A Tense Moment in the ER

by Danielle Ofri
The Lancet (pdf)

The young man stormed into the doctors’ station in a far corner of the emergency room, and held up his toddler. “My baby’s choking and you guys aren’t doing anything,” he yelled, the ends of his cornrows slashing against his sweatshirt. This work station was set behind a staff meeting room, so it was clear that the father had entered spaces that were typically off-limits to patients. As soon as he shouted his opening statement, every person on the medical team froze.

The medical student who was there looked on with alarm. As a student, she didn’t feel qualified to assess the medical merits of the situation, but as the only African-American person among the white doctors, she was acutely aware of the fraught dynamics. To the best of her limited clinical acumen, this did not appear to be an acute emergency—the child seemed to be coughing rather than choking. The student toyed with the idea of stepping forward to accompany the family back to their room and begin the medical evaluation. That could potentially calm the situation. But she was lowest on the totem pole and she knew it wasn’t her place to take charge.

The highest person in the medical hierarchy at the moment was the emergency medicine fellow, and she assumed control. “Go back to your room, sir,” she said calmly, but with clear authority. “We’ll be with you in a moment.” The father edged back, but remained disconcertingly close. Close enough that no one moved a muscle. As the minutes ticked by, the tension ratcheted up. The student’s eyes tracked back and forth between the father and the medical team. Who was going to break first? “I’m just going to take my baby out of here and go somewhere else,” the father finally shouted, turning on his heel. The emergency medicine fellow didn’t hesitate. “Call security,” she snapped. “Don’t let that man leave.”

The hospital, by definition, is a stressful place for patients and families unsettled by the vulnerabilities of the human body. Add in issues of race, class, gender, power dynamics, economics, and long wait times, and you have the ingredients for combustion just hankering for tinder.

But even these obvious factors aren’t so clear-cut. Many of them intersect, even contradict. Was this confrontation primarily about a black man challenging a group of white people? Was it about a man acting aggressively toward a group of women? Was this about a patient breaking the unwritten rules of doctor territory? Was this a clash of a white-glove institution sitting in the midst of an economically disadvantaged community?

There’s no avoiding that fact that bias is a potent force in medicine. The racial and ethnic disparities in medical care are extensive, even when economic issues are factored out. Explicit discrimination may be less overt than in generations past, but implicit or unconscious bias is still entrenched. Even doctors who do not exhibit explicit bias can still show unconscious bias. In one study, doctors were given vignettes of identical cardiac conditions with only the patient’s race varied and asked to recommend treatment. Treatment of the patients was unequal and it was specifically the degree of implicit bias that correlated most strongly with preferential treatment of white patients. This was evident even with doctors who showed no evidence of explicit bias. The study suggests that even doctors who do not consciously feel affected by the race of their patients can still harbour implicit racial bias and this may be a driver of unequal medical care.

When the medical student related the story to me, I asked her whether she thought her colleagues were being racist. This was a complicated knot for her to untie. These doctors had been generous to her with medical knowledge and encouragement. These were role models—strong women—whom she looked up to. And yet, she witnessed their automatic reaction to a black man on their turf. “’Racist’ is not a term I use lightly,” she said, choosing her words diplomatically. “But I guess I hadn’t been aware of the strength of their bias.” When the father stormed into the doctors’ station, she saw fear and concern; her fellow physicians saw aggression.

The student described her complicated sense of kinship with the father. On the one hand, their lives had nothing in common. She had several Ivy League diplomas under her belt and was attending a top US medical school. The young father was living in a poor, urban neighbourhood, relying on charity medical care. On the other hand, the student observed, “that father and I look the same to the outside world.” She talked about how she, like other black doctors, was often assumed to be a technician or clerical worker. It crossed her mind that if she’d walked into the emergency room as a patient, maybe in a crabby mood because of her illness or the 6-hour wait, these doctors whom she genuinely respected might treat her the same way they’d treated that father.

