A Problem Shared - Dealing with prejudice in practice

GPs must not let patients' attitudes or prejudices prevent them from providing good care.

THE PROBLEM

A middle-aged male patient whom you have seen a couple of times before makes a somewhat racist, joking comment about the Asian female patient you have just seen. What do you do?

DR RAJ THAKKAR'S VIEW

Your own feelings are important. It would be inappropriate to let your views interfere with the care of this patient. If your feelings are strong, discussing the comment with the patient might help to offload and restore the doctor-patient relationship. An alternative would be to treat the patient and discuss management of this patient's behaviour with your colleagues at a later date.

There is also the issue of this behaviour affecting other patients. The Asian patient might have heard the comment on her way out. It might be worth checking with reception if she mentioned it.

Discussing the comment with the patient might not be easy. You might want to leave it to the end of the consultation, after you have addressed the patient's medical concerns.

Consideration of sanctions is the next issue. Ideally, the patient should leave with the doctor-patient relationship intact, but the patient should be made aware that the behaviour is unwelcome in the practice. This is a difficult situation to manage because there is risk of conflict and damaging the doctor-patient relationship.

Nevertheless, discrimination has no place in general practice. My view is to objectively tackle the comment after you have dealt with the patient's medical concerns. To determine with clarity what the patient meant by the comment is the first step, followed by an explanation of why that behaviour is not acceptable. If the patient 're-offends', further action might be required.

- Dr Thakkar is a GP in Woodburn Green. He won the registrar prize in the GP Enterprise Awards 2004

DR TILLMANN JACOBI'S VIEW

In this scenario there are a number of questions, for example: how well do you know the patient, or is he completely new to you? What do you know about his age and background? Are there any relevant headings in the medical history, particularly neurological, psychiatric and cardiovascular conditions such as dementia, strokes or Tourette's syndrome? Is he specifically trying to test you, or is it something simply spoken straight from his mind?

You could challenge him straight away, particularly if you feel strongly about this issue and would find it almost unacceptable to treat him as if you had not heard his comment. Here you risk a complete diversion in the consultation. However, he would be the one who caused this diversion.

As a modern GP you are expected to take a neutral stand in society regarding extreme political or spiritual opinions, because discrimination directly compromises the level of care you are giving to particular individuals.

Be careful not to start lecturing him in any way, because this is likely to increase conflict and defensiveness on either side.

If his comment is racist, be clear about your duty to protect the other patient as well as our own integrity. You could mention the zero-tolerance policy for abuse in your practice and clarify that this applies to staff as well as anyone else on the premises. You could bring the case up in a significant event meeting or over a coffee break and discuss the most appropriate course of action with trainers and partners.

- Dr Jacobi is a salaried GP in York. He qualified as a GP in February 2005

DR VIBHORE PRASAD'S VIEW

I first presumed the patient is white. This might reveal my own prejudice.

Furthermore, your own ethnicity might play a part in this because I felt more offended by the comment because I am Asian.

Only by accepting prejudice can you eliminate it. The previous patient deserves the right to confidentiality and respect. The current patient might feel that you are over-reacting if you say you feel he is prejudiced because his comment was joking. By saying nothing you might look as if you agree with his views. How the consultation starts is important in establishing rapport. If spoilt, I might be unable to provide him with a good-quality service as his doctor.

I would like to register my feeling that the previous patient's consultation/interaction with me is between only her and me and, as her doctor, I must maintain her confidentiality.

I should not take offence to the extent that we cannot continue to have a fruitful encounter as doctor and patient.

- Dr Vibhore Prasad is a GP registrar in Banbury, Oxfordshire

LEARNING POINTS

What to do when a patient makes a racist comment

This is a difficult situation to manage because there is risk of conflict and damaging the doctor-patient relationship.

As a GP you are expected to have a neutral stance regarding political or spiritual opinions because discrimination could compromise the level of care you give your patients.

How the consultation starts is important in establishing rapport.

Objectively tackle the comment after you have dealt with the patient's medical concerns.

Establish if there are any medical history headings, particularly psychiatric, to explain the patient's behaviour.

Try to determine with clarity what the patient meant by the comment, followed by an explanation of why that behaviour is unacceptable.

If the patient re-offends, further action might be required.

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