{"id":46646,"date":"2020-02-13T15:07:20","date_gmt":"2020-02-13T14:07:20","guid":{"rendered":"https:\/\/blogs.bmj.com\/bmj\/?p=46646"},"modified":"2020-02-25T11:30:15","modified_gmt":"2020-02-25T10:30:15","slug":"roger-kline-what-if-a-patient-wants-to-choose-the-ethnicity-of-their-doctor","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/bmj\/2020\/02\/13\/roger-kline-what-if-a-patient-wants-to-choose-the-ethnicity-of-their-doctor\/","title":{"rendered":"Roger Kline: What if a patient wants to choose the ethnicity of their doctor?"},"content":{"rendered":"

Last autumn trauma and orthopaedic surgeon Radhakrishna Shanbhag shared his experience of being racially abused by patients during his 27 years working in the NHS<\/a><\/span>. One particular incident, when a patient requested a white doctor instead of him, left him feeling \u201cdevastated.\u201d He added that he had not directly refused the patient\u2019s request as he had been unsure whether he would have had his employer\u2019s support in doing so.\u00a0<\/span><\/p>\n

In response to extensive publicity, Secretary of State for Health and Social Care Matt Hancock initially said instances of racial discrimination against staff must be “properly managed individually”, a flawed approach that meant cases would be managed in a piecemeal manner with the onus of initially challenging such requests left to individual staff or managers. To his credit, Matt Hancock\u2019s view then changed and he wrote to all NHS staff insisting doctors should simply answer “no” if a patient requests a white doctor and should always feel confident their managers would support them, since \u201cthis sort of abuse is unacceptable and we will not tolerate it.”<\/span><\/p>\n

Abuse of doctors and other healthcare staff form ethnic minorities is not new. ITV reported that racist attacks against staff in the NHS rose from 589 in 2013 to 1,448 in 2018 while medical students report harassment, including racial harassment, from patients<\/a><\/span>. More generally 28% of NHS staff<\/a> as a whole reported being bullied, harassed or abused by patients, service users, relatives and the public last year.\u00a0<\/span><\/p>\n

Shanbhag\u2019s case is not unique.\u00a0 Last year Glasgow GP Punam Krishan described how a patient <\/span>saw her in reception and then asked for an appointment, but not with an Asian doctor. The practice receptionist said: \u201cShe\u2019s Scottish.\u201d The patient replied: \u201cShe doesn\u2019t look Scottish\u201d, to which her receptionist asked: \u201cWhat do Scottish people look like?\u201d Silence followed and eventually an appointment card was taken.<\/span><\/p>\n

Six years ago Nadeem Moghal<\/a><\/span>\u00a0described how parents in his hospital said they only wanted white British doctors to care for their child. The local clinical director agreed that because of the clinical need of the patient, the hospital would uphold the parents’ request. That decision was eventually overturned, but only after a board level inquiry which the parents ultimately accepted.<\/span><\/p>\n

Matt Hancock\u2019s letter to NHS staff and employers states \u201cno one is entitled to choose the\u00a0colour\u00a0of the skin of the person giving [them] healthcare\u201d explaining that \u201cstaff of all backgrounds should rightfully expect to work in an NHS that exhibits a healthy, inclusive, and compassionate culture\u201d.<\/span><\/p>\n

So how should doctors and other NHS staff respond? What is the appropriate balance between patient choice, NHS values and discrimination law? What about potentially harder areas, for example: if insisting the patient cannot choose the ethnicity of their doctor risks harm to the patient? What if the patient points out patients can ask for a female or male doctor? What if the patient is mentally impaired and incapable of rational explanation at that moment in time?\u00a0<\/span><\/p>\n

I suggest six principles.<\/span><\/p>\n

First, there is no good clinical reason for choosing a white doctor rather than a doctor from an ethnic minority (or the reverse). Since there is no evidence that minority ethnic doctors as a whole provide inferior care compared to white doctors, it is difficult to imagine any motive other than a discriminatory one.\u00a0 Doctors in the UK and elsewhere have described how extraordinarily distressing such demands are, especially since they may well experience race discrimination<\/a> in the rest of their working lives. <\/span>Moreover conceding such a request might leave an employer open to a race discrimination claim.\u00a0<\/span><\/p>\n

Second, while there might be circumstances where it is entirely appropriate for a patient to request a female or male doctor\u2014such as the intimate nature of the examination, personal experiences such as a history of trauma, safety, trust and gaining more compliance from women for particular types of treatments such as cervical smears\u2014these are clinical reasons and ones which would not be offensive or undermining to other doctors.\u00a0<\/span><\/p>\n

Third, some patients might not be able to give reasoned requests, where<\/span> demanding a white clinician might be an expression of an underlying disorder. In such cases, doctors and the relevant team would usually be able to distinguish between racist behaviour and those whose behaviour is the expression of underlying pathology. There should be no tolerance for the former, but clinicians may need sensitivity in responding to the latter. If an underlying pathology is the reason that should be discussed with the clinician and possibly relatives. Any possible (and very rare) exceptions must bear in mind Hancock\u2019s advice, since they can easily reinforce racism, demoralise staff and risk the impact of stereotype threat with resultant clinician anxiety.\u00a0<\/span><\/p>\n

Fourth, there might be urgent situations where clinicians agree that a refusal to provide choice risks serious harm. The default response should again be to refuse such a request. Any decision to provide <\/span>emergency treatment should not include any further treatment where a racist request continues. As one trust put it<\/a> \u201c<\/span>They will still receive emergency treatment at A&E if needed, but for anything else they will have to go elsewhere.\u201d<\/span><\/p>\n

Fifth, the same principles should apply to all staff in all settings\u2014GP practices, social care employers, and private healthcare providers seeking NHS work.\u00a0<\/span><\/p>\n

Sixth, this policy must be embedded in healthcare training and in guidance from professional regulators.<\/span><\/p>\n

The BMA\u2019s call for third party harassment protections to be reintroduced into the Equality Act could helpfully make employers liable if they fail to take reasonable steps to protect staff from such harassment by third parties including patients.<\/span><\/p>\n

Experience suggests that when it is made clear that patients cannot choose the ethnicity of their clinician, few patients challenge the policy. But some may, so receptionists and others at first point of contact need clarity and support.<\/span><\/p>\n

The default position should be that patients do not choose the ethnicity of their clinician and employers should make that crystal clear. Anything else is a very slippery slope.<\/span><\/p>\n

 <\/p>\n

\"\"<\/a>Roger\u00a0Kline<\/strong> is research fellow at Middlesex University Business School. He was the author of \u201cThe Snowy White Peaks of the NHS\u201d\u00a0(2014), and co-author of\u00a0\u201cThe Price of Fear\u201d (2018) on the cost of bullying in the NHS and co-author of \u201cFair to Refer\u201d (2019) on disproportionate referrals of some groups of doctors to the General Medical Council.<\/em><\/p>\n

Competing interests<\/strong>: None declared<\/em><\/p>\n

He tweets at @rogerkline<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

Last autumn trauma and orthopaedic surgeon Radhakrishna Shanbhag shared his experience of being racially abused by patients during his 27 years working in the NHS. One particular incident, when a […]<\/p>\n

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