By Jacquelyne Gaddy, MD, MS
While I am rather early in my career, I would consider myself seasoned in my experience of witnessing how implicit biases impact patient care. As a young African American female oncology fellow, I look at the world through a unique lens with the eyes of someone who is often the only African American in the room. My patients' eyes often light up as they are excited to see what they consider to be a familiar face when I enter their room. Considering my experience through medical school, residency, and now fellowship, I still found myself disappointed when I received a particular consult request while rotating on palliative medicine during my first year of fellowship.
I can recall returning the page; it was answered by a resident who gave an impressive detailed history of the patient’s hospital stay. From a diagnostic standpoint I felt that I had a good handle on the patient’s disease process. The resident explained to me that this woman in her 60s had recently been diagnosed with widespread head and neck cancer and he was hoping that I would be able to have a further conversation with her (and her family) regarding her goals of care. Initially, it seemed like a straightforward consult—until he went on to say that the encounter may be challenging as the patient was illiterate. I thought to myself that illiteracy may challenge my approach, but I also figured that I would be able to further explain certain details to her family. He quickly denied that assumption as he went on to inform me that the family lacked health literacy.
Upon ending our conversation, I sat with the details briefly, trying to determine the best approach for this patient and her family. Before going to the patient’s room, I completed a thorough chart review, as I would do for any other consult. I quickly noticed that in nearly each progress note it was documented that this woman was illiterate. I was uncertain as to how the conclusion was made but I trusted the validity. Once I considered myself prepared, I informed my attending and the rest of the team. We walked into the room and there I saw a cachectic African American woman lying in bed. She appeared slightly uncomfortable and somewhat scared. Her mass was visibly appreciated.
I introduced myself to my patient and had a brief conversation with her. It was immediately clear that her communication was limited by her mass, prompting her to inform me that I have further conversation with her family members, who were at her bedside. I will admit that I saw myself in this family, as they physically appeared like my relatives. As they began to speak, I was even further brought to a place of familiarity—their language had a distinct accent that is often appreciated in certain areas of the southern United States. While I am from Buffalo, NY, I grew up visiting my extended family in rural areas of North and South Carolina. Considering my experience, it was easy to understand them.
While leading the conversation, it became evident that the family in fact did not lack health literacy. The patient’s sister, who served as her primary caregiver, gave me a detailed summary of her understanding of her sister’s disease and the poor prognosis associated with it. She understood the role of hospice. The sister and other relatives participated in the discussion with many thoughtful questions regarding what to expect next and how they would return their loved one home. There was a brief discussion regarding the placement of a feeding tube, as that had been mentioned earlier in the hospital course. I reviewed the details of such a procedure and the low likelihood of it providing any benefit. These details were also understood and received by the family. The patient and her family returned home the next day with hospice services established.
Take Time to Dig Deeper
Considering the racial climate of the United States, I find it even more valuable at this time to reflect on our role as physicians to dedicate time to truly understand our patients. Our medical school and residency training provide us with the tools to understand complex disease processes with hopeful treatment options, but that is not the complete summary of our role as providers and educators. In order to effectively understand our patients as a whole, we must consider more than their actual disease process. We should encourage our trainees (medical students, residents, fellows) and colleagues to dig into the social history—further than, “How long did you smoke?” There is value to understanding how far the patient lives from the clinic, how the cost of parking is a burden, or how the lack of a support system at home impacts their care.
By diving into the details of our patient’s lives (outside of their diagnosis) I am hopeful that we will refrain from allowing our implicit biases to seep into our thoughts about a patient. It is easy to assume that because one is silent that they don’t want to engage in their care. It is easy to assume that lack of response is equivalent to lack of understanding. It is additionally easy to believe that when a patient does not look or speak like you that they may lack the same level of understanding that you possess. Easy, however, is not always right. By kneeling at the patient’s bedside, I quickly appreciated her fear, pain, and ultimate inability to actively discuss her goals of care considering her prominent neck mass. My patient (and her family) did, however, hear and understand me.
What if I instead chose to believe the claims in her chart about illiteracy and have only a short and impersonal goals-of-care conversation? What if I instead copied forward the illiteracy details in my consult note? As providers, it is important to listen to your colleagues as they hand off patient details and request consults, but it is equally (or even more) valuable to gain your own personal understanding of the patient. My openness allowed me to quickly understand that my patient was far from illiterate and that her sisters were beautiful women from a small town in North Carolina who cared deeply about their dying sister. Yes, they spoke differently than I may, but their understanding was far beyond what was relayed to me.
As a soon-to-be practicing attending, I found this encounter to be extremely valuable for endless reasons. I challenge myself and colleagues to take the time to listen closely, observe intentionally, and refrain from allowing implicit biases to seep into the care that is given to your patient. It is far too common that patients with less access to care or different skin color or unfamiliar language are assumed to not understand. Maybe it is in fact that we didn’t take the time to understand.
Take the time to know your patient beyond what is written in a chart. Write your own story, which may in fact correct what has been previously documented. Listen in a way that you would listen to your loved one. Document an encounter as you would describe a conversation with a relative. Educate your patients while also educating your colleagues.
Dr. Gaddy is a current second-year hematology/oncology fellow at the University of North Carolina at Chapel Hill. She completed her medical school training at Loyola University Chicago Stritch School of Medicine and her internal medicine training at Jacobs School of Medicine and Biomedical Sciences. Her primary research focus is on racial/ethnic disparities and improving health outcomes in the treatment of solid tumors. She is a 2012 recipient of the Medical Student Rotation for Underrepresented Populations and a 2019 recipient of the Resident Travel Award for Underrepresented Populations from Conquer Cancer, the ASCO Foundation. Disclosure.