CHAPTER TEN
WHAT YOU SEE
The young man stormed into the midst of a medical team congregated at a doctors’ station in a back corner of the emergency room. “What are you guys doing?” he demanded, holding up his pink-clad toddler. “My baby’s choking, and you guys aren’t doing anything!” The ends of his cornrows slashed against his gray hoodie sweatshirt as he spoke angrily to the medical team. This particular doctors’ station was out of public view, set behind a staff workroom, so it was clear that the man had crossed through areas that were typically off-limits to patients. As soon as he yelled his opening statement, every person on the team, who were nearly all female, froze.
Ekene, the medical student, looked on with alarm. An “angry black man” invading the doctors’ space—this wasn’t going to end well. As a medical student, she didn’t feel qualified to assess the medical merits of the situation, but as the only African American person among the white doctors, she was acutely aware of the fraught dynamics.
To the best of Ekene’s limited clinical acumen, this did not appear to be an acute emergency—the child seemed to be coughing rather than choking. Ekene toyed with the idea of stepping forward and offering to accompany the father and daughter back to their room and begin the medical evaluation. This could potentially calm the situation. But she was lowest on the totem pole and she knew it wasn’t her place to take charge.
The highest person in the medical hierarchy at the moment was the ER fellow, and she assumed control. “Go back to your room, sir,” she said calmly but with clear authority. “We’ll be with you in a moment.”
The father edged a few steps away but remained disconcertingly close. Close enough that no one moved a muscle. As the minutes ticked by, the tension ratcheted up. Ekene’s eyes tracked back and forth between the father and the medical team, all seemingly cemented in place. Who was going to blink first?
“Fuck you all,” the father finally spat, turning on his heel. “I’m just going to take my baby out of here and go somewhere else.”
The ER fellow didn’t hesitate. “Call Security,” she snapped. “Don’t let that man leave.”
When I first heard this story from Ekene, I thought about it in terms of the bias that runs through medicine—both for patients and for staff. In writing this book, however, I’ve also started to consider the incident in terms of medical error. Ekene was not part of the eventual medical evaluation of the toddler, so she never learned the final diagnosis and treatment, but I’ve often wondered how it played out with the ER fellow and the patient. The doctor is a human being too and could easily have been rattled by the encounter, or resentful, or distracted. She may have exhibited unconscious racial bias toward the father that leeched over toward the daughter. Or maybe not. She might have performed a more cursory physical exam, or entertained a narrower differential diagnosis, or prescribed a lower-level treatment. Or maybe not. I do not know what happened, and the medical care may have been perfectly excellent. But the situation was, at the very least, a less-than-ideal backdrop within which to begin diagnosis and treatment. It’s not a stretch to contemplate that medical error might be higher in these types of charged situations.
Additionally, in this particular encounter there might be biases beyond race that could affect judgment. Many of the biases intersect, even conflict. Was this ER confrontation primarily about a black person challenging a group of white people? Was it about a man acting aggressively toward a group of women? Was this about a patient breaking the unwritten rules of doctor territory? Was this a clash of a white-glove institution sitting in the midst of an economically disadvantaged community? There are so many elements beyond the child’s actual symptoms that could have impacted this particular interaction.
There’s no avoiding the fact that bias, particularly racial bias, is a potent force in medicine. Maternal mortality, for example, is almost three times higher for African American women than for white women in the United States.1 There are disparities in outcomes for diabetes, cancer, and heart disease. Socioeconomic factors play a role, no doubt, but significant disparities remain, even when economic differences are factored out.2
Explicit discrimination may be less overt than in generations past, but implicit or unconscious bias is still entrenched.3 Even doctors and nurses who are the most egalitarian specimens of their generation can still demonstrate unconscious bias.
The effect on patients can be difficult to measure in the clinical setting because it’s not the type of situation amenable to the usual randomized, double-blind, placebo-controlled trial. But there have been a number of thought-provoking studies in lab settings that suggest that bias could increase medical error. In one such study, doctors were given case studies and asked to recommend treatment. The clinical scenario was identical in all cases (symptoms of a possible heart attack), only the race of the patient was varied.4 In what is a regretfully unsurprising result, doctors recommended more appropriate (and more aggressive) treatment for white patients than for black patients, even though the clinical situations were identical. This doesn’t prove that bias causes medical error, but both diagnosis and treatment were impaired for the hypothetical black patients in this study.
