AMA Journal of Ethics^®

The student was aghast. Pain, anger, doubt, and frustration intermingled within her. She was devastated and tearfully left the patient's room. I don't know what must have been going through the mother's mind at that time. Did she feel that she had successfully protected her child from some assault by a poorly educated black woman? Did she feel that the debased medical student would suddenly come to her senses and give up her study of medicine after such harshly delivered discouragement? Did she feel good about herself for having made another human being of a different race feel bad?

The medical student, who was a hard-working scholar and researcher, had performed wonderfully during her 4 years of medical school. Her university had historically accepted few African American students per class and there were even fewer minority faculty despite the fact that the medical center was in a predominantly minority community. Most of the hospital staff were African American as were the vast majority of the patients. In fact, the patient's mother was seeking to establish a protective circle of whiteness in a sea of cultural difference. The reality was that there was no affirmative action program in place at the medical school and that the student's scores and undergraduate performance allowed her to select from multiple offers from medical schools. She had done research as an undergraduate and spent all of her summers prior to medical school engaged in scholarly endeavor. She enjoyed her experience in pediatrics so much as a third-year medical student that she elected to do a subinternship in pediatrics during her fourth year and was ranked among the best students in her cohort. Her goal was to train to become a pediatric intensivist.

The student immediately reported the events of the early morning to her senior resident and asked what she should do for resident rounds. Her colleague suggested that she should describe the situation to the attending physician during teaching rounds and see what she recommended. Meanwhile, the remainder of the team, excluding its only African American, would examine the child during work rounds and prepare the progress note. They would also arrange for an intern to handle this patient in her place. After all, who would want to serve a patient who had so severely insulted them?

Life in a teaching hospital is often complicated by patient requests that the most senior member of the team perform the procedure or examination, but most understand that medical students and residents are an essential part of a university health care system. History-taking and non-invasive physical exams are generally well-tolerated for the relative inconvenience they bring to the inpatient experience. Some rightly think that the more minds weighing in on their problem, the better; and many enjoy the chance to help train the nation's emerging physician workforce. The mother did not seem to have a problem with the teaching hospital concept, because she did not prevent other physicians-in-training from examining her child. It was clear that the single overriding issue was race. Cultural intolerance was afoot here. During teaching rounds the situation was detailed for the attending physician.

What were the options for the attending? If she honored the mother's wish, she would have to exclude the fourth-year medical student from the team when examining and discussing this patient. If she invited the student into the room with the team and insisted that the she remain the primary contact with the parent, the attending would be negating the parent's request. A final option would be to explain the nature of the teaching hospital and the attending physician's responsibility to educate tuition-paying students and to offer to help the mother secure care at a different institution. Counterbalancing these options were the hospital's financial interest in caring for a well-insured patient, the potential disruption of the referral pattern if an unsatisfied patient were to complain to the referring physician, and the desire to comfort a fearful mother during the stressful period of her child's illness.

In this case, the attending physician chose to ask the fourth-year medical student to remain in the hallway while the rest of the team examined and discussed the patient's progress. The budding pediatric intensivist was completely devastated and sought recourse through the medical school. Fortunately, the situation was short-lived and the patient was soon discharged; however, the damage had been done. The humiliation, alienation, and pain were too intense for the student. In selecting a residency program, these events weighed heavily and caused the student to bypass her own university and complete a residency in pediatrics elsewhere. And what message was transmitted to her colleagues-in-training through their observations of the way she had been treated? Will they perpetuate the behavior exhibited by their teaching-attending physician or will they recognize the irrationality and pain associated with racism and act to confront it in the future?

Questions for Discussion

1. How should the attending physician have handled the situation in which a mother refused to allow an African American medical student to care for her child?
2. What core values are in conflict here?
3. What are appropriate expressions of and limits to patient preferences?
4. Is it acceptable for a patient to refuse care from a physician of a particular gender or from a physician who the patient thinks is too young or too old?