The doctor-patient relationship is a truly remarkable bond. On regular days, patients come into clinics and hospitals and tell a relative stranger about their life, sometimes details they do not tell their closest friends and family. On their worst days, patients are transported to emergency departments and trauma centers in extreme duress, with life and limb-threatening emergencies, expecting to arrive at a place where their injuries will get the full attention of the medical staff without prejudice.
Unfortunately, the system is not setup to work equally for all. We have been taught to be biased as physicians[1]. We were told (incorrectly) as students that physiology and pathology is different for people of different races[2, 3]. Our teachers have insisted that age and gender are important when many times they are not. The books that have been written and updated for edition after edition have led us to believe that discriminating against our patients is practicing good medicine.
How can a physician start a new patient-physician relationship without bias? This is where our “shadows” come into play. As physicians, we need to train ourselves to evaluate encounters with patients from the bystander’s point of view – as our shadow might. As we listen to patients and gather data, either in an effort to establish a diagnosis or to assess the success of our treatment course, we need to look for the clues that tell us the relationship is broken. We need to be able to evaluate the phrases that our patients will use to tell us we are not having success. When the patient says, “something is wrong,” or “I am concerned,” it is the physician’s duty to “seek out disease,” to search high and low for what is wrong and address the problem or reassure the patient that everything is OK.
Likewise, if these concerns are coming from the patient’s advocate, we must respect their relationship with the patient and their observations. Assume the pure intentions of everyone involved and go above and beyond to make sure the fears of all concerned are alleviated. This is hard work, to be certain. It is not even work that may be compensated fairly when it comes to the time spent at the bedside. It is, however, work that can potentially save lives. We need to actively explore concerns. We need to ask clarifying questions and address our patients’ concerns head-on.
As physicians, remember we do not practice in a vacuum. Medicine is a team sport. In academic and teaching settings, it is important to seek out the observations of learners and other members of the team. Talk to the least experienced people in the room. Ask for their thoughts. Ask what they observed about the encounter. In all settings, listen to nursing and ancillary staff. Seek out their opinions and respect their expertise. Discuss what is said when you are not in the room. Ask social workers, discharge planners and therapists to give you their opinions of the patient’s course. Setup the environment so that they understand why the questions are being asked. It is important to make sure everyone on the team understands that we are not looking for affirmation. We are looking for problems and solutions before bad outcomes occur.
We, as a profession, need to rethink our practices. We need to reprogram our brains to listen to our patients and not just attempt to recreate debunked statistical norms. We need to listen to our colleagues that have sounded the alarm and pointed out the inaccuracies in our textbooks and teaching practices. This should be especially true when we might not have the same life experiences as our patients or come from a different socioeconomic background. If we truly listen to our patients, they will tell us what is wrong. They might even present us with the solution.
Disparities and systemic racism in healthcare are real[3, 4]. They lead to outcomes that, at their best, are disappointing and, at their worst, are deadly. Not even the most knowledgeable people, our physician colleagues, are immune from these biases. We do not have to look very far to find examples of these lapses in treatment. They occur every day.
1. Amutah, C., et al., Misrepresenting Race – The Role of Medical Schools in Propagating Physician Bias.N Engl J Med, 2021.
2. Inker, L.A., et al., Effects of Race and Sex on Measured GFR: The Multi-Ethnic Study of Atherosclerosis. Am J Kidney Dis, 2016. 68(5): p. 743-751.
3. Hoffman, K.M., et al., Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A, 2016. 113(16): p. 4296-301.
4. Ellis, L., et al., Racial and Ethnic Disparities in Cancer Survival: The Contribution of Tumor, Sociodemographic, Institutional, and Neighborhood Characteristics. J Clin Oncol, 2018. 36(1): p. 25-33.