ROCHESTER, Minn. — Recently, Dr. Nusheen Ameenuddin stepped into a skyway to grab a coffee just off the grounds of the Mayo Clinic. A staff pediatrician at Mayo who was educated and trained in the U.S., Ameenuddin is Indian by birth and a Muslim woman who wears a hijab. She was alone in the elevated hallway on that morning when a man approached her on a motorized scooter from the opposite direction.
“Don’t belong here,” he called as he passed.
“Part of me was like, ‘Did I really just hear that,’?” she said with a small laugh of disbelief, recalling the incident she subsequently shared on Twitter. Ameenuddin wasn’t wearing her ID at the time. In a town where doctors routinely wear badges on the sidewalk, she does not feel safe letting strangers see her name. But the remark recalled the earliest days of her medical training. Back in the early 2000s a caller received her name from an appointment scheduler, “then called back to ask if I was ‘one of those foreign physicians.” Then the caller asked for a new doctor.
You can reach the highest designations of medical training, it turns out, and still be engaged on the level of your race, religion, gender or ethnicity at the hands of some patients. They don’t necessarily tell you to leave the country. They just ask for a different doctor. In the past, bias-based incidents like these have provoked silences, leaving medical workers confused about how to proceed. Medicine is a culture trained to attend to patient needs, after all.
But the rising problem with bias incidents in medical settings harms employees, damages morale and exposes hospitals to legal liability for failing to address discrimination in the workplace. All of which is why Mayo has joined a growing movement within top-flight medical centers including Harvard, Penn State, The University of Chicago and others to develop formal policies for dealing with patient requests, comments and actions expressing racial, ethnic, cultural or gender bias.
“We need to be better upstanders than bystanders for our staff,” says Dr. Sharonne Hayes, co-author with Dr. Rahma Warsame of a recent paper in the AMA Journal of Ethics laying out the Clinic’s 5-Step Policy for Responding to Bias Incidents. The policy, which went into effect in 2017, was developed after anecdotal reports of bias-based requests for doctor characteristics, requests which in the absence of guidance often went granted.
The new policy provides a road map for all staff in the form of scripted questions and responses to bias-based requests, and it includes a formal mechanism for reporting incidents. It also includes limited exceptions to the policy in the case of medical crisis, prior trauma or requests that reflect cultural traditions.
“People see this and say ‘I’m shocked.’” says Hayes. “Well, I’m not shocked. I’m saddened, but it happens so frequently. Young people, Muslim people, brown people, young women, people with accents, they are all affected. Our senior white, male colleagues are kind of surprised and horrified when they learn about it, because it has never happened to them.”
As Dr. Natasha Arbelo-Ramos describes it, the typical request for a new doctor is transparently unrelated to the reasons given.
“It was two years ago, in 2017, and I was a first-year resident,’ says the chief resident in pediatrics. “I’m from Puerto Rico. I do have an accent. I look very Spanish. I was talking with a family, and the dad stopped me and said ‘I’m very sorry but I don’t understand what you are saying. I just want an American doctor.”
Arbelo-Ramos, for those who may be wondering, is soft-spoken and could host a radio news hour if she so desired. “I looked at him kind of stunned. I felt like it was extremely racist, because I knew he could understand me.”
Arbelo-Ramos took the father’s complaint to her supervisor, who told the father the request was not respectful. The father persisted in asking for a different doctor. “We just want to blend in,” is how Arbelo-Ramos describes her reaction. “We’re here to follow our dreams, to get ahead. You don’t want these kind of things to stop you from what you set out to do.”
It was also 2017 when Dr. Yaw Asmoa-Bonsu, then a first-year pediatric resident at Mayo, encountered an aggressive, hostile encounter with bigotry. After entering the room of a child being treated for serious illness, then briefly stepping away, he prepared to assist the attending physician only to be told that the child’s father was now in a rage. Asmoa-Bonsu,who trained in Ghana before arriving at Mayo, was informed that the child’s father was angrily accusing him of attempting to friend the man’s wife on Facebook.
“I check my Facebook once a year,” Asmoa-Bonsu says of the volatile charge. “On my birthday. He was saying ‘I am going to report you to administration and get you fired.’” As the supervising physician and father soon discovered, while an African citizen had indeed attempted to contact the man’s wife on social media, he had an entirely different name. “My name was on the whiteboard in the child’s room the whole time,” says Asmoa-Bonsu. “The doctor pointed at the board and asked the father ‘Did you even consider checking the names?’ It was all because I was the only black person on the team.”
“I was very sad,” he remembers now. “My attending doctor asked me if I wanted to go home but I stayed and finished my work. I had trained so long and struggled to get into a prestigious medical program. We had just moved into town. I was in my first year. Now this man was telling me ‘I am going to get you fired.’ Usually I don’t let things get to me. I know how racism works. But this was the first time someone was so verbally abusive.”
“The easy statements to spot are a racial epithet,” says Hayes. So-called microaggressions are harder. “It could be something as simple as ‘you are a pretty good doctor for a woman,’ or ‘you’re a pretty smart guy for a black person.’”
“One of the more common stories,” says Ameenuddin, “and one that I have experienced, is a patient’s relatives saying ‘Wow, I never heard one of them speak English so well.’ ... right there in front of you.”
“This is not a new problem but it is getting to be more prevalent.” Hayes said. She says she affirmed as much after she recently spoke to a room full of health care administrators from across the country. “I asked them, 'How many of you have seen an uptick in this kind of behavior?’ Almost every hand in the room went up.”
“I’m not sure if people are getting bolder,” says Warsame, “but I do know medicine is getting more diverse. Having this policy really creates a safety net. It’s unfortunate that it’s necessary but it’s great that it’s available.It really empowers employees, and creates an environment of mutual respect.”
“Patients come to us in the most vulnerable time of their life,” says Hayes. “We can show compassion to the fact that patients may not be at their best, that when they are sick, they may be frightened and the worst may come out. We need to care for them but we also need to care for our staff.”