Racism is the elephant in the hospital room: it’s time we confronted it | Ranjana Srivastava

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‘Many foreign doctors have a story to tell but are loath to voice it for fear of reprisal.’

“Everyone knows I don’t like the fucking Chinese!!” she bellows, shattering the quiet hum of the clinic. The doctor holding her file is flummoxed. The horrified secretaries just put their head down and continue working, the patient’s obscenities mingling with the ringing phones. All the waiting patients feign an interest in their laps.

I pull my colleague into my office.

“Are you OK?”

“Just got abused by a patient.”

“Do you want me to say something?”

“Oh no! As long as she gets good care. She’s probably tired.”

Not wishing to prolong his palpable discomfort, I let the matter go. The file moves to an Anglo-Saxon doctor who dispenses with the patient politely, quickly. Nothing more is said about the incident, then or ever.

I remembered my colleague when the New England Journal of Medicine ran an unprecedented essay called Dealing with Racist Patients. The journal is recognised more for publishing research on stem cells and guidelines on osteoporosis than advising doctors on the delicate problem of managing racist patients, so many readers were pleasantly surprised to find the matter finally accorded the attention it deserves.

He wryly observed that on the phone, the offending patient would never have guessed his country of origin from his thoroughly Australian accent. He’d been unsettled by the patient but the feeling had turned to anger when the next patient astonishingly sought to justify the vitriol, instead of expressing regret. I asked him how this patient had managed to attend frequent appointments and never once encountered him.

Here, it turns out, the patient was right. Everyone really did know of her aversion to “the Chinese”, so to spare him any awkwardness, there was an unspoken pact that an Anglo-Saxon doctor would keep the patient out of his path. In this way, the patient got seen quickly by the doctor she demanded, while protecting her bigoted stance. The squeaky wheel did get the grease, every time.

Australia is one of the countries most heavily reliant on foreign doctors. According to the 2011 census, 56% of GPs and 47% of specialists were born overseas. Of these, 40% were also overseas-trained, with the largest influx coming from the Indian subcontinent, south-east Asia, Nigeria and Botswana.

Gone are the days of mostly British and Irish expatriates: the new arrivals stand out in appearance and accent, neither of which should automatically diminish their professional stature but research shows that it does. A Queensland experimental study found that despite comparable qualifications, education and personality, a doctor with Pakistani credentials was less likely to be hired than one with Australian credentials.

A Korean GP observes that for every sick certificate he refuses to furnish for a weekend hangover, the patient sniggers that “in Australia, we do things differently”. A patient calls a doctor “clueless” for not knowing John and Jack are interchangeable but makes no effort to pronounce her name correctly. Someone asks an Indian specialist if she came to Australia to escape “all that bride burning”. A patient tells an African trainee to get the “real doctor”.

Racism is the elephant in the room but, committed to serving patients, what’s a doctor to do? Most say nothing. Intoxicated and drug-affected patients in the emergency room are known (and repeatedly excused) for their racist abuses but mostly, racism is subtle and implicit. It disperses before you even recognise it for what it is and then, it seems churlish to say anything. Casual racism, it’s called.

For doctors, reacting to racism is anathema. We would rather suffer the indignity of the occasion than draw attention to ourselves. We are steeped in the learning that the patient always comes first and that the power imbalance between doctor and patient is so great that to object to a patient’s conduct is ungallant.

Also, there has never been a strong culture of administrative support to shield doctors from racist patients. Indeed, when I asked my colleague why he didn’t report the encounter, which had dozens of witnesses, he replied that the thought didn’t occur to him as no one would take it seriously. This is a familiar theme among doctors who tolerate bullying and harassment for similar reasons.

Studies document the unconscious bias, prejudice and discrimination that doctors exhibit towards patients of a different race or colour, therefore compromising their healthcare outcomes, but the bias doesn’t stop at patients. Racial aggressions are also directed by doctors at other doctors.

Last year a British medical tribunal reprimanded a Syrian surgeon accused of racist rants against Indian doctors, suggesting that the “bloody Indians” should stick to cleaning toilets and gardening.

Following his advice might just hobble the NHS since Indians constitute the largest percentage of foreign doctors working for it.

If you thought only ill-educated and uncultured people were racist, think again. An Egyptian trainee, wholly educated in Australia, is told by his supervisor that he needn’t bother competing with “the locals”. A Vietnamese doctor is advised by her boss to aim “no higher” than a GP. A Sri Lankan surgeon is told that it’s curious but he just doesn’t “look” like a surgeon. Such remarks made under the thin guise of offering counsel besmirch the reputation of the entire medical profession.

If this is accepted wisdom, how should we address racism in medicine? The same way as we address it everywhere else – beginning with the acknowledgement that it exists so that we can appreciate what it looks like, and strengthen institutional integrity to denounce it.

Foreign doctors who occupy positions of influence must support and mentor their peers. If we are going to rely on foreign doctors to take care of us, all of society has a duty of care towards them.

Top medical schools and hospitals are now scheduling lectures on unconscious bias, forcing us to confront an uncomfortable question that we have never ever thought to do, “Could I be a racist doctor?” The New England Journal of Medicine uses its clout to underline the problem of racist patients.

Who would have thought? At long last, we have arrived at a place where it is permissible to discuss how race intersects with healthcare.