Everybody judges in the exam room

As a medical student, I am being taught not to judge patients. If a patient tells me that he has smoked cigarettes for forty years of his life despite the protests of his wife, I am supposed to nod my head understandingly without showing my inherent disapproval. If a patient tells me that she has given her husband genital herpes because she is cheating on him, I am not supposed to flinch. I agree with the heart of this teaching because it properly reflects the sacredness of a patient-doctor relationship. Patients share information with their doctors that they may not be able to share with anyone else, even their spouses. We do not want to repay our patients’ vulnerability with unsympathetic judgments. So how are we supposed to respond instead?

Our doctoring instructor at school, who teaches us the ins and outs of the doctor-patient relationship, tells us that he judges patients the minute they walk through the door. He believes judging is a critical part of the diagnostic and therapeutic process. His patient’s skin color matters — so does his or her age. Our doctoring instructor’s differential diagnosis could vary based on his patient’s weight thus he uses immediate judgments as vital components to his healthcare.

In agreement with this methodology, I am forced to question, “How are we supposed to judge and not judge someone at the same time?”

After all, we are humans too, and enter the profession with our own laundry list of issues and self-diagnoses. For example, if you are a doctor who, when growing up, had an alcoholic father who abused your mother, how are you supposed to not “judge” your alcoholic wife-beating patient?

While I do not have a discrete answer, I do know this: Judging has a very negative connotation these days but deep down inside, we all know that judging can be, and is often, morally neutral. What I mean is that we judge people everyday in order to help us make even the simplest decisions in our lives. I choose to be friends with someone because I have judged that he or she is a good person to be friends with. With the reality of judgmental commonplace in our every day lives, the focus of interest shifts to what we do after we have judged someone as the ultimate core of this investigation.

It is true that if an African-American male patient walks into my clinic, I cannot and will not ignore his ethnicity and gender in my medical judgment — for example, I should be aware of the fact that sickle cell anemia affects African-Americans more than any other ethnic group in the U.S. The real question becomes how I will treat him because of his ethnicity. Will I carry myself, converse, or administer health care any worse because of his size, gender, or profession? I certainly hope not.

As I continue my preparation in order to become a doctor, I hope to be a fair judge. It is only natural that I will indeed make judgments, but I want to strive to treat all patients with the respect they deserve even if I do not agree with their lifestyle. I will not be blind to someone’s skin color, but I hope to embrace it. Does judgment have a place in medicine? I believe it has to, but without leading to inequality.

Edward Chang is a medical student who blogs at ProspectiveDoctor. He can be reached on Twitter @ProspectiveDr.

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  • JR

    There is a difference between:

    1. Being judgemental (or prejudgmemental).
    2. Coming to a conclusion by examining all relevant evidence.

    Generally, a physician isn’t making moral judgments but evaluations of symptoms.

    Avoid creating arguments based on semantics. It’s like arguing “belief” in god and “belief” in vaccines because the same word, “belief” was used for both. One use of that word is referring to faith, one is referring to an evaluation based in evidence based science.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Agree with JR. Edward, we are supposed to take note of appearance, behavior, odor, etc, but not to discriminate in provision of medical services as a result.

  • Patient Kit

    I think I need you to define your terms. Having good judgment is not the same thing as being judgmental. At all. In fact, some would say they are opposites.

    • http://www.idealmedicalcare.org PamelaWibleMD

      Agree with Patient Kit as well.

  • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

    Many years ago a philosophy professor of mine made a point of distinguishing “prejudice” and “discrimination,” two words that were often interchanged at the time. Prejudice, literally pre-judging, is always suspect, and when applied to people is likely unethical. Discrimination, on the other hand, is when we take note of difference. This “taking note” is a cornerstone of human intelligence; it allows us to form theories about the world and operate meaningfully in it. Failure to take note of obvious differences between people may signal dementia or another neurological disorder. Choosing to do this voluntarily is a perfect example of throwing the baby out with the bathwater.

    Blinding oneself to data or observation in order to avoid prejudice is clearly a mistake. I think that was the point of the author’s post, and it’s a good distinction to make when learning to see patients.

  • Guest

    Hmm my better half is tiny, small boned, light colored, and every female in her family (all taller and some darker) has been on medication for osteoporosis. They are judging her rightly, as they should.
    Randy