The woman was from northern Indiana and had come to our regional medical center heralded for its expertise in pediatric medicine. Her child was not doing well and she wanted the best. Further, she was willing to travel into a neighborhood very much different from her own to insure this expertise. On morning pre-rounds, the African American fourth-year medical student entered the infant's room and was confronted by the child's mother who inquired and then accused. The medical student explained her role was to examine the child and to learn what had transpired in his health care overnight. She stated that she was a part of a larger team that included the internationally famous attending physician who was leading the teaching effort. This was unfortunately not sufficient for the mother's satisfaction.
She stated that she did not want any of "your kind" touching her child. She elaborated further that anyone who had been granted admission into medical school through affirmative action should not be there, and that no recipient of societal welfare is going to touch her sick child. The student was aghast. Hurt, anger, doubt, and frustration intermingled within her. She was devastated and now tearfully left the patient's room. I am not sure what must have been going through the mother's mind at that time. Did she feel that she had successfully protected her child from some assault from a poorly educated black woman? Did she feel that the debased medical student would suddenly come to her senses give up her study of medicine through such harshly delivered discouragement? Did she feel good about herself for having made another human being of a different race feel bad?
The medical student, who was a hard-working scholar and researcher, had performed wonderfully during her 4 years of medical school. Her top university had historically accepted few African American students per class, and there were vanishingly few minority faculty despite the fact that the medical center was in a predominantly minority community. Most of the hospital staff were African American as were the vast majority of the patients. In fact, this mother was seeking to establish a protective circle of whiteness in a sea of cultural difference. The reality was that there was no affirmative action program in place at the medical school and that the student's scores and undergraduate performance allowed her to select from multiple offers of acceptance from medical schools. She had done research as an undergraduate and spent all of her summers prior to medical school engaged in a scholarly endeavor. She was a person of diminutive stature and quiet unassuming personality. She enjoyed her experience in pediatrics so much as a third year medical student that she elected to do a subinternship in pediatrics as a fourth year and was ranked among the better students in her cohort. Her goal was to train to become a pediatric intensivist.
The student immediately reported the events of the early morning to her senior resident and asked what she should do for resident rounds. Her older colleague suggested that she should describe the situation for the attending physician during teaching rounds and ask what she should do. Meanwhile, the remainder of the team, excluding its only African American, would examine the child during work rounds and prepare the progress note. They would also arrange a change in coverage so that the intern would handle that patient as opposed to the original distribution of patients. After all, who would want to serve a patient who insulted them so?
Life in a teaching hospital is often complicated by requests from patients who ask for the most senior person on the team to do the procedure or examination; but, most understand that the presence of medical students and residents is part of the package in coming to the university system for care. History-taking and relatively non-invasive physical exams are generally well-tolerated for the relative inconvenience they bring to the inpatient experience. Some rightly think that the more minds weighing in on their problem, the better; and many enjoy the chance to help train the nation's emerging physician workforce. It did not appear that the mother had a problem with the teaching hospital concept, because she did not prevent other physicians-in-training from examining her child. It was clear that the single overriding issue was race alone. Cultural intolerance was afoot here. During teaching rounds the situation was detailed for the attending physician.
What were the options for the attending? If she honored the patient's mother's wish, she would have to exclude the fourth-year medical student from the team when examining and discussing this patient. If she invited the African American student into the room with the team and insisted that the student be the primary contact with the parent as had been her original assignment, she would run the risk of negating the parent's request. A final option would be to explain the nature of the teaching hospital and the attending physician's responsibility to educate tuition-paying students, and to offer to help the mother secure care at a different institution. Counterbalancing these options were: the financial incentive the attending had for caring for a well-insured patient; the potential referral pattern that might be disrupted if an unsatisfied patient complained to her referring physician about her preference rejection; and the desire to give a fearful mother comfort during the stressful period of her child's illness.
So, what would you have done as the attending physician? How would you have helped the fourth-year student deal with the doubt, rejection and humiliation she experienced? How could you use this experience to demonstrate the impact of cultural intolerance to the other residents and students on the team? How would you have comforted the parent and ensured patient satisfaction?
In this case, the attending physician chose to ask the fourth-year medical student to remain in the hallway while the rest of the team examined and discussed the patient's progress. The budding pediatric intensivist was completely devastated and sought recourse through the medical school. Fortunately, the situation was short-lived and the patient was soon discharged; however, the damage had been done. The humiliation, alienation, and pain were too intense for the student. In selecting a residency program, these events weighed heavily and caused the student to bypass her own university in the residency matching process. She is now successfully completing her pediatrics residency elsewhere. However, what message was transmitted to her colleagues in training through their observations of their colleague's treatment? Will they perpetuate the behavior exhibited by their teaching-attending physician or will they learn the irrationality and pain associated with racism and act to confront it in their future?