Our team is nearing the end of our call day when the ER pages us with one last admission. The ER attending starts with an apology — “I’m sorry,” she sighs, “this patient is a handful. He is homeless, belligerent, has a significant psychiatric history. He came in with ocular trauma. The ophthalmology resident thinks he may need surgery.” One of the interns on the team is busy with a discharge, and the other is wrapping up another admission. So I grab a sheet of paper and head down to the ER.
There, I find Mr. Reyes standing at the edge of his stretcher, rummaging through a rucksack of his belongings with one hand and pushing into his cane with the other. He is unshaven and carries all his excess weight in his belly. I introduce myself and hold out my hand. He continues to rummage before looking up at me through his one good eye with a quizzical expression. The other eye is swollen shut.
“You Mexican?” he asks. I put my hand back down. It has become clear that he isn’t interested in formalities. A transporter arrives with a wheelchair to take him to his room.
“No,” I say, simply. “I’ll meet you up in your room.”
Working as a resident in a major city, I had noticed that patients were often curious but rarely concerned about my ethnicity or religion. So while I find Mr. Reyes’ question abrupt, I am not particularly surprised by it.
A few minutes later, I find him in his room, dressed in a hospital gown now and busy rolling his street clothes into a bundle. He seems to be learning to see the world through one eye — walking up close to the window at an angle to see the view, then moving his whole body around to survey the room. When he sees me at the door, he waves for me to come in and takes a seat on the bed.
“I want a private room,” he says first motioning to the second bed in the room. “Don’t give that bed to nobody.”
“I’m afraid that’s above my pay grade,” I say with a laugh. “But let’s talk about what happened to your eye?”
“I was attacked!” he exclaims loudly. “I was minding my own business when some idiot jabbed me with the end of his cane.”
From my review of his medical record, Mr. Reyes has a history of bipolar disorder, hypertension, COPD and had gotten into a fight at a homeless shelter. The ophthalmologists wanted a CT scan to visualize the optic nerve and canal. They were concerned about traumatic optic neuropathy. If there was compression of the optic nerve, surgical intervention would be necessary.
I review a list of Mr. Reyes’ home medications with him. He admits, without hesitation, that he has not been taking any of them for months. “I ran out,” he explains. “How do you expect me to keep track of those things?”
“So, you Mexican?” he asks again. I shake my head. “Italian?” I shake my head again, wondering how many guesses it will take before he gives up. “Arab?”
I give in. “I grew up in Jersey, but my parents are from Pakistan,” I say.
“Good. I hate those dirty Mexicans. And the Italians. And the Arabs. Me, I’m Cuban,” he says proudly.
I pause for a moment at the doorway when I hear this, trying to conjure a response. Though I am neither Mexican, Italian, or Arab, many of my colleagues are. Finding no appropriate way to respond, I simply keep walking. It is the end of a long day. It seems that it is the end of an even longer day for Mr. Reyes. I shake it off as a comment fueled by frustration and pain and don’t think about it again for the rest of the evening.
The next morning, I assign Ikemba, one of the interns on the team, to start following Mr. Reyes. I give Ikemba no warnings about what to expect. I am fairly convinced that Mr. Reyes will be more pleasant this morning after he’s had some rest.
An hour later, the team gathers to round. We start outside Mr. Reyes’ room. As Ikemba starts to tell Mr. Reyes’ story, Mr. Reyes emerges from his room and declares: “I don’t want to be seen by that black doctor,” gesturing towards Ikemba with his cane, then starts to lumber down the hallway without awaiting a response. The attending shakes his head. I watch Mr. Reyes disappear down the hallway. Ikemba finishes his presentation. Mr. Reyes’ does not return to his room, so we move on.
From a flicker that began the evening before, I start to build a great, burning, self-righteous anger towards Mr. Reyes as we progress through the remainder of our rounds. I had wanted to like Mr. Reyes and wanted him to like me. After all, being well-liked by our patients is a marker of success and the sign of a good physician, isn’t it? But Ikemba is part of my team. It is my job to build his confidence and to ensure that he feels comfortable at work.
Later, I apologize to Ikemba — but sheepishly, because I know that an apology is just a gesture and not a solution. Later, I tell Mr. Reyes’ that Ikemba is his primary physician and that I will not re-assign his care to another intern. Mr. Reyes’ does not protest. He simply asks for pain medication. It is as if he doesn’t remember the incident from this morning. Anger melts to confusion.
Mr. Reyes, I know, is in a desperate position. All patients are. They are subject to what their doctors prescribe. We dictate what they can eat, how often they will have their blood drawn, and where they can go within the hospital. Physicians, too, are relying on their patients. How our patients respond to us builds us up or breaks us down. Some of our patients make us feel appreciated and respected while others make us feel incompetent and unworthy.
Despite the power differentials, we still want to be on the same side of the struggle. Sometimes physicians pretend that pain or mental illness is an excuse for racism. Sometimes patients pretend long hours and busy days are an excuse for lack of communication or compassion. But other times, we put the excuses aside, and the fire inside is kindled. I still don’t know how best to respond the next time that fire builds — let it burn, put it out, exit the building?
Sadaf Qureshi is an internal medicine resident.
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