The "N" Word: A Reflection on Patient Care

The field of medicine has a long history of racial discrimination. Physicians have both intentionally and unintentionally perpetuated, propagated, and sustained racial stereotypes that have fueled common misconceptions about racial differences (1). As physicians and researchers have started to examine racial and ethnic health care disparities, the same degree of scrutiny has not been applied to examining the racial discrimination faced by health care providers (2). As I delved into the literature after my patient encounter, I found minimal guidance on ways to respond and react to overtly discriminatory patients and on appropriate next steps.

The American Medical Association (AMA) Principles of Medical Ethics provides little guidance on the complexity of the interaction between physicians and patients of different backgrounds beyond stating that "a physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical care" (3). This is a woefully inadequate sentiment in the context of a racially discriminatory medical system, a multitude of patients with racially discriminatory beliefs, and a country charged with racial strife. Looking beyond the AMA's Principles of Medical Ethics, the opinions of the AMA Council on Ethical and Judicial Affairs elaborate on the physician's right to choose but specifically indicate that the physician must not discriminate "against a prospective patient on the basis of race, gender, sexual orientation or gender identity, or other personal or social characteristics that are not clinically relevant to the individual's care" (4). This document goes further and describes limited situations in which a "physician may decline to establish a patient-physician relationship with a prospective patient, or provide specific care to an existing patient, in certain limited circumstances," including if the "individual is abusive or threatens the physician, staff, or other patients, unless the physician is legally required to provide emergency medical care" (4).

Yet what constitutes abuse? What constitutes a threat? The significant and traumatic history of the "N" word, which has been used to dehumanize persons of African descent, allows for a cogent argument that the mere use of this word directed toward an individual of African origin constitutes abusive behavior (5). The American Psychiatric Association's Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, unfortunately, does not provide further clarification, stating that "the doctor-patient relationship is such a vital factor in effective treatment of the patient that preservation of optimal conditions for development of a sound working relationship between a doctor and his or her patient should take precedence over all other considerations" (6).

But can a "sound working" doctor-patient relationship be forged between a physician with an understanding of the "N" word and a patient who uses it in a derogatory fashion? If the "act of revealing oneself fully to another and still being accepted" is the "major vehicle of therapeutic help," and if it "is an essential part of the therapeutic relationship to develop some kind of positive emotional experience between" the provider and the patient then "a sound working relationship" would be difficult to forge (7) in such case. Physicians are human, and human beings are subject to the effects of discrimination, including threat-related emotions and cognitions, which could prevent their ability to "inject warmth, enthusiasm, support, and empathic skepticism" into the patient-physician relationship (7, 8). A patient who is able to hide his or her racist beliefs would allow for a steady patient-physician relationship, minimize harm to staff, and facilitate a wider environment of healing. However, this would prevent relevant exploration of the racist beliefs. My patient, unfortunately, could not regulate the expression of his racist beliefs, which prompted consideration of the options available to address these beliefs in the acute setting.

An ethical analysis of dealing with racist patients suggests that regardless of a physician's decision to continue or to terminate care with a patient with racist views, "patients should be informed that hateful or racist speech is not allowed" (9). Yet, what if despite the pain elicited by the "N" word, I had been able to moderate my loathing of my patient in that moment? What if, in my capacity as a psychiatrist, I had leveraged this unique opportunity in a different way?

What if I had employed silence? The patient would not have felt reprimanded and would have left the encounter with the unreasonable belief that his use of the "N" word was condoned. He likely would have been able to better align with the team and further explore his traumatic experience with the team in the future. The implied acceptance of his language may have led to inadvertent negative consequences among staff. These staff, including the primary team, may have been less equipped to provide strict boundaries. They would be subject to the negative health consequences of discrimination and the more intangible experience of a system unwilling to confront the ramifications of institutionalized racism (5). My own distress would have increased as I grappled with the effects of my silence as a supposed advocate for equality.

What if I had simply terminated the consulting relationship? The patient would likely have been prevented from beginning the process of healing by sharing his traumatic experience. This may have prevented his future engagement with mental health services due to a negative experience in the hospital. This approach would have been unlikely to curb his use of the "N" word, which would have continued to negatively affect the primary team and staff.

What if I had encouraged my team to undertake an exploration of his language? Given my own inability to neutralize my emotional experience, I could have asked a team member to pursue open-ended questioning of the patient's use of racially discriminatory language. The patient may have been provided with an opportunity few others have provided him: to assess his own value system and beliefs about another's race. This pursuit could have led to insight for the patient and, at the very least, would have enabled him to continue to build rapport with the treatment team and hospital staff. Regardless of whether this would have elicited change in his behavior, the fact that these discussions would have occurred may have provided some reassurance to staff that attempts to minimize harm had been pursued.

I am content with my initial response: I set a clear boundary while validating the patient. I could have additionally invoked hospital policy and set another firm boundary, which required the patient to be "considerate of the rights of other patients," including "the right to be free from all forms of abuse or harassment" (10). As an advocate for addressing microaggressions in health care, I could not sit idly as an overt aggression was exercised. Despite this, his behavior may have only been modified within the confines of our hospital, and that also feels woefully inadequate.