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.
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.
As a young international medical graduate, woman of colour I came to experience racism the moment I arrived to Canada, and now as a fully licensed physician I continue to experience this from all levels of the health care system, patients and patients’s family members.
Enough is enough!
I question all of you when will we have strong regulations that protects patients, but also health care workers from racism and discrimination? When our regulating bodies will take racism seriously and create policies for the safe delivery of care that protects patients but also health care providers? What are the implications for patients and physicians in situations like this? where to report it?.
Dr. Ugarte, I am sorry you have had such a disappointing and hurtful experience in Canada.
I am not sure what regulations could be put in place to halt racism, if the hearts and minds of the people are not won first. Certainly hateful and hurtful acts must be outed and dealt with, but we must be careful not to make laws that worsen the situation we are trying to fix, as has happened so often in the past in Canada.
I believe education and social connections are far more effective tools to end racism than are increasingly heavy handed laws.
Please don’t give up on Canada. While there is a vocal minority of small-minded people here, just like anywhere, most of us are a friendly, open bunch who welcome newcomers in our midst.
What can be done, is stop the current system of marginalization of IMGs where entry level jobs as resident physicians are protected for CMGs to ensure that they are advanced in medicine. Conversely, IMGs who are Canadian citizens and permanent residents are denied the right to compete for 90% of the jobs as resident physicians. I know, that most readers will say: there are CMGs who are people of colour and some IMGs are not. This is true, but the majority of CMGs are Caucasian and the vast majority of IMGs are people of colour. So long as Canadians who are IMGs are treated differently and denied the right to compete on the basis of individual knowledge and skills, this neural brain connection of IMG/race inferiority will continue. The CMA’s Equity and Diversity Policy in Medicine says all the right things, but when we pointed out that the policy was contravened by the first step of access to medicine, i.e., access to resident physician positions, the CMA was not prepared to act to do more than design the policy. It did not intend that the policy be applied to the access to residency training system in place which perpetuates the prejudice that IMGs are inferior. It did not intend to apply this policy to the reality that so long as IMGs are primarily people of colour and it is acceptable to deny them the same opportunity other Canadians receive, that the assumption will be that people of colour are not welcome and inferior. The impact of the current system can be seen in pictures of governance in medicine. For example: http://www.afmc.ca/en/about/board. Have a look at the faces on the other boards that govern medicine. Social scientists would have no issue explaining the genesis of the race problem nor its perpetuation.
If our medical schools were to adopt a trauma-informed approach, students would be provided with the tools to work with discrimination. It wouldn’t remove all the pain of the interaction, although it would certainly make it more understandable. A trauma-informed approach would also support patients in a way that they would be less likely to have their own extreme states of mind triggered out of fear, powerlessness and the evocation of past trauma. Thank you Amr for your article and your humanity.
(In our current psychotherapy training program, the Medical Psychotherapy Association of Canada recognized the importance of navigating similar interactions and three of the five modules are focused on compassion, trauma, the therapeutic alliance and on transference and countertransference. This kind of training, perhaps in adapted form, would probably serve in all medical curriculums – for instance to fully stand in compassion we do best when we understand ourselves, understand trauma, and understand that compassion is a state that does not negate our other emotional reactions, but allows us to hold a great deal of both ourselves and our patients in a way that doesn’t deplete us).
Compassion, yes, but you have no obligation to continue seeing a patient that is racist toward you.
The first patient I ever fired, I fired because of his racism. It was my very first day of work here in Sherbrooke, NS, 19 June 1995. He came in the office, sat down and said, “Thank God we finally have a white doctor in this town!”. I asked, “Excuse me, what do you mean?. He replied, “There’s no way I am going to see that n….r!”.
To say I was shocked is putting it mildly. I took a minute to gather my thoughts, and then told him, “Sir, you will not be seeing me either. After your hateful remark directed at my colleague, a man far more learned and capable than myself, and whom I admire and look up to, I will not be able to treat you with the respect and objectivity the doctor-patient relationship demands. We are done here. Good day”.
This is a small town. Word gets out and travels fast. No one has ever made similar racist comment in my office since then.
Thanks, you and I admire you to have the courage the talk about this,This was a very meaningful post for me. Thank you.
