When I think about how doctors respond to patients who are labeled "undesirable" for whatever reason – for being homeless or drug-addicted or mentally ill or obese or malodorous – I try to make the analogy to physical discomforts that arise in the medical setting. Over the years, I've tugged off socks with lives of their own. I've changed dressings on putrid, oozing wounds. I've encountered maggots, roaches, semen, and diarrhea during physical examinations. I've felt close to vomiting many times – I'm as squeamish as the next person. I can't control my physical reactions, as I can't control some of my emotional ones. But I can endeavor to control what I do with them. With enough focus, I can tame my outer behavior.
But is that enough? Even if I hide how I feel when I am uncomfortable with a patient, my feelings still may influence how I communicate in ways that could result in poorer medical care. This is a genuine fear of mine. Will my unconscious – or conscious – biases send signals of disrespect no matter how hard I try to corral my visible reactions? Will I drive these patients away from medical care, even when these patients are often the ones who need care the most?
Modifying our external behavior and how we communicate is clearly important, but I believe we in the medical profession have a duty to work to change our inner landscapes as well. It's a tall order, I realize, but if we wish to claim the high mantle of professionalism, we need to at least be actively attempting to challenge our gut feelings. The first step is to own up: doctors and nurses need to be honest about biased feelings, however distasteful and awkward this process may be. We need to catch ourselves in the act of jumping to a conclusion, to notice that we're doing it, and then to question ourselves about the conclusions. We need to talk with our colleagues about biases in our practice to figure out where we might have blind spots. Perfection will never be achieved, but that shouldn't be an excuse to resign ourselves to the status quo. The very act of paying attention, of attempting to notice our shortcomings, is how any change begins.
Another approach, to borrow a technique from behavioural psychology, is to "act as if." If a doctor can act as if an obese, or a smelly, or an irritating, or an alcoholic patient doesn't bother her, in time the uncomfortable feelings may begin to lessen. It's a bit like smiling when you feel sad – weird at first but then you grudgingly start to feel better. Pressing yourself to go against the grain is by nature an awkward action. But, in time, it can influence how you feel, in this case by allowing the doctor to get to know the patient better. Again, this may seem like window dressing, and if that's the only thing a doctor attempts, it will indeed amount to just that. But if it's part of a genuine eff ort to recalibrate how you feel and act in situations in which you might be biased, it will likely chip away at those biases.
And even if the changes are only external at first, a doctor's behavior serves as a model to the students, interns, and medical staff around him. The benefits of setting the behavioural tone, even if not (yet) fully heartfelt, cannot be underestimated.
Joan Noonan was a nurse in our clinic when I started as an attending physician at Bellevue, and even she would refer to herself as an old-school nurse. She proudly wore her nursing school pin on her white coat and still treasured her nursing cap, though she joked that if she wore it to work most of the younger staff would think she was sporting a coffee filter on her head. Ms. Noonan was a nurse extraordinaire, and what stood out to me was her impeccable reverence for each and every patient. She referred to every male patient as a gentleman. She could have the most disheveled, smelly, obstreperous alcoholic ranting in her exam room and she would never utter a disparaging word. "There's a gentleman in my room who might need a little extra medical attention," she would say calmly to one of the doctors. "Do you think you might be able to pop in for a minute?" Her tone of voice was always exquisitely respectful, and it would be identical whether the patient was one of the guys who hung out near the homeless shelter on First Avenue or the president of the United States, for whom Bellevue is the designated hospital should something untoward happen to our head of state while visiting New York City. Her attitude was genuine through and through, and the effect of her behavior on others was remarkable. You could be the most raving misanthrope on the staff and you'd find yourself inexplicably rising to her level of civility.
Respectful behaviour is contagious, so even if your inner emotions haven't quite caught up yet, the actions you exhibit will inform those around you, especially if the attempt is genuine and not just a masquerade. Your subconscious will eventually be prodded along.
Excerpted from What Patients Say, What Doctors Hear by Danielle Ofri, MD (Beacon Press, 2017). Reprinted with permission from Beacon Press.