Like many anesthesiologists, I have the privilege of serving in an academic institution where teaching medical students is a fulfilling aspect of any given day. Normally, the educational domain revolves around the applications of pharmacology, airway management, and pathophysiology. But on this particular day, rearrangement of the OR schedule was necessary to care for a patient who risked loss of a surgical graft. Unbeknownst to me, this simple schedule change would bring to light a moment of hostility and subsequently a teachable opportunity about how to handle a disrespectful patient – disrespect that I perceived to be rooted in racism.
“As a physician – both a woman and an African American – I only have my experience when perceiving the world, and I strive to avoid automatic defaulting to these identities as the reason for ill treatment. Undeniably, it is exhausting to be on the receiving end of such derogatory treatment, and it feeds into career exhaustion.”
My encounter with the Caucasian male patient began with routine inquiries into his past medical and surgical history. It became unfriendly upon the assessment of the Mallampati classification and my inspection of his oral cavity – the patient lacked many of his natural teeth and did not have artificial replacements. When asked if there are any loose teeth, the patient responded by gesturing his middle finger to me. It took me a few milliseconds to process what he was communicating, but the message became resoundingly clear as two colorful and sizable Confederate flags on the dorsum of his hand were advertised. He allowed the gesture to linger for emphasis.
In my experience, there is only one meaning when someone gives you the middle finger. Plus, my limited encounters with individuals with tattoos of the Confederate flag have been inimical. I was stunned, but I sought clarity first . . . just to be sure.
“Sir, did you just give me the middle finger?”
There was a prolonged silence.
With a nervous laugh, he offered, “Oh, I was referencing that all I want for Christmas is my two front teeth.”
I did not laugh. While looking him directly in his eyes, I replied, “No, sir, you gave me the middle finger, and I did not think it was funny or appropriate. As your doctor, I have shown nothing but respect for you in our brief interaction. Also, this is the month of May – not even close to Christmastime. So, allow me to reset the expectations of our interactions. I find your action disrespectful and unwarranted. Please refrain from repeating such behavior to anyone taking care of you.”
He responded, “Yes ma’am.”
The remainder of the exam and the general anesthetic was uneventful.
Now, to be fair, the patient never verbally stated that he had discriminatory intent, but from my vantage point, the unspoken racism was real. In fact, giving me the middle finger is a stark contrast to the esteemed courtesy traditionally afforded to a physician – especially one that is preparing to administer intravenous medications. On reflection, I questioned why this esteemed status was not afforded to me. Perhaps it is associated with preconceived notions of achievement or limited representation within anesthesiology. Data from 2021 from the AAMC shows there are 9,553 anesthesiology faculty members working at U.S. medical schools. Only 37 of whom identify as African American female at the rank of Associate Professor. I am one of the 37 (asamonitor.pub/3F2eTLP). Arguably, most patients are not concerned about the details of the academic rank of their physician; instead, they simply want appropriate and compassionate care. As a physician – both a woman and an African American – I only have my experience when perceiving the world, and I strive to avoid automatic defaulting to these identities as the reason for ill treatment. Undeniably, it is exhausting to be on the receiving end of such derogatory treatment, and it feeds into career exhaustion.
During the debrief with my medical student, it was helpful to dissect the event, as advised by several resources created by the AAMC (asamonitor.pub/3uu4T9q; MedEdPORTAL 2020;16:10971). Fortunately, these resources were top of mind because of our institutional initiatives to educate residents on identifying disparities in health care (asamonitor.pub/3BdEOil). In addition, our institution had recently published a graphic on how to handle bias in the workplace. My teaching points were to acknowledge the issue and resist the patients’ attempt to deflect the unspoken act using direct and clear communication. In addition, I was very intentional to implicitly model a professional and calm demeanor during the interaction. I used salutations such as sir, I did not raise my voice, and I maintained control of my body language. Most importantly, I was compassionate and gave the patient my best. It is my hope that these lessons demonstrated to my fourth-year medical student (now an anesthesiology resident) will prove useful in her career as an African American anesthesiologist.
Admittedly, the insult of this encounter lingered but was additive to other situations. In the past, I have cared for patients with swastikas, Confederate flags, and other tattoos announcing their individual views, but none have ever been so overtly profane. To add to this, I am certain that I have perceived strong unspoken vibes of hostility and unexpected disgust from patients, which I suspect stem from an undercurrent of racism, but I do not judge nor alter my compassionate care for them.
Perhaps the most upsetting realization of this encounter was that insulting behaviors are pervasive in health care. Because of this, medical school curriculum and continuing medical education will need to expand their anti-racism and cultural competency curriculum in order to prepare future and practicing physicians. The lessons will need to model compassion and professionalism in a manner that is transferrable across a range of disrespectful aggressions. More importantly, the solutions to racism will require systemic change that extend beyond health care.
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