Bigotry, Medicine, and Pittsburgh

“You’re one of them wealthy people, from that wealthy family — what are
they called? The Rothbergs?”

“You mean the Rothschilds?” I asked.

“Yeah they’re the ones. You’re related to them?”

“No, sir. My last name is Rothstein — different family but same religion.”

Most of the time I don’t hear about race or religion in medicine but often
enough I do have interactions with patients about my religion that make me
wince. In another instance I saw a patient after a large surgery. I
introduced myself and asked him how he was doing. “I’m okay,” he responded.
Then, after a pregnant pause, he looked at my ID badge, then my face, and asked, “You’re Jewish, right?”

“Yes, I am,” I responded.

“I have great respect for the Jewish people. You know Jesus was Jewish, right?”

“Yes, I did know that.”

“But you don’t believe Jesus was the Messiah, right? You know, Jesus is our
Lord and Savior and he performed incredible miracles while he was alive.
Did you know that?”

“Yes, I’ve read some of the New Testament and I’ve spoken with Christians
about their beliefs.”

“Well, then, why not believe in Jesus? He built on Judaism. His thinking
revolutionized religion. It is the latest prophecy, the latest and truest
Word of God. Would you be interested in seeking out Jesus?”

“I appreciate the offer but I’m comfortable with my own religion.”

“Well, you should convert. It’s the only way to seek the real Truth. Jesus
is the Messiah and if you don’t convert you won’t be going to heaven.”

“Thanks, but I’m okay. Now, how’s your surgical site doing? Are you still in
any pain?”

Sometimes it even goes beyond this. There was a patient I saw regularly in
the hospital who would intermittently get aggressive, annoyed, or
anxious. The nurses called me to talk him down. One evening he was
particularly upset about being in the hospital. I entered his room as the
nurse was leaving. “Tell that n***er to leave me alone!” he shouted.

“Excuse me, that is inappropriate. We do not use that kind of language.”

He looked at my name badge and shouted, “Well guess what? I’m Hitler, so I
think you should leave.”

This is not to mention a co-resident who was told by a patient,
“You’re such a Jew.” Or another patient who told a Jewish co-resident,
“All you want from me is a pound of flesh” — a reference to The Merchant of Venice, where Shylock, a Jew, lends money to a Christian and demands a pound of his flesh as security.

These experiences and others I’ve had run the range from threats of
violence to humorous to uncomfortable, but there is a theme behind them.
Unfortunately, my experiences are not unique. All physicians take care of
racist or bigoted patients. In January 2018, the Wall Street Journal
published a piece

on racist patients, quoting doctors discussing their experiences. In a 2017 blog post by the
American Academy of Family Physicians, multiple physicians retold their stories of interacting with bigoted
patients. Dr. Lachelle Dawn Weeks, a resident at Brigham and Women’s
Hospital in Boston, wrote a

short 2017 essay for STAT News
 chronicling her experience with racism. She concludes that

in an ideal
world, hospitals would categorically disavow cultural and religious
discrimination. Hospital administrators would publicly refuse to cater
to culturally biased demands and express a lack of tolerance for derogatory
comments towards physicians and staff as a part of patient non-discrimination policies.

Dr. Dorothy Novick, a pediatrician,

wrote in a 2017 Washington Post op-ed
 that “When I treat racist patients but fail to adequately address the effect of
their words and actions on my colleagues, I not only avoid teachable
moments; I condone hate.” Dr. Farah Khan

wrote in 2015 in The Daily Beast
, denouncing bigotry she’s faced in the hospital. She asserts, “We should be
taking strides within the medical community to break down unfair judgments
and racist ideals.” Moreover, “Of all the things that I had imagined brown
could do for me, I never really expected it to make me feel out of place
both inside and outside of the hospital.”

These interactions do make a physician’s job difficult. Patients refuse
treatment from a particular physician or verbally abuse him or her on the basis of race or religion. A physician cannot offer
an argument against this to assuage the patient. And it is
difficult to hear or experience these insults and epithets after
years of training to help others.

What, then, ought to be done? Many of the physicians I cited above offer
condemnation and resolve not to tolerate racist behavior. But in
practicality these are non-specific, anodyne proposals. Of course hospitals, and we, should condemn such behaviors. But what does that mean in terms of our conduct in the hospital?

