Sapién, Robert E. MD
In this issue's perspective entitled “Are we teaching racial profiling? The dangers of subjective determinations of race and ethnicity in case presentations,” Acquaviva and Mintz1 raise interesting points regarding racial profiling in medicine, how it is perpetuated through medical education, and the effects it may have on patient care. I believe the discussion should be broadened to include profiling based on general appearance and the impact such assumptions can have on health care.
Let me start by describing my physical characteristics: male, almost 50 years old, 5′8" tall, 180 lb, black hair (what's left of it), brown eyes, glasses, limited facial hair, and skin color that often causes people to assume I speak Hindi, Spanish, Arabic, Tagalog, Farsi, Navajo, or (on occasion) English. I think I have been profiled more by skin color than by race or ethnicity (my surname is not common to my Mexican American ethnicity). I have been profiled by my appearance, not by the foods I eat, the religion I practice, the cultural music de mi gente (of my people), or the countries of origin de mis abuelos (of my grandparents).
I have been profiled, but I am also one who profiles. I have profiled patients on the basis of race and ethnicity, as well as general appearance—all of which could have significantly affected the health care I delivered. Two patient interactions in particular have taught me a great deal about profiling by general appearance.
Personal Experiences in Profiling
Case 1: Profiling a patient
My patient in the pediatric emergency department (ED) exam room was a 14-year-old male with a stab wound to his left middle finger. His skin color and hair color were similar to mine. He had a short buzz haircut and wore a white, sleeveless, ribbed T-shirt, baggy khaki pants, a black webbed belt, and very white tennis shoes. As I examined and talked with him, I made five mistakes. I assumed the wound was from a gang knife fight or from jumping a fence escaping the police—mistake 1. I asked his hand dominance; he was right-handed, so I assumed the injury was not likely to have a serious impact on his future—mistake 2.
When I asked him how he was injured, I expected to hear the usual “I was standing on the street corner, minding my own business when …” story—mistake 3. He told me he had cut his finger while helping cook dinner. I chuckled a little and asked, “No, really what happened?” thinking that helping his mother was a condition of his probation—mistake 4. His mother said, “Really, he was helping me.”
I finished my exam a bit sheepishly and told him I would be back to numb his finger and suture the wound. As I turned to leave, he said, “Doctor, you'll be able to fix my finger, right? I play the violin and I just want to be sure it will be okay.” I stopped halfway out the door, wondering whether I should I run out in embarrassment over my misjudgments and prejudices or go back and find out more. I turned and asked him, “Oh, you're in the school orchestra?”—mistake 5. He said, “No, I take private lessons. I do yard work for my violin instructor, and she teaches me the violin.”
Call me dense, but indeed it took all of that for my assumptions and prejudices to finally crumble. This young man not only studied the violin but was also an honor roll student, helped around the house, and had been accepted into a NASA Space Camp over the summer. My assumptions based on his general appearance—partially his skin color but mostly his clothing that I mistakenly thought was a gang uniform—had turned me from a lifelong victim of profiling into a perpetrator. If I, who have a similar complexion and probably a similar grandmother who cooked traditional New Mexican foods like tamales and posole, could profile someone by general appearance, then how easily others can do it too.
Because hands and fingers are so important for livelihood and activities of daily living, we always take special care when treating them in the emergency setting. The potential impact is even greater when the injury involves a dominant hand or the patient uses both hands for specific tasks, such as playing the violin. Finally grasping the importance of this patient's nondominant hand to his future prompted me to be even more careful with the procedure than usual. I fear that had he not elucidated to me the importance, my assumptions and prejudices could have affected the care I provided.
Case 1 discussion
The medical literature reports that health disparities exist by race and/or ethnicity (e.g., infant mortality, asthma, hypertension). The complex, multifactorial etiologies of these disparities include (but are not limited to) genetic constitution and vulnerability, environmental and situational effects on genes (epigenetics),2 inequities in health care (e.g., socioeconomic status, insurability, transportation, telephone availability), and racism on the part of health care providers or the health care system.
Furthermore, race and ethnicity are themselves complex concepts. As Acquaviva and Mintz1 state, “race is a social construct that offers limited information regarding a patient's genetic makeup.” As Brower3 explains, there is controversy over the concept of distinct races of humans by genetic variation. This would be as if there were subspecies of humans when actually the genetic variations are based more on variation in geographic origins and hence local gene pools. Whatever happened to the adage, “there is only one race, the human race”? Ethnicity is also a complex concept, one that involves culture, language, religion, health care perceptions, and basic disease and body perceptions (e.g., hot versus cold illnesses, the spiritual impact of touching a baby's head during the physical examination).
Although assumptions about race and ethnicity certainly affect health and health care, there is a broader issue. I misjudged my patient's needs because of my assumptions related to his general appearance. Poindexter4 discusses a similar case of health care providers allowing their assumptions from general appearance profiling to delay diagnosing as HIV-positive a woman described as “Irish American, middle-class and college educated,” not the typical demographics of populations most at risk for HIV.
