Sachin H. Jain, MD, MBA
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Jain S.; The Racist Patient. Ann Intern Med. 2013;158:632. doi: 10.7326/0003-4819-158-8-201304160-00010
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Published: Ann Intern Med. 2013;158(8):632.
In my final months of residency, I was summoned to see an angry patient. Mr. R. was furious that our pharmacy did not stock his brand of insulin. He wanted to issue a complaint.
“You guys always mess up my insulin whenever I am here. I told the other doctor, and now I'm telling you. You guys just can't get it right.”
“I'm sorry,” I told him. “If you prefer, your family can bring your insulin from home and our nurses can administer it. Would that be an acceptable solution?”
“You people are so incompetent.”
Kevin Jon Williams, MD, FACP
Section of Endocrinology, Department of Medicine, Temple University School of Medicine
April 18, 2013
The Racist Patient - or maybe not?
When a patient makes an overtly racist remark – or any other inappropriately hostile act towards a health care worker – a mental status exam becomes mandatory. With all due respect, Dr. Jain should have asked the patient’s son, who was in the room, “Is this a new behavior for your father?” A colleague of mine recently had a similar experience. A patient did not want care from him, demanding a physician who was “more white.” My colleague is an immigrant from northern Europe, with 100% Caucasian ancestry. It turns out that the patient was newly psychotic. There is a good chance that the son of Dr. Jain’s diabetic patient was embarrassed and confused by his father’s behavior. Reaching out to the son might have revealed – who knows? – a brain tumor, Alzheimer disease, or impaired mentation from hypoglycemia. A racist remark means that something is wrong, but it does not necessarily mean a “racist patient”.
CWRU School of Medicine
April 22, 2013
"There are clear limits to that service that I am unwilling to compromise.". I don't think that that limit is your decision. You should have apologized to the patient.
Mitchel Galishoff, MD
April 24, 2013
25 years ago I faced a similar situation with a horrid antisemitic. I was raised with holocaust survivors. I finally asked my attending to be reassigned. He said No! I was a physician and must fulfill my responsibilities to my patient regardless of who and what he was. My personal feelings were immaterial. My attending was right. This patient truly wanted his diabetes treated properly in a hospital that would not provide his medications. His complaint was legitimate and offering to use his own insulin was a pathetic reply to his call for you to solve the problem. You missed an opportunity to heal and win over a fellow man.
David Nardone, MD
An Institution’s Obligation to Intercede
As I read Dr. Jain's article (1), "The Racist Patient," I felt considerable anxiety and concern for his situation. However, I believe institutions have major responsibilities to their patients, providers, and staff to pro-actively anticipate, address, and resolve these situations, as conflicts in health care are common. Leaving clinicians to their own coping mechanisms, guidance from mentors, and peer support relationships is not adequate.
Bonds between patients and providers are based on mutual trust, and the ability of both parties to communicate candidly and respectfully. Relationships can be strained due to severity of illness, confrontational and destructive behaviors, as Dr. Jain experienced, substance abuse, non-compliance, and failed expectations. Further, some patients represent a danger to themselves and their providers.
I propose the “3D” model, an interdisciplinary committee approach with oversight by the Clinical Chief Executive (2-3) to address dangerous, drug-seeking, and difficult patients (“3D”). Staff members review and discuss each case, prepare an action plan, and if appropriate an enforceable patient contract. Although the goal is to avoid abandoning or firing the patient, the contract, can place firm restrictions. Such a system reduces adverse interactions, and providers become more accepting of treating difficult patients. The “3D” model has been shown to decrease costs of care and emergency visits (2).
An institution can fulfill its obligation to its providers, staff, and patients through a program, like CCRB, to identify problem patients, set limits on negative behaviors, and promote a culture where mutual respect is both valued and practiced.
1. Jain SH. The Racist Patient. Ann Intern Med. 2013;158:632.
2. From the Field: Portland VA Runs Unique Program to Deal with Difficult Patients. (Accessed 21 April 2013 @ http://www.ethics.va.gov/docs/bkissues/Newsletter_2002Spring_From_The_Field.pdf)
3. Carlson MJ, Baker LH. Difficult, Dangerous, and Drug Seeking: The 3D Way to Better Patient Care. American Journal of Public Health 1998; 88: 1250-1252.