Abusive patients affect everyone in the profession. With the added weight of pandemic care during the COVID-19 crisis, doctors are struggling even more. The doctor-patient relationship is part of the healing process and based on compassion, honesty and genuineness. For a healthy society, we need healthy doctors. Burnout is toxic for physicians, because it’s associated with loss of compassion and empathy. Furthermore, it shut doors to a meaningful doctor patient relationship. Consistent practice of the Buddhist path will make letting go much easier, but this takes most of us a bit of time and effort. According to Buddhism, we must let go of attachment and desires if we are to experience happiness. However, letting go doesn’t mean you don’t care about anyone and anything. It actually means you can experience happiness, if we could simply let things go that are not important to our life and our survival. Similarly, it is important to understand the value of forgiveness for ignorance.
Compelling new research shows that health care is in the midst of a compassion crisis. According to a new book 40 seconds of compassion can save a life. It’s important for many reasons, one of which is that it has a profound impact on quality of health care. Compassionomics: The Revolutionary Scientific Evidence (analysis of more than 250 available research on compassion in health care) that Caring Makes a Difference is a appealing new book written by two physician-scientists, Stephen Trzeciak and Anthony Mazzarelli makes a strong argument for the ones who are kind and warm, not just because they’re more pleasant, but because they have better patient outcomes. The book interestingly, uncovers the eye-opening data that compassion could be a wonder drug for the 21st century. Furthermore, this book provides overwhelming evidence for the healing power of compassion and the kindness could bring for patients and for clinicians. When a physician is compassionate, patients heal better and faster, and the doctors are happier and less burned out. We can’t underestimate the power of compassion and therefore, physicians, and the media should now acknowledge that compassion in health care is matters and powerful influence of the compassion on the health outcomes of patients as well as on health care providers overall health and wellbeing.
Thank you for raising this painful subject. But I would add that it is time to look to medical schools and the profession, not just to patients. I recently met an anesthesiologist from Iran whose compassion and skills were so outstanding, he became renowned internationally before he immigrated to Canada under the skilled worker fast track. His application for immigration was processed promptly due to Canada’s shortage of physicians including anesthesiologists. But when he came to Canada ten years ago, despite his exceptional abilities and accomplishments and a proclaimed shortage of anesthesiologists, there was no pathway for him to licensure. He aced the MCCQE1 and 2, and the NAC. He worked as a clinical trainee in BC to gain Canadian experience. He had commendations from physicians, other hospital staff, and patients which confirmed his ability, dedication, and compassion transferred seamlessly to Canada. But alas, the province he immigrated to (BC) reserves anesthesiology residencies for graduates of Canadian and American medical schools. The 8 residency positions in other provinces he was restricted to (over 100 across Canada IF he had been educated in Canada or the US) were subject to filters such as preferring residents of the home province, date of graduation, age, electives in the home school, and others. This physician tried repeatedly to ascend the insurmountable path he was forced onto for licensing. He has been deprived of the work that gave his life meaning. But the greatest source of his pain is his young daughter. She goes to school and is educated in the principles of equal opportunity and worthiness of every member of our society and how the only limit on one’s dreams is one’s persistence and abilities. A Canadian is a Canadian, regardless of where they went to school. And thus, she knows that her father does not practice medicine, because he simply isn’t good enough. Racism and patent discrimination are an integral part of the medical profession. Canadian medical students are subtly encultured during medical school to believe that they are superior to international medical school graduates and that they are entitled to the limited number of entry level jobs into the profession. Their path to licensure is made virtually certain by protecting them from competition with other citizens and permanent residents of Canada. The purpose of this protection is to ensure that old and new Canadians educated outside Canada and the USA do not displace graduates of Canadian and American medical schools who are considered more worthy of ascension in the medical profession through competition on individual knowledge, skills, and characteristics. A historic review of the development of this system points clearly to racism, elitism, and nepotism as the origin and justification for the discrimination against this sector of Canadians. The structure of the system proclaims and endorses superiority of Canadian and American medical school graduates through selection. Medical educators and administrators are not blameless in the perpetuation of racism and discrimination. When leaders in the profession tell the public that international medical graduates, most of whom are people of colour, are unlicensed because of “credential recognition” and “public safety”, it is only reasonable for a public educated on Canadian principles to believe this to be true, when it is not.
I commend Amr for this profound piece. Even with a “superpower” it takes courage to be compassionate. We all must bravely and forthrightly face discrimination, not only in our patients but also in ourselves.
Amr, your advice to medical educators is heard.
Diane L Aubin
Wow. Just WOW. You are a beautiful person.
A very sensible, honest and practical handling of approach to a very sensitive issue. Required reading. Well done, doctor.