Bias in the Clinical Setting

By Alyssa Cartwright

The pre-operative suite felt abnormally chilly that Tuesday morning. Or perhaps it was  the lack of hot coffee coursing through my body since I woke up too late to stop for my daily  Starbucks latte before arriving to my Anesthesiology rotation at 6am. Either way, I had to power  through because the team had a full day of surgeries ahead of us for which we needed to prepare. 

I began my pre-rounds like any other morning, popping in and out of various pre- operative bays to introduce myself to patients, chat with them for a bit, and grab them anything  they might need (warm blankets were a hot commodity that morning!) I was finally hitting my  stride when I stopped by Bay 19. I quickly scanned the chart and saw that the patient inside was  documented as a 46-year-old male presenting for hernia repair. As I entered the bay, I stood in  front of the bed as the elderly nurse continued talking with the patient and their visitor about how  the flow of the day will work, what to expect after the procedure, etcetera. 

As I listened to this conversation, I observed the body language of both the patient and  their visitor – they both seemed uncomfortable, beyond that expected of a person about to  undergo surgery. I quietly continued to listen to the interaction and quickly realized the reason  for their joint discomfort: the patient was a transgender woman and was being continually  misgendered by the nurse. While of course this is an uncomfortable situation to begin with,  matters were made worse when the nurse made the statement “okay gentlemen, and I use that  term very loosely, let’s get ready to go” with a tone of disdain in her voice. 

The patient and her partner visibly cringed at this comment and there was a tangible  sense of awkwardness in the air as the nurse left the bay. I took this opportunity to introduce  myself and sit down by the patient’s bed so we could chat. During my introduction, I ensured to  state my personal pronouns in hopes that the patient would feel comfortable enough sharing  theirs. This tactic seemed to work, as the patient sighed a breath of relief and introduced herself  along with her pronouns as well. I immediately apologized for any discomfort she or her partner  might have felt from the interaction with the nurse, and the patient quickly dismissed it, saying  she was “used to it”. 

I reflected on this encounter for a long time, growing more and more angry and deeply  saddened the more I thought about it. While it is important to take generational differences into  account, healthcare workers are tasked with the responsibility of prioritizing patient comfort and  safety above all else. While the patient’s pronouns were not documented in the chart (which is  an entire issue in and of itself), if this nurse had been paying closer attention to the tone of the  room, she would have realized that the patient was extremely uncomfortable during the  interaction and could have addressed it in the moment, thus likely rectifying any issue before it  escalated.

The patient feeling uncomfortable and likely unwelcome given the snarky comment made  by the nurse is entirely unacceptable, but what also concerned me deeply about this situation  was the possibility that patient safety could have been compromised. If a patient does not feel  that they can trust their healthcare team (whether it be for reasons of prejudice, bias, or anything  else), there is a substantial chance that they will not be forthcoming with information needed for  proper health management, which can in turn lead to a plethora of safety issues.

Although this encounter occurred several months ago, I find myself reflecting on it  almost daily in my clinical rotations. While thinking back on this experience recently, I asked  myself, “what interactions have I had with patients who made me uncomfortable?” I began to  think of patients I had seen in the hospital who were imprisoned for dangerous crimes and even  those who had extremist or aggressive political views. Then, a realization suddenly dawned on  me: not only is it imperative to address our judgments and biases against patients in terms of  their gender, sexual orientation, home life, or health history, but also regarding things patients  have done that we do not necessarily agree with morally, such as the aforementioned political  extremists or those with a criminal history. Now, before knocking on the door to see a new  patient, I have been actively reminding myself to mind my biases and do my absolute best to stay  open-minded and non-judgmental during the encounter no matter what, as that is our duty as  healthcare workers — to respect the humanity of each and every patient we see. Maintaining this  attitude and utilizing open and honest communication with our patients are some of the most  useful tools we have as healthcare workers to nurture trusting relationships and ensure that  patient comfort and safety are always being upheld.