As part of the study, these doctors also took tests to measure both implicit and explicit bias. Interestingly, it turned out that it was the degree of implicit bias that correlated most strongly with poorer treatment of the black patients. This was evident even with doctors who showed no bias on tests of explicit racial bias. At the very least, this study suggests that even doctors who do not consciously feel affected by the race of their patients can still harbor implicit racial bias, and that this implicit bias may be a driver of unequal medical care as well as medical error.
There are some data to suggest that more diversity in the medical workforce could improve outcomes. In one intriguing study from California, 1,300 black men were randomly assigned to either a white doctor or a black doctor. The doctors—who did not know that the study was about race—were told to encourage their patients to get a flu shot and undertake screening tests for diabetes, cholesterol, hypertension, and obesity. Those patients who were assigned to black doctors were far more likely to agree to the health screening tests.5
The possible factors at play—trust, communication, cultural awareness, practice style, preconceptions—are too complex to dissect here, but studies like these offer hints that increasing workforce diversity might improve patient safety, particularly in the realm of diagnostic error.
When Ekene told me the story of the man and his toddler in the ER, I asked her whether she thought the doctors on her team were being racist. This was a complicated knot for her to untie, because these doctors were her team. She worked with them intensively, liked them personally, and deeply appreciated how generous they had been with their medical knowledge and encouragement. These were role models—strong women—whom she looked up to. And yet . . .
And yet, she witnessed their automatic reaction to a black man being on their turf. “‘Racist’ is not a term I use lightly,” she said, clearly choosing her words diplomatically. “But I guess I hadn’t been aware of the strength of their bias.” When the father stormed into the doctors’ station, Ekene saw fear and concern in his actions; her fellow physicians saw aggression.
Ekene described her complicated sense of kinship with the father. On the one hand, their lives had nothing in common. She had several Ivy League diplomas under her belt and was attending one of the top medical schools in the United States. This young father was living in a poor, urban neighborhood, relying on charity medical care.
On the other hand, Ekene observed, “that father and I look the same to the outside world.” She talked about how she, like other black doctors, was often assumed to be a technician or clerical worker. There is certainly suggestion of racial bias in how society responds to doctors who’ve made medical errors. Consider the case of Dr. Hadiza Bawa-Garba from the previous chapter. She was convicted of manslaughter in England for the death of Jack Adcock, the six-year-old boy with Down’s syndrome who died from septic shock. She was initially banished from medical practice for life. Although the lifetime ban was overturned on appeal, the manslaughter conviction remained.
Two years after Jack’s death, a British transplant surgeon, Dr. Simon Bramhall, was found to have branded his initials on patients’ livers with an argon laser during surgery. It’s not known how many times he did this, but two cases came to light when the patients underwent a second surgery and the initials were discovered. Although the branding caused no medical harm to the livers, the patients were horrified when they learned of it. For this transgression, Dr. Bramhall was fined the equivalent of $13,000 and sentenced to a year of community service.6
The discrepancies in these cases shocked many medical observers. In Dr. Bawa-Garba’s case, Jack’s situation was clinically complex with legitimate diagnostic uncertainty and several plausible approaches that could be reasonably debated. Additionally, there were a number of external factors that might have tripped up even the most conscientious medical professional—having to cover the patient load of two other doctors, the EMR being down, the patients having switched rooms. While there were definitely errors in Jack’s care, by all accounts there was no indication of proactive malicious intent.
By contrast, in Dr. Bramhall’s case, there wasn’t a hint of gray. There isn’t any logistical challenge, no diagnostic uncertainty, no overburdened schedule, no clinical conundrum that could inadvertently lead to a doctor’s initials being branded on a patient’s internal organ. This was a conscious, premeditated, and unethical action, even if it didn’t cause any medical harm. Yet Dr. Bramhall got off with a fine and a bit of community service, while Dr. Bawa-Garba was convicted of manslaughter and initially banned from practicing medicine for life.
Dr. Bawa-Garba is a black Muslim woman, originally from Nigeria, who wears a headscarf. Dr. Bramhall is a middle-aged white man who grew up in England. While it is not possible to prove, there is certainly a sense that racial, ethnic, and gender bias might be factors in the vast discrepancy in these cases.
Of course none of this changes the fact that a six-year-old boy died and that his death was possibly preventable. Regardless of the circumstances, the final outcome was that a patient suffered grievous, irreversible harm at the hands of the medical system. Jack’s parents were secondary victims who suffered agonizing harm from what transpired in the hospital. It may feel indecorous in the face of such a tragic death to parse the indignities experienced by the doctor, but it is crucial to recognize that how we deal with medical error has potent ramifications for whether and how future errors can be prevented. If blame is incorrectly apportioned, or if there is bias in how penalties are meted out, medical workers are much more likely to hide errors and near misses. Such secrecy only serves to make medical care even more dangerous for patients.