She explained to me that during the confrontation she experienced an awkward dissonance. Was she first and foremost a medical student, part of the clinical team that was being accosted by an angry patient? Or was she viewing this primarily as an African American, witnessing the white community prejudging a black man’s intentions? On top of that, there were the power dynamics that played out in contradictory ways. She was part of the powerful group—the doctors—but as a medical student, she was singularly powerless. To the father, though, she probably looked like one of “them.” To the other doctors on the team, however, a medical student might just as well be part of the furniture.

“In a cardiac arrest, the first procedure is to take your own pulse”, wrote Samuel Shem in his satirical novel, The House of God. It’s advice that is relevant in all tense situations, but especially ones in which stereotype, bias, and gut reactions can have lasting implications. And it’s equally important to check the pulse of the others around you. What is everyone else responding to?

In the vast and messy cauldron that is medical training, there are always salient experiences that hone the contours of the doctor one will eventually become. For this student, the encounter in the emergency room was clearly one of those. Reflecting back on the episode some years later, she told me that she wished she had taken the initiative to help the father and defuse the situation.

“I no longer take for granted,” she said “that we doctors have it right.” This is an Rx that many of us in the medical profession could stand to benefit from. She began exploring the experiences—both bitter and excellent—of friends and family at the hands of the medical profession. “I seek out those stories now,” she said.

Addressing bias is a priority in the medical field, at least a professed one. Substantive resources have not caught up to the rhetoric yet and, frankly, I doubt they ever will. For better or worse, this leaves much of the issue in the hands of the individuals in the trenches.

When I reflect back on the tense encounters I’ve observed over the years—a surgeon screaming at a nurse, a hospital employee confronting an angry patient, a resident dressing down a student—it’s always the other person, the one who initiated, who’s saddled with the blame. Even if that person ultimately acknowledges his or her supposed transgression, it’s still held up as the precipitating factor: the nurse gave the wrong instrument, or the patient was out of line, or the student’s work was shoddy. Our very human egos demand a mitigating context for our ill-advised actions, especially if these don’t fit with our publicly stated values. Most of us, after all, want to feel that we treat everyone equally, so if we do or say something that falls short, we instinctively reach for a justification. These justifications always seem “objective” because we surely know that we are not racist, or sexist, or homophobic. We are good people and we have chosen to work in a profession dedicated to helping others, right? How could our actions possibly reflect bias?

“When one’s own behavior can be construed as negative,” researchers Debra Roter and Judith Hall astutely noted, “one is particularly inclined to blame it on the other person”. Holding back on that blame is a tall order for individuals singularly steeped in the hierarchy of health care, but it’s a first step in pulling back the bias that so infects our field.

What can we as individuals do? Of course we should be pushing for institutional change, supporting policies that reduce inequities. But turning a battleship is both an arduous and an incremental process, and certainly offers no help in the moment, which is when these crises typically occur. In the moment, however, individuals can “seek out those stories.” What might have happened if that emergency medicine fellow, when confronted by the father, had simply asked, “What’s going on?” This would not necessarily have undone the hours of frustration, and certainly not repaired centuries of institutionalised racism. But at the very least it would have dialled down the temperature. An explosive situation could have turned into a neutral, ordinary one. And, if the doctor had been willing to listen honestly to the answers, there might even have been a chance for this to become a positive experience.

For all its technological innovations, medicine remains an intensely human field: illness is experienced in human terms and medical care is given in human terms. We humans bring along our biases and stereotypes—that is true—but we also bring along our ability to communicate and to listen. We will never, of course, achieve perfection in our interactions with others. No matter how determined we are to be fair and conscientious with everyone, there will always be times when we fall short. But if we take the time to listen—genuinely—we’ll at least have the opportunity to peek into the lives of our fellow imperfect humans. We may not be able to step into their shoes, but we can slide onto the bench next to them and follow their gaze. We can attempt to see what they are seeing. This approach may not be high-tech, but it might very well be one of our most powerful tools for chipping away at entrenched bias.

[With grateful appreciation to Ekene Ojukwu for sharing her story. ]