Be an upstander and not a bystander [PODCAST]

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“The incident bothered me all day and the following many days. I couldn’t quite put a finger on what it was and brushed it aside and stopped thinking about it. In the wake of recent events, it dawned upon me that it wasn’t the patient’s comments that bothered me. It was the fact that no one standing in the room witnessing the conversation stepped in. Not during the conversation, and not after. Considering I’ve worked with my colleagues every single day, and in the same place for the last 12 years, I felt strangely betrayed.

Stories like this happen every day and are sadly more common than we realized. There will always be racist, insensitive, inappropriate comments by people across life. Its how we react to them is what will shape our lives. Most individuals have asked how they can help. Well, start by being an upstander and not a bystander. That will mean the world to us, people of color, and immigrants.

And let’s start teaching and training students in medical school, nursing, and technical schools how to identify and stand up to inappropriate comments. It may take us a few generations to make seismic changes, but we must start now.”

Aasma Shaukat is a gastroenterologist and can reached on Twitter @aasmashaukatmd.

She shares her story and discusses her KevinMD article, “Be an upstander and not a bystander.”

This episode is sponsored by The Nuance Dragon Ambient eXperience (DAX). The Nuance DAX solution makes it possible to forget the tech-toggling and reduces documentation burdens no matter how or where care is being provided. 

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Aasma. She’s a gastroenterologist, and she wrote the KevinMD article “Be an upstander and not a bystander.” Aasma, welcome to the show.

Aasma Shaukat: Thank you so much for having me. It’s a pleasure.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Aasma Shaukat: Yes, absolutely. So I’m like many other people in your audience. I grew up in Pakistan and moved to the U.S. after medical school, and did my postgrad training here, also postgrad residency followed by fellowship. I have a master’s in epidemiology and biostatistics, and then I joined the faculty and rose through the ranks of academic life. I am a professor of medicine, and I do research in colon cancer.

I’ve lived in multiple different cities and have pretty much been here for the last 20 years, and I really feel like I’m part of the fabric of our landscape. I’m married, I have three young children, and I have a pretty well-settled life.

Kevin Pho: Excellent. And how is the pandemic affecting you professionally and personally?

Aasma Shaukat: The pandemic has been a challenge. We are considered health care workers and pretty much first line, and a lot of our work is outpatient endoscopy, which has been very, very slow or static. But it’s brought the challenges of telemedicine, as well as trying to get care to the ones who need it the most. These would be individuals who are disadvantaged, where they don’t have great internet connections to do telehealth with, or they have other issues such as hearing or visual impairments, or they really need to be seen in person.

So it’s been a challenge, but we’ve been lucky. Our hospitals had enough PPE, and we’ve slowly ramped things up, so people who were overdue for different clinical work, we’ve started to bring them in, and we’ll be at 100 percent capacity next month.

Kevin Pho: Excellent. So let’s talk about your KevinMD article, “Be an upstander and not a bystander.” Now, for those who haven’t read your article, can you walk my audience through it and share the story of why you decided to write it?

Aasma Shaukat: Absolutely. So over the 20 years that I’ve practiced medicine in this country, there have been different isolated incidents where you come across either colleagues or patients who make certain remarks that are inappropriate, and by and large, you learn to just ignore them and move on. But in the last few years, it’s become a lot more systematic and a lot more frequent, to where it’s becoming harder and harder to ignore these. Particularly, you know, we’re exposed to all kinds of patients, and we want to help them, so we have a very high level of tolerance. But at some point, it does make you wonder how long it will take for you to feel like you’re completely assimilated and as credible or as accepted as your white colleagues or people who were born and grew up in this country.

One particular incident really struck a chord with me, and that’s when I decided, you know, enough is enough. We should write these stories, because it’s not the one and only story for me, and I’m certainly not the only one this happens to. It’s about time that we start bringing attention to issues such as this, where everybody who doesn’t look or speak a certain way just doesn’t look like they fit in, but then they’re made to feel bad about it, and that’s where the problem comes. We should celebrate diversity, and we should obviously not pretend to be something we’re not, but we should also not put people down just because of the color of their skin or how they look, or their religion, their race, their sex, and a multitude of other factors. There’s been a movement abound in this