Case 2: Being profiled
Three-year-old Ashley, a fair-skinned female with red hair, presented to the pediatric ED with fever for the past six hours. She had developed the fever on a plane returning from Hawaii with her parents, who rushed her to the ED from the airport. As I interviewed Ashley's parents, a trickle of clear mucus ran from Ashley's nose. Her mother gently dabbed it, exclaiming, “See how sick she is! Do you think she caught something on the plane? Or did the plane ride cause the fever?” After an ED shift filled with parents barely able to provide their child's history, I thought this family was refreshing. I enjoyed talking with Ashley's parents, who seemed completely centered on their child and able to relate precise details of her illness.
I smiled to myself and explained that the fever was not terribly high, that it would be too soon for an illness contracted on the plane to cause a fever, and that plane rides did not cause fevers. Ashley, who clutched her well-loved stuffed rabbit, was absolutely delightful and extremely verbal. During the history taking, she interjected her thoughts and described her trip to the beach in Hawaii as I asked about immunizations.
I washed my hands and approached Ashley. Being a pediatrician by training, I know that the physical exam with kids depends on getting what you can, when you can get it. Ashley was quiet, so I started by checking her heart and lungs. As I placed my dinosaur-decorated stethoscope on her chest, she let out a blood-curdling scream. I was able to examine for two breaths and noted that there was no obvious heart murmur before the scream.
As Ashley screamed, her father chuckled and said to me, “Don't worry, it's just that she has never seen a doctor like you!” My mind quickly filled with thoughts that grew out of years of prejudice and feelings of inferiority. I wondered, What has she never seen? A doctor with glasses, a short doctor, a clean-shaven doctor, a doctor with brown eyes, a doctor with black hair, a doctor with dark, brown skin? I finished my examination very quickly—because the rest of the exam received a loud response from Ashley—but I could tell I was severely distracted by the remark, which I perceived as racist. I excused myself.
Once I had developed an emotional scotoma, I returned to the room and examined Ashley again. This time she did not cry and I performed a complete exam. I had not missed anything the first time; she only had a viral illness. I did my usual education about fever-in-children with the parents. I finished my examination very quickly—because the rest of the exam received a loud response from Ashley—and I could tell I was severely distracted by the remark, which I perceived as racist. Ashley hugged me as she left.
Case 2 discussion
Looking back at the incident, I do not think Ashley's father knew my race or ethnicity. I believe that he profiled me on the basis of my general appearance, not because of racism as I had viscerally presumed. How can a physician who has been hurt by a patient's or (patient's relative's) offensive comment proceed and be sure that the patient gets appropriate and thorough care?
There are five approaches a physician might consider when faced with a similar situation:
1. The physician could assume the comment is racist and confront the patient/relative about the comment, but he or she should be aware that doing so may further ill feelings on both sides and ultimately compromise patient care.
2. The physician may choose to excuse himself or herself and find a new physician for the patient/family if possible, which may cause duplication of effort and delay in care.
3. The physician could discount the patient's illness and acuity as a defense mechanism (which benefits no one and may confirm biases), change the focus of the interaction to the insult, and compromise the patient's care.
4. The physician could be especially careful in the patient's assessment and workup, seeking reassurance that he or she did not miss anything and is not responding as in approach #3. Although this may involve unnecessary tests and discomfort for the patient, the physician may be greatly tempted because he or she may feel as if he or she is under a magnifying glass.
5. The physician could take a few moments to focus on the patient, who is the entire reason he or she is there—in my case, the adorable Ashley. Such focus may be difficult depending on the past hurts the episode evokes. It is important, however, for all physicians to learn how to recognize the effects of a strong emotional interaction and how to regain balance.
Physicians should be aware of their own prejudices and put them aside when dealing with patients. Making assumptions about patients based on their appearance, race, ethnicity, gender, socioeconomic status, or current state in life is unfair and dangerous. This is particularly challenging when the physician is a victim of racism, prejudice, or profiling based on appearance.
Jones5 offers a logical framework for three levels of racism, which could also apply to general appearance. Institutionalized racism involves parts of or a whole system and denies resources on the basis of race. There is no specific perpetrator, but many victims. Personally mediated racism, in contrast, involves a perpetrator and victim and incorporates prejudice and discrimination. Making assumptions about an individual on the basis of race is prejudice, but acting on these assumptions to deny societal resources and opportunities or to inflict harm is discrimination. Both institutionalized and personally mediated racism cross and affect many generations, making both types of racism inherited and generational. Internalized racism occurs when an individual of a defined racial group perceives and ultimately accepts feelings of inferiority and doubt in his or her abilities as a result of his or her personal history as a victim of personally mediated racism and/or institutionalized racism.
Ashley's father exhibited both prejudice and discrimination based not on race or ethnicity but on my general appearance, so that was a case of personally mediated racism. My internal response to the father's statement is an example of internalized racism.
Betancourt and Maina6 summarize an Institute of Medicine report which offers recommendations for academic health centers to address racial and ethnic disparities. Some are directed at patient care and others are targeted at the training of health care professionals. The report recommends increasing cross-cultural education and awareness of disparities. I believe that these recommendations should be expanded to include education that helps health care providers and trainees become cognizant of how their own prejudices and assumptions—based on race, ethnicity, and general appearance—can affect their approaches to patients and ultimately the care they render.