Some years ago, I went with my now-late mother to a consultation to discuss the results of an MRI scan of her shoulder, in which she had been experiencing extreme pain. The surgeon put the film up on the screen, and began to refer to the images in explaining his diagnosis. This physician and I had never met, and he knew nothing about me or my background, so it was unclear whether he was attempting to inform me, or to lord his putatively superior knowledge over me. Even more significant, however, was his addressing me, for whatever reason, instead of my mother, who was the patient. I stopped the doctor’s presentation in order to call my mother over so that she could look at the MRI scan as the surgeon was explaining, in fairly technical terms, the problems that the scan revealed.
Even though I’m not a physician, other fields of study have required me to earn a rather comprehensive knowledge of musculoskeletal anatomy. I was therefore able to not only translate the professional lingo for my mother, but also to show her on her own body what structures the surgeon was referencing; and also to show her on the MRI exactly what problem the surgery was intended to correct, even as the surgeon continued to direct his comments more to me than to my mother.
The surgery — in the vernacular, rotator cuff surgery — was successful. The procedure was arthroscopic, which meant that it was what’s known in the profession as minimally invasive, which also meant that rehab and recovery were relatively quick and uncomplicated. This was an undeniable testament to the surgeon’s skill. But it takes much more than technical knowledge and skill to make a “good doctor.” The field of biomedical ethics, customarily known as bioethics, contains a foundational precept called “respect for persons.” At its most basic, respect for persons in medicine means that given the choice between regarding a patient encounter as engaging a person with an illness versus engaging an illness attached to a patient, the former choice is the more worthwhile, the more efficacious, and the more ethical. Ignoring a patient who is right there in the room as a diagnosis and treatment plan are being discussed is the perfect example of the absence of respect for persons. It is unclear whether the reason for this was simple professional arrogance, or whether there might have been a racial component that added an extra measure of toxicity to the consultation. Either way, there is no acceptable reason to, in effect, deny someone their humanity.
In medical education and training, as well as in medical practice, there is an institution known as the “hidden curriculum.” In addition to learning the scientific underpinnings of medicine, physicians-in-training are expected to learn to make judgments about the “worthiness” of patients to receive the best that the physician and the healthcare system have to offer. This is perhaps most pronounced in transplant medicine, in which the vetting process for prospective organ transplant recipients is extensive, with most of the evaluation (i.e., judgment) being based upon factors such as home environment, lifestyle, the ability or willingness to understand and follow instructions, and how well the recipient is going to protect the precious resource that is the transplanted organ. Leaving aside the fact that the more precious resource is the life of the person the transplant is intended to save, this evaluative process, though less explicit in other medical specialties, is pervasive in medicine. Physicians are required to appeal to their clinical judgment — that is, technical training combined with what in some circles are considered to be inherently superior powers of observation — in making determinations regarding whether the patient deserves the full benefit of their time (the average amount of time in a physician-patient office visit is approximately 15 minutes), expertise and a place (or a bed) in the healthcare system.
Challenging the assumptions a physician might be inclined to make is a tricky business. For example, demonstrating knowledge about an area of medicine, such as musculoskeletal anatomy in a pre-surgical consultation, can be regarded as a challenge (or a threat) to a physician’s authority, power or both. The last thing a patient would want is for a physician to feel threatened. So, demonstrating prior knowledge of the issues at hand — particularly in a situation in which there’s not only a physician-patient power differential but also a sociopolitical power differential between a patient of color and a physician not-of-color — requires careful navigation of the physician-patient encounter. This is perhaps even more important when a patient’s family member serves as advocate and translator. The pre-surgical consultation referenced above might have gone quite differently if instead of telling my mother that she should see and hear what the surgeon had to say, I had told the surgeon directly that he should be speaking to her and not to me.
In some respects, this is an old story. Black people have always had to be circumspect in how they engage with the dominant culture. It’s possible to regard the hidden curriculum in medicine as a structural issue, which to some means that the system bears a greater burden than any individual does. But since personal responsibility is one of the dominant culture’s favorite catch phrases, it’s reasonable to point out that the choices that individuals make matter, especially among the powerful.
Future posts will deal more directly with the issues that Black males face in navigating health inequity and healthcare inequity. But the current post is meant to set the terms of certain aspects of future discussions. Whether advocating for oneself or on behalf of another, the essential issues remain the same.
Richard Robeson lives and teaches in the Piedmont Triad Area of North Carolina. In addition to credits as a musicianship educator, recording artist, and composer for theater, dance theater, and film, he has since the 1980s taught bioethics/medical humanities in medical and professional schools. His bioethics/medical humanities writing has been published in The Ethics of Sports Technologies and Human Enhancement (Routledge); The Journal of Law, Medicine and Ethics; The American Journal of Bioethics; and Healthcare, among others. Artistic works can be found/referenced at his website: www.gandivaus.com.
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