In an earlier post, I’ve written about the more general difficulties physicians regularly experience because of frustrated patients, who may swear at, insult, or even slap us, and since writing those words I’ve been punched or swung at by
patients multiple times. I’ve been accused of not caring about my patients,
of being a bad physician. This is part of the difficulty of the profession.
Physicians and nurses bear the brunt of patients’ frustrations or hatred. And while we
can tell patients that their language is inappropriate, part of being a
physician is offering our services when they are ill, despite
how we might feel about them or they might feel about
us.

This is nowhere more true than during war. As I’ve previously written about the role of the Hippocratic Oath in wartime, “The physician … is responsible only for the good
of the patient no matter what uniform that patient may wear. The Oath makes
no exception for wartime or for the treatment of an enemy.”

Tree of Life synagogue in Pittsburgh / CTO HENRY (Creative Commons)

One of the most recent and heartening examples of such principled medical
practice was after the attack in Pittsburgh this past week, where an anti-Semitic gunman killed 11 Jews in a synagogue, screaming

“All Jews must die.” After being injured in a gunfight with police
officers, the gunman arrived at a hospital

where Jewish doctors and nurses took care of him
.

Yes, there are bigots and racists who not only insult those who are
different but murder them. However, in the face of such hatred we must
continue to offer the patient treatment. To treat patients in their time of
acute need despite what they’ve done or said is part of our professional
responsibility.

This may strike some as a deeply unsatisfying conclusion. Where is
justice? Where is the punishment for these people? Why shouldn’t they face
consequences for their hatred? But we see these
patients for a brief moment in their lives. Distributing punishment is not
our purpose, nor will a refusal to treat them change the way they feel or
act. In fact, a physician is far more likely to change such behavior and to
make an impact by treating the patient. After that, we trust our legal
system to distribute punishment, and hope the prejudiced patients figure the
rest out themselves.

Pregnancy and Awkward Realities

I can’t think of a more awkward social situation for a single, twenty-six-year-old male to be in. A previous experience as the only Jew in a room full of
Catholics singing songs about Jesus didn’t hold a candle to this. I was observing a group of fifteen pregnant women discussing pregnancy and getting
pregnancy screening tests. Nurse practitioners run this group to aid and educate pregnant women who do not have enough money to pay for individual
physician visits or are uninsured or even undocumented. Some of the screening tests, which occur at specified times during pregnancy, include maternal blood pressures and weights, labs to identify low blood counts, tests for sexually transmitted diseases that are a danger both to the
mother and the fetus, ultrasounds of the fetus, dopplers of fetal heartbeats, fundal heights (a measurement of the top of the pelvic bone to the top of the uterus) to assess
fetal growth, and more.

Image via Shutterstock

These tests provide obstetricians with abundant information about the health of the mother and the fetus. For example, a test for gestational diabetes determines whether the pregnant mother may have insulin resistance — a state in which she is unable to store sugar properly, which could cause the fetus to receive excessive sugar and grow too large, resulting in shoulder dystociahyperinsulinemia, and hypoglycemia at birth. Screening tests help
physicians to identify these sorts of problems early enough to prevent complications.

Obstetricians also examine the cervix, which is the lower part of the uterus. It
may be most helpful to think about it as the passageway between the vagina and the uterus. As females progress through childbirth the cervix dilates up to
10 centimeters to allow for passage of the baby from the uterus. The cervix effaces as well; that is, it shortens. Obstetricians check for fetal station, too, an assessment of how far down the fetal head lies in the
pelvis — the range is -3 to +3, where +3 indicates imminent birth. They use monitors with probes to assess the fetal heart rate and uterine contractions.
The fetal heart rate gives the physician a sense of the baby’s health status. If the baby’s heart slows down too much, the baby lacks oxygen, necessitating
immediate delivery.