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Alyssa Cartwright is a third-year medical student at FIU Herbert Wertheim College of Medicine in Miami, FL. She is currently pursuing her decade-long dream of becoming an Emergency Physician to serve her local community in their most difficult times.

Do You Know The Maharaja? The Art of Listening

By Brian Gross

I walk into the common room of the facility to find a man sitting in a chair hunched over a table. His face was covered by long strands of tangled white hair. He was intently scribbling notes into a book. I glimpsed at the notes to see wildly drawn symbols and disjointed sentences. His eyes were fixated on the writings. I tapped him on the shoulder, and he looked up and smiled. “Good morning”, he said. “Do you know who the maharaja is?” I stood there puzzled and told him I was not sure who that was. He then began to tell me about “his master, the maharaja” and all the teachings of peace and tranquility he instilled in himself. I listened intently, wondering the significance of this conversation. What did he want me to get out of this? Why is he talking about this person? The conversation continued until the point was exhausted, and yet he continued to state the same points repeatedly. It became clear that this “master” was an important figure in this person’s life. A point was reached when I could steer the conversation away from this topic. I thanked him for sharing about himself and introducing me to such an important person in his life. I then continued with the rest of the mental status exam.

When speaking with him he seemed calm and collected. His words came rapidly as he switched from one topic to the next, but he seemed level-headed. I then asked if I could read his notes. He agreed and handed me a pile of papers, strewn about in different directions. Swirling circles of green and red were superimposed on a backdrop of red numbers. Statements were scribbled in the margins reading “the green ball sits on the silver court”, “the children are being euthanized”, and a plethora of random legal statutes. It was clear that he was in the midst of psychosis. I finished my exam and told him I would see him again tomorrow. He thanked me for my time, and for listening and we went our separate ways. Me, back to the comfort of my apartment, and him back to his small one-window room.

When I got home, I thought about how a man who seemed manic yet collected, could internally be experiencing a psychotic break. How did he keep his internal thoughts from spilling out into his speech? I never would have guessed he was psychotic unless I asked to read his writings. How could I better understand his experience? With his psychosis, how could I build enough trust with this patient?

                                                            “The Maharaja”

I began to read up on the maharaja, his teachings, and practices. I learned more about meditation and yoga, and the peaceful tenants of the maharaja. The next day I arrived at the facility to once again find my patient hunched over his notebook, legal papers strewn about the table. I greet him and tell him I looked up his master. He smiled and began to talk about how much his teachings mean to him, how these tenants of peace and tranquility allow him to survive his “imprisonment”. We spent a little while talking about the teachings of the maharaja and the importance of meditation and yoga in the patient’s day to day life. I listened and learned. I discovered the needs of my patient, his interests, and his desires. This interaction with my patient seemed to change our relationship. I was no longer a student prodding and poking at him so that I could learn. We developed a partnership, one in which we began to understand each other and with this understanding, he began to trust me.

This partnership culminated on the last day in clinic. When I first met the patient, he was unmedicated and uninterested in treatment. While he was cooperative, he had little interest in following our recommendations. Begrudgingly, he began treatment in response to a court order, but we knew that he would require further pharmacological intervention for which he would have to provide informed consent. Instead of purely focusing on convincing him to start medication by discussing his symptoms and labs, I learned who he was as a person.

As we discussed further treatment options, I was shocked to hear the words uttered: “whatever you think is best for me”.  He explained that his acceptance was due to our connection, and I was honored to be given his trust. This experience will always serve as a reminder to learn about who my patients are as a whole. It reinforces the importance of learning about their lives, their passions, what made them the person they are today, and the person they hope to become. Despite the many pressures that the day-to-day work of medicine will bring, I hope I continue to remember the importance of listening to our patients, learning about them, and striving to build a strong therapeutic alliance built on partnership and trust.

Brian Gross is a fourth-year medical student at Florida International University (FIU). He is an aspiring psychiatrist, home-brewer, vinyl collector, and cinephile.