David A. Nardone, MD
Sunil K Sahai MD FAAP FACP
UT MD Anderson Cancer Center
May 3, 2013
Been there, Not done that
As a US born Indian American, I can sympathize with Dr. Jain's feelings. I have witnessed and been involved in similar situations, but have never lost my cool in the presence of the patient. Any frustrations were expressed in private among my colleagues and family.
I agree that Dr. Jain should have apologized for the remark, but the patient should have been aware that his comments were inappropriate and hospital admin should have followed a protocol for dealing with such situations. I still am at a loss on how to deal with comments about how good my English skills are, or how do you like living in the USA? I usually just tell them that I was born in the states and move on.
As physicians, we are taught to take the high road, but we don't ever let the patient know that they are inappropriate for fear of offending the patient. I feel that Dr. Galishoff's comment about the use of the patient's own insulin was not appropriate. In these days of restricted hospital formularies, having a patient continue their own meds from home is an accepted practice. What other alternative is there? I am continually faced with the challenge of the hospital formulary having drug X, while the patient's own insurance only covers drug Y.
St.Peters Health Partners, Asst Clin Prof, Albany Medical College
May 2, 2013
In your essay,The Racist Patient, you wrote that Mr.R. spat out: Why don't you go back to India? That was horrible, and it brought back painful memories of your childhood. As a Japanese-American who grew up with taunts in the shadow of WW II, I wholely sympathize with your hurt. But I do not sympathize with your: Why don't you leave our (expletive) hospital? When Mr. R. launched his racist insult, did you know his mental status; did he have dementia or depression or sleep-deprivation? Isn't it our responsibility to know these things? Did your cursing response add to your stature as aperson or to the stature of our profession? Now I know that you and I are just human, and on-the-spot analysis might be beyond us, but couldn't you have simply said: That's unacceptable, Mr. R.?
Christine Laine, MD, MPH, Editor, Michael A. LaCombe, MD, Associate Editor
Annals of Internal Medicine
June 5, 2013
In Response: We accept for publication in On Being A Doctor essays that reflect the condition of doctoring and that provoke thoughtful discussion of controversial aspects of our professional lives. Such acceptance never implies endorsement of a particular behavior nor alignment with any expressed philosophy. The provocative discussion generated by Dr. Jain’s essay (1) has been particularly robust; the four letters selected for publication here represent a spectrum of that discussion. As editors, we found Jain’s piece most appealing for its central message: that we are all human and that even physicians make mistakes. Our reaction to his egregious behavior, that we would hope we would not make the same mistake, is the sort of reflection we wanted this piece to engender – rather than mere judgment. And while our aim is to provoke, Dr. Jain’s is to elicit empathy. Drs. Sahai and Nakao express this, and offer their hope-for responses. Dr. Nardone’s more formulized course of action is a welcome suggestion. Finally, Dr. Galishoff’s letter brings to mind the compelling story by Richard Selzer (2) wherein religion and profession collide in a Jewish physician caring for an abusive patient even while contending with a torrent of emotion about to boil over.
While we can in no way condone Dr. Jain’s action, we do commend him for his courage in telling his story, and thank him for stimulating such frank discussion.
Christine Laine, MD, MPH, Editor
Michael A. LaCombe, MD, Associate Editor
Sachin H. Jain, MD, MBA
Harvard Medical School
I want to clarify misconceptions that may have arisen as a result of my piece, "The Racist Patient." I am in no way proud of how I reacted to Mr. R's incendiary comments. If I were faced with a similar situation in the future, I hope that I would react differently--employing one of the techniques or responses suggested. Angry or foul language does not have its place in sound clinical interactions between physicians and patients.
I wrote the piece to raise the fact that, as clinicians, many of us are unprepared for degrading interactions with patients. They happen and they hurt. We bring our own baggage to work every day. As it did in my case, this baggage--in the form of a childhood that exposed me to significant racism--influences the quality of our interactions with our patients. They impose real, often unexpected limits in our ability to do our jobs.
I want to thank the editors of the Annals for publishing my piece and spurring rich dialogue about professional conduct, patient conduct, and race and racism in medical practice.
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