The Dilemma of the Racist Patient

The doctor–patient relationship is a powerful cornerstone for medicine. Confidence in the physician results in higher satisfaction for both parties and adherence to the treatment regimen on the part of the patient. Prejudiced interactions threaten the therapeutic alliance between patient and provider. Research has investigated how race plays a role in the doctor–patient relationship. When permitted, patients more often pick a provider of their own race.¹⁷ One of 5 African American patients wishes to have an African American provider, and such a desire is often based on a previous negative racist encounter.¹⁸ A patient’s perceptions of discrimination in general correlate with preference for same-race providers, highlighting that a patient’s overall experience with discrimination leads them to prefer a same-race physician. Race-concordant relationships (ie, one in which the provider and patient are of the same race) not only show increased satisfaction, but patients also perceive that their interactions with a racially similar physician are more participatory.^19-22 In non–English speaking groups, preferences for racially similar physicians are largely based on language similarity, but Latinos feel that Latino physicians are more empathetic to their complaints.²³ Such views are felt not only by patients, but also by providers. One of 3 physicians feels that patients receiving care from a physician that is of the patient’s own race is superior to that provided by a race-discordant physician.²⁴ Superior outcomes from race-concordant doctor–patient relationships have led some to argue in favor of granting a patient’s wishes for a provider of similar race because doing so can confer additional health benefits.²⁵

Possible Solutions

The solution to such a complex and uncomfortable issue begins with addressing the problem. Patients who make racist remarks and racist demands should be courteously informed that their behavior is inappropriate and hurtful. Failure to voice such a concern results in passive, tacit approval of racist remarks and can be distressing to other patients and staff members in the vicinity.²⁶ It is unfair for a physician, as the leader of the care team, to ignore such behavior because it places staff members, who spend much more time with the patient, in a potentially abusive situation and leaves them feeling helpless.²⁷ Toward this end, appropriate training, beginning in medical school and continuing in residency, in confronting racist patients is needed to ease the too often felt sense of discomfort among providers.^7,26

Medical school, although rightly placing patient comfort at the center of dialogue, too often drowns out the personality of the student in the name of professionalism, which becomes a problem as a young physician struggles to reconcile his or her personality with the newly ingrained teaching to remain professional. This internal conflict can lead to frustration. A necessary prerequisite to beginning dialogue is that the physician recognizes his or her own emotional baggage from prior racially charged events and continues to remain professional. Airing the issue can help establish dialogue that can identify underlying causes of the patient’s misplaced anger. An illness and its subsequent hospitalization can make a patient feel vulnerable and helpless, and in those with poor coping mechanisms, misdirection of emotion is not uncommon.

In more difficult scenarios where attempts at dialogue reach an impasse, an ethics team should be consulted. Most institutions have such help available. Their expertise and experience can help in addressing the needs of the patient judiciously. Some institutions have dedicated multidisciplinary teams to help providers deal with dangerous and difficult patients. The implementation of the teams has reduced confrontation and litigation.²⁸ If the impasse remains despite intervention, the physician should step aside after the patient’s care is transitioned to a provider that satisfies the needs of the patient.

In clinically emergent scenarios, ethics consultation or prolonged discussion may not be feasible. In such cases, the patient’s wishes should be honored and attempts should be made to receive permission for life-saving or limb-saving intervention. At large tertiary care centers, the wishes of the patient can be more easily granted than at an outlying facility or rural clinic. If the patient’s wishes cannot be respected in a life-or-death scenario and the patient continues to refuse care, the principle of patient autonomy dictates that no care can be provided. Much in the same way Jehovah’s Witnesses can refuse transfusion of blood products based upon their belief system, any patient can and should be allowed to freely refuse care from a provider.

Racism is a societal disease that is complex and multilayered, and it can be deeply entrenched in the minds of those afflicted and, thus, difficult to eradicate. The manifestations of bigotry in medical settings are only one example of a mindset that likely exists in multiple aspects of life. Hospitals and clinics can become a place to establish dialogue between racially intolerant patients and their providers, but they are not the venue where firmly held racist views can be expected to be wholly reversed. Having the objective to reverse prejudiced beliefs prior to providing care is discordant to the practice of medicine and can harm a patient if an unnecessary delay ensues. Although hospitals should try to avoid offending staff members, there should be an understanding that appropriate and timely patient care is the primary goal in medicine.²⁹ As we move to a more multicultural society, it is the hope of the authors that these already infrequent racist encounters will continue to diminish, and that medical schools and residency programs will train physicians who are highly understanding and culturally competent.