How to Handle a Racist Patient with Medical Students
5-7 Minute Read
Author: Judy Hanrahan, JD, MA
Purpose
To provide clinician educators with a framework for addressing patient requests to have an undergraduate trainee removed from their care team based on race, sex, religion, or other protected status.
Learning Objectives
Recall the patient has an unequivocal right to exclude undergraduate trainees from their care team;
Describe why a patient’s bigoted exclusion of one undergraduate trainee requires that no other undergraduate student be allowed to participate in the care of that patient; and
Remember that when a patient makes a bigoted comment to a member of the healthcare team, but doesn’t withdraw consent for their participation, the targeted team member should always be allowed to decide whether to continue participating in the patient’s care.
How do you respond to a patient’s demand to be seen by a different provider, to be cared for by a different nurse, or to exclude a trainee based on race, ethnicity, sex, gender identity, disability, or religious beliefs? The answer to this question differs depending on the clinical setting and position of the person who the patient wants to exclude. When it comes to undergraduate medical trainees, a class of students that includes medical students, PA students, and nursing students, the patient has an unequivocal right to refuse student participation, even if the reason for the exclusion is racist, sexist, or based on another protected class. At the same time, trainees, as students, are protected from discrimination in their education based on race, sex, religion, disability, or other protected status.(1-3) For graduate trainees, residents and fellows, the patient’s right to exclude these physicians requires a more complicated analysis as they are students AND employees; this topic will be covered in a future edition of Preceptor.
While preceptors have little control over what patients say to a trainees, preceptors are obligated to respond appropriately to patients’ discriminatory request and remarks. If a patient rejects an undergraduate trainee’s participation based on a protected characteristic of the particular student, NO OTHER UNDERGRADUATE TRAINEE should see the patient.(4) The bigoted exclusion must be treated as a blanket exclusion for undergraduate trainee participation. This ensures that the trainee is not, indeed, excluded from a valuable educational experience that other students are able to take part in because of a protected personal attribute. This is true regardless of whether the patient is experiencing an emergency. As a matter of educational anti-discrimination laws(5), remember that NO OTHER UNDERGRADUATE TRAINEE should see this particular patient.
What if a patient makes a bigoted remark to an undergraduate trainee, but doesn’t withdraw consent for the student’s participation? The undergraduate trainee should be exempted from continuing to participate in the patient’s care.(4 p471) If the undergraduate trainee wishes to continue to work with the bigoted patient, they should be allowed to continue. The precept that the person who is targeted by a racist, sexist, homophobic, etc comment gets to decide whether to continue participating in the patient’s care, is important to remember. If the undergraduate trainee opts out of working with the patient, other undergraduate trainees should also be excluded from participation for the same reason as before: to partake in an educational experience the student would have to risk further discriminatory remarks while others are able to partake in the experience free of discrimination.
Whenever a student is treated unreasonably by a patient, the preceptor should ideally report the incident to the appropriate educational official(4) and debrief with the student(6), or the whole care team if other members of the team were present. The targeted student and others on the care team may need support to process the incident.(6,7)
Considerations
As a clinician, you will also have to consider how to address such an incident with the patient. Several recommendations have emerged for addressing hateful or racist speech with universal agreement that the first step is always to assess the urgency of the patient’s medical needs.(4-7) If the patient is unstable or in the middle of a medical emergency, the care team must stabilize the patient or attend to the emergency. The ethical principle of beneficence overrides other considerations and, in the hospital setting, the Emergency Medical Treatment and Labor Act requires that any patient who seeks treatment must receive an evaluation and be stabilized.(5)
Consider the following suggestions for addressing a patient who has made a bigoted comment or request:
1) Ascertain the reason behind the patient’s statements, is it bigotry that is motivating the request or an ethically, and perhaps clinically, appropriate concern?(7 pp1114-5) Take for example a patient who says, “I am a rape survivor, I would really prefer to have no male students around during my pelvic examination” versus a patient who says, “Woman shouldn’t be surgeons, there is no reason to have HER watch my surgery.” The rape survivor’s request for a female provider is likely rooted in PTSD surrounding a rape, while the other patient’s desire appears to be rooted in stereotypes about the capabilities of women and men.
2) For overt comments rooted in bigotry, the patient should be told, unequivocally, that racist, sexist, homophobic, ableist, or religious discrimination is unacceptable. Consider responding with something like, “Are you suggesting that women shouldn’t be surgeons?” followed by “you know my wife is a surgeon?” or “some of the best surgeons I know are women” or “evidence actually suggests that people have fewer complications after surgery when the surgeon is a female.”(8,9) Statements like that can help to both confront the bigotry head-on, and depersonalize the event (10). Whitgob, Blackenburg, and Bogetz contend that “discrimination is often motivated by patients’ fears and anxiety about the unknown.”(10) If you can get a patient to acknowledge their statement comes from a place of fear or anxiety, you may be able to allay the fear and anxiety, elicit an apology from the patient to the targeted individual, and perhaps facilitate a better therapeutic relationship.
3) For patients who are stalwart in their bigoted beliefs, the care team may consider asking the patient to sign a behavior contract or offer assistance with finding another provider or transferring to another facility.(4)■
References
Title VI of the Civil Rights Act of 1964. 42 US Code §2000d et seq.
Title IX of the Education Amendments of 1972. 20 US Code §1681-1688.
Section 504 of the Rehabilitation Act of 1973. 29 US Code §794.
Paul-Emile K, Critchfield JM, Wheeler M, de Bourmont S, Fernandez A. Addressing patient bias toward health care workers: recommendations for medical centers. Annals of Internal Medicine. 2020;173(6):468-473. doi:10.7326/M20-0176
Emergency Medical Treatment and Labor Act. 42 US Code §1395dd.
Wheeler M, de Bourmont S, Paul-Emile K, et al. Physician and trainee experiences with patient bias. JAMA Intern Med. 2019;179(12):1678. doi:10.1001/jamainternmed.2019.4122
Wheeler DJ, Zapata J, Davis D, Chou C. Twelve tips for responding to microaggressions and overt discrimination: when the patient offends the learner. Medical Teacher. 2019;41(10):1112-1117. doi:10.1080/0142159X.2018.1506097
Wallis CJ, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ. Published online October 10, 2017:j4366. doi:10.1136/bmj.j4366
Slomski A. Female patients fare worse with male surgeons. JAMA. 2022;327(5):416. doi:10.1001/jama.2022.0147
Whitgob EE, Blankenburg RL, Bogetz AL. The discriminatory patient and family: strategies to address discrimination towards trainees. Academic Medicine. 2016;91:S64-S69. doi:10.1097/ACM.0000000000001357