“In a cardiac arrest, the first procedure is to take your own pulse,” wrote Samuel Shem in his satirical novel The House of God. It’s advice that is relevant in all tense situations, especially ones in which stereotype, bias, and gut reactions can have lasting implications for both medical error and its aftermath. And it’s equally important to check the pulse of the others around you. What is everyone else responding to?
Reflecting back on the encounter in the emergency room some years later, the medical student Ekene told me that she wished she had taken the initiative to help the father and possibly defuse the situation. “I no longer take for granted,” she said, “that we doctors have it right.” This is an Rx that many of us in the medical profession could stand to benefit from. She began exploring the experiences—both bitter and excellent—of friends and family at the hands of the medical profession. “I seek out those stories now,” she said.
It crossed Ekene’s mind that if she’d walked into the emergency room as a patient, maybe in a crabby mood because of her illness or the six-hour wait, these doctors whom she genuinely respected might treat her the same way they’d treated that father. She might have received flawed or substandard medical care.
But being on the doctors’ side of things was equally complicated. During the confrontation in the ER, Ekene experienced an awkward dissonance. Was she first and foremost a medical student, part of the clinical team that was being accosted by an angry patient? Or was she experiencing this primarily as an African American, witnessing the white community prejudging a black man’s intentions? And what about the issue of being a female facing a man who feels entitled to challenge the authority of women in charge?
Layered on top of these complications were the power dynamics that also played out in contradictory ways. She was part of the powerful group—the doctors—but as a medical student she was singularly powerless. To the father, she looked like one of “them.” To the other doctors on the team, however, a medical student might just as well be part of the furniture. When I reflect back on the tense encounters I’ve observed over the years—a surgeon screaming at a nurse, a hospital employee confronting an angry patient, a resident dressing down a student—it’s always the other person who’s saddled with the blame.
Even if the person who made the outburst ultimately recognizes the inappropriateness of his or her own behavior, it’s somehow the other person who “provoked” the outburst: the nurse gave the wrong instrument, the patient was acting aggressively, the student’s work was shoddy. There’s always a ready explanation.
Our very human egos demand a mitigating context for our ill-advised actions. These justifications always seem objective because we know that we are not racist, or sexist, or homophobic. We are good people and we have chosen to work in a profession dedicated to helping others, right? How could our actions possibly reflect bias?
“When one’s own behavior can be construed as negative,” researchers Debra Roter and Judith Hall astutely noted in one of their analyses, “the person is particularly inclined to blame it on the other person.”7 Holding back on that blame is a tall order for individuals singularly steeped in the hierarchy of healthcare, but it’s a first step in pulling back the bias that so infects our field and jeopardizes the health of our patients.
Addressing bias is a priority in the medical field now, at least a professed one. Resources, though, have not caught up to the rhetoric yet, and frankly I doubt they ever will. Turning a battleship is both an arduous and an incremental process, and certainly offers no help in the moment, which is when these crises typically occur. For better or worse, this leaves much of the issue of addressing bias in the hands of the individuals in the trenches.
For all its technological innovations, medicine remains an intensely human field: illness is experienced in human terms and medical care is given in human terms. We humans bring along our biases and stereotypes—that is true—but we also bring along our ability to communicate and to listen. We will, of course, never achieve perfection in our interactions with others or in our medical care. No matter how determined we are to be fair and conscientious with everyone, there will always be times when we fall short. But if we take the time to listen—genuinely—we’ll at least have the opportunity to peek into the lives of our fellow imperfect humans and attempt to deliver the best medical care possible. We may not be able to step into others’ shoes, but we can slide onto the bench next to them and follow their gaze. We can stretch a bit more than usual and attempt to see what they are seeing. This may not be high-tech, but it might very well be our most powerful tool for chipping away at the entrenched bias that jeopardizes medical care.
Thinking back to Jay’s case, I wonder how things might have transpired if anyone on his medical team had taken the time to slide onto the bench next to Tara, to follow her gaze and attempt to see what she was seeing. Even if the medical outcome didn’t change (though it might have), that small act might have averted a lawsuit. But as things played out, no one really saw Tara’s point of view, and her voice—that of a woman, and “just a nurse,” at that—was essentially ignored. Losing your voice is a familiar experience for many people in groups that have been historically discriminated against.
Filing a lawsuit can be a way to regain that voice.