Amr F. Hamour is a resident in the Department of Otolaryngology – Head & Neck Surgery at the University of Toronto


I will not have that crow as my doctor.

It was early on in my clerkship. I was rotating through a busy and valuable rural family medicine rotation in Northern Alberta when I overheard an inpatient make his plea to the nurse – “I hope to never see that crow again.” I had to give him some credit. On the pain scale adjusted for creativity, this was definitely a 10/10. Crow. I Googled it. An epithet used towards Black and, in some cases, Indigenous people. I didn’t know whether to be upset or to thank him for expanding my vocabulary. Taking care of this gentleman for the next two weeks was a challenge for me. Through the Hippocratic Oath, I pledged to do no harm. I committed to devoting time and attention to each patient, irrespective of external factors. This type of situation was not in the playbook. I recall asking myself, “how does one deliver exceptional patient care in the face of discrimination?” As citizens, we deserve to be treated with respect. As public servants, we often are asked to put personal grievances aside for the sake of the patient.

This phenomenon, let’s call it discrimination-induced countertransference, is an often overlooked experience that many medical learners and physicians go through. Time and time again, patients are identified as the number one source of racial or gender-based discrimination. I recall discussing my encounter with several classmates, many of whom shared similar stories. The overarching theme was one of internal struggle – we wanted to treat our patients equally and fairly, but it felt like some patients were making that goal very challenging to achieve.

As physicians, we are not social arbiters tasked with determining the fate of discriminatory patients. Yes, we must stand united to denounce any form of discrimination in the workplace. That is a given. But we should not flex our supposed moral superiority in our interactions with patients. This is a trap that can alienate us from our patients and irreversibly damage the physician-patient relationship. A discriminatory, or even hateful patient, has a story. We should not assume that we have a complete understanding of their circumstances. An individual expressing hate is often calling out for help and, while it’s frustrating to be on the receiving end of hurtful comments or subtle micro-aggressions, we must understand that compassion is our trump card.

Shifting one’s vantage point from that of the oppressed victim to the compassionate healer is a superpower. Physicians should not feel responsible for carrying someone else’s baggage, but we are obliged to try to understand. Difficult interactions with discriminatory patients are best met with a compassion-informed, holistic, and nuanced approach when responding to the situation. I’ve had a handful of similar encounters since that initial event. With each subsequent experience has come much reflection and personal development. Learning to utilize a deliberately compassionate approach is a valuable skill that can be learned and ought to be taught. In no way have I mastered it, but I am keen to keep striving.

Whitgob and colleagues highlight that cultivation of a therapeutic alliance with patients as a response to discrimination serves as a productive strategy. Such an alliance is obtained through building rapport and trust with the patient by focusing the discussion around their medical care. This strategy is best utilized following an acknowledgement of the discriminatory comment. Wheeler and colleagues suggest a different approach and advise opening a dialogue with the patient about their discriminatory remark, to learn more about their perspective. This allows the physician to express empathy for the patient’s difficulty without endorsing the bias, thus allowing for the deconstruction of any pre-conceived biases the patient may possess. Both strategies, while distinct, underscore the importance of a compassionate approach.

It should go without saying that each learner or physician will bring a different set of personal lived experiences to each difficult encounter. Such a fact highlights the importance of understanding our own limitations and providing ourselves with space to make mistakes. We should not be expected to confidently address these encounters and employ a compassionate approach from day one. Similar to learning otoscopy or understanding the clinical significance of a high C-reactive protein level, these skills are learned and constantly improved upon.

As personal exposure to discrimination is associated with increased levels of burnout in physicians and learners, the time is now for Canadian medical educators to take action.

Appropriate education should be instituted early in medical school. It is the responsibility of medical educators to train competent and compassionate physicians of the future. At the University of Toronto, we recently held a case-based workshop for clerkship students where we explored these issues in depth. Students expressed deep concern and acknowledged their lack of confidence in delivering care to discriminatory patients. We taught the following compassion-informed four-step approach : 1) check your own visceral reaction, 2) assess illness acuity, 3) determine whether to respond at the bedside or in a subsequent encounter, and 4) attempt positive regard towards the patient, whilst giving yourself room. The attendees were then provided the opportunity to work through various real-life cases using the tools they learned. All attendees stated that the learning experience was a valuable use of their time. This signaled to us that the gap in training exists. We just need to be proactive in building the bridge that gets us to the other side.

For me it has been, and continues to be, a journey. During my clerkship experience over four years ago, I pretended as if I hadn’t heard the epithet. I avoided talking about it. I continued to provide care for the patient as if nothing happened. Reflecting back, I know I was doing myself, as well as my patient, a disservice. Having a better understanding of the human being behind the hurled epithet is important. Each discriminatory, or even hateful, patient has a past. Compassion is our superpower for gaining access to their story.

Acknowledgements

The author would like to acknowledge Dr. Yvonne Chan and Anita Balakrishna for their support in the development and implementation of the workshop at the Temerty Faculty of Medicine at the University of Toronto.