Image via Shutterstock

The nurse practitioner performed these tests and more for each member of the group over the course of nine months. After some brief screening tests in this
particular session, the women sat in a circle and played games. As the only male in the room, I had a difficult time participating in some of these. One
game consisted of suggesting an object to bring to the hospital when it was time to have the baby and then listing all the objects the previous patients had come up with — one had to propose something new and remember what others had proposed. Some objects included: a fluffy pillow, baby clothes, a stuffed animal, an R&B CD,
a scented candle (cinnamon), and others that I can’t recall. When it came around to being my turn, although I appreciated not being treated as just a fly on the wall I couldn’t help but feel at this moment like a knight in those scenes in Monty Python and the Holy Grail: “Run away! Run away!”
I had the eyes of fifteen pregnant women on me. Some of them giggled, either with anticipation or, more likely, because my face turned red and I sheepishly
grinned, declaring, “I shouldn’t be here.” I blurted out: “I feel like Arnold Schwarzenegger in Junior.” The reference was lost on every single person in that room; too young, I
guess — or too terrible a movie to bother with. So I started to name the objects they had chosen, things that I probably would not take anywhere even if
I did own them. I stumbled a bit but managed, with some help, to claw my way through it. When I then had to suggest an object I would bring if I were
expecting, I said food. This was met with nods of approval. A love of food is one of those things that certain pregnant women and I share in common.

We next took a short break, during which the conversations mostly covered topics I couldn’t relate to: potential baby names (my only reference for that is
this Seinfeld episode but after my previous pop-culture reference fell flat, I knew better than to mention it), pregnancy clothes, car seats, baby clothes, nail polish, and
past episodes of morning sickness. I excused myself to “go to the bathroom,” which really meant “avoid the conversations and wander the halls until the
break was over.” What else is a twenty-six-year-old male to do in this situation? This was so far removed from any of my experiences or thoughts. After the
break, we watched a corny video about the process of giving birth — the acting was so bad that all the actors convinced me that they felt opposite what
they claimed to feel. It was a nice time for me to check out mentally.

As ridiculous as this experience seemed at times, there is a deeper, more serious matter worth thinking about here. Many of these women were young enough to be in high school and needed a doctor’s note to
excuse them from school. Some of them did not know who the baby’s father was; all except for two were unmarried; and many could not rely on anyone but a
single parent for help. Sociologists have thoroughly studied the deleterious effects of these kinds of social situations. As Derek Thompson asserts in The Atlantic:

Among what you might consider “modern families” (e.g. the 61 million people married and living together, both working), there is practically no poverty.
None. Among marriages where one person works and the other doesn’t (another 36 million Americans) the poverty rate is just under 10 percent. But take away
one parent, and the picture changes rather dramatically. There are 62 million single-parent families in America. Forty-one percent of them (26 million
households) don’t have any full-time workers. This is something beyond a wage crisis. It’s a jobs crisis, a participation crisis — and it’s a major driver of
our elevated poverty rate.

Indeed, Kay Hymowitz, the William E. Simon Fellow at the Manhattan Institute, writes in the Wall Street Journal that homes without
married parents put children “at an enormous disadvantage from the very start of life.” Additionally, teen pregnancy itself causes a range of harmful
consequences for both children and their mothers. The National Institutes of Health points out here that teen mothers are more likely to live in poverty, have infants with
developmental problems, have baby girls who grow up to be teen mothers and have baby boys who grow up to be arrested and jailed. Furthermore, teen
pregnancies have higher rates of illness and death for both the mother and the infant. Though the rates of teen pregnancy are dropping, the problem and its
manifestations are evidently very real.

It is difficult to know what exactly the physician’s role should be in this process. How much should physicians encroach on the job of parents, who ought
to address this issue with their children? When there are no stable parental figures in a child’s life, how much paternalism does the physician offer? Will
such paternalism backfire? At what age is it appropriate to start speaking to teenagers (or preteens) about sexuality, reproduction, and parenting? And what is the best
way to do it? Here’s the CDC’s anodyne take on it: “Make your clinic teen-friendly. Provide your adolescent patients with
confidential, private, respectful and culturally competent services, convenient office hours, and complete information.” It’s not that easy, nor is it that
benign.

The medical profession is unusual in that the private lives of patients are relevant to nearly every visit. Consequently, no matter how uncomfortable or
awkward or humorous it may be for physicians, these issues inevitably come up. Undoubtedly, then, medical practitioners will play a role in this deeply
significant sociological quandary — how large that role is depends on the physician and the specialty.