dr. Rebecca Blankenburg, a clinical associate professor of pediatrics at Stanford School of Medicine and a co-author of the new paper.
"What we were really struck by was that everyone has at least experienced discrimination or witnessed discrimination, so even if they aren't the one being discriminated against, we all need tools," she said. "There are some papers that look at faculty or staff discrimination, but to specifically look at how patients and families discriminate against providers, this is the first of its kind."
One of medicine's 'open secrets'
In addition to the survey, Whitgob and her colleagues interviewed 13 pediatric faculty members at Stanford University about discrimination and how they would respond to clinical scenarios of families discriminating against doctors.
The researchers analyzed the interview transcripts, comparing them with each other and identifying trends in responses. Whitgob said their findings could translate to the rest of the medical field.
"A lot of foreign medical graduates had stories about their accents and being discriminated against," she said. "Other stories were from people who were Latino, but they didn't have Hispanic last names, and they heard from their own patients about other Latino providers, like, 'Oh, I don't want those kind to take care of me.' So being stuck in that position where you are 'those kind' but the patients don't know, you almost hear worse comments because they don't know who they're talking to."
Whitgob also conducted an extensive literature review to determine whether any existing research offered guidance on how doctors or hospitals should address discrimination.
Although hospitals have policies about staff members discriminating against each other, many lack policies about patients discriminating against staff, she said.
Additionally, the American Medical Association said in an email to CNN that its Code of Medical Ethics doesn't specifically address discrimination against doctors by patients, but it does offer ethical guidance for disruptive behavior by patients (PDF).
The code recommends to "terminate the patient-physician relationship with a patient who uses derogatory language or acts in a prejudicial manner only if the patient will not modify the conduct. In such cases, the physician should arrange to transfer the patient's care."
Without any clearly defined policies or guidelines in place, some hospitals might put themselves at legal risk.
Law experts weigh in
In 2013, a neonatal nurse sued Hurley Medical Center in Flint, Michigan, claiming that she was reassigned when a man requested that no black people care for his baby. The nurse had been working at the hospital for 25 years.
"I recently spoke to physicians at a major New York area medical center and found that roughly 40% of the physicians in attendance had experienced this themselves or knew someone who had been rejected by a patient based on race or ethnicity," said Kimani Paul-Emile, an associate professor at Fordham University School of Law and associate director of the university's Center on Race, Law and Justice, who was not involved in the new paper.
"Scenarios such as this are more common than one might think and occur at hospitals throughout the country," she said of physician reassignments. "I call it one of medicine's open secrets, because you would be hard-pressed to find a physician, particularly a physician of color, who hasn't had this experience or who doesn't know someone who has."
In a paper published in the New England Journal of Medicine in March, Paul-Emile and her co-authors suggested that medical institutions should not accommodate a patient's prejudiced reassignment demands, because doing so might violate physicians' employment rights.
Rather, individual physicians may accommodate the demands if all involved physicians are comfortable with the decision and accommodation does not compromise effective medical treatment.
"For many physicians of color, rejection by patients based on bigotry can be distressing and demeaning experiences, which cumulatively contribute to moral distress and burnout," Paul-Emile said.
Often, when discrimination in the medical field is discussed, the conversation focuses on how doctors might have biases against patients. For instance, black patients are often prescribed less pain medication than white patients, several studies show.
As a result of this racial bias history, many patients of color often request or would prefer doctors of their same race. A 2002 study from the Johns Hopkins Bloomberg School of Public Health found that patients who are of the same race as their doctor report more satisfaction with their physician.
"I would love to live in a world where racism, sexism and bigotry doesn't exist," Blankenburg said. "We really need action around these issues, being able to explicitly say 'this is not tolerated' and having the faculty development and staff development to be able to role model appropriate behavior in order to combat racism, sexism and other bigotry."
It turns out that such bigotry also can happen outside the medical setting.
What a doctor looks like
Tamika Cross, a Houston-based black obstetrician and gynecologist, said this month that she was discriminated against while aboard a Delta flight departing from Detroit. She wrote about the incident in a Facebook post that has been shared more than 48,000 times.
In the post, Cross wrote that a man sitting two rows in front of her was unresponsive, and flight attendants asked whether there was a physician on board the plane to help him.
When Cross raised her hand, a flight attendant told her, "Oh, no, sweetie, put your hand down, we are looking for actual physicians or nurses or some type of medical personnel; we don't have time to talk to you."
"I tried to inform her that I was a physician, but I was continually cut off by condescending remarks," Cross wrote in the Facebook post, adding that the flight attendant eventually asked for Cross' "credentials."
Then, Cross wrote, a white man approached the attendant and said that he was a doctor. Cross was promptly told that he would help, and she stayed seated.
After Cross' Facebook post went viral, medical professionals across the country showed support on social media by posting selfies of themselves with the hashtag #WhatADoctorLooksLike.
Whitgob, the Stanford pediatrician, said that "because there was so much conversation about the event on the airplane, I think it just highlights that this is a conversation that has to happen."
In a statement responding to Cross' post, Delta indicated that a full investigation into the incident was underway and "the experience Dr. Cross has described is not reflective of Delta's culture or of the values our employees live out every day."
"What would be a really interesting thing to study is discrimination against physicians outside of the hospital setting, and outside of just physicians and patients and families, but how other people in the community discriminate or perceive doctors and who is a doctor," Whitgob said.
"If we turn on the news any day, there are current events that are happening that have discrimination at the core of them," she said. "This is one more area where it's happening, and it's not being talked about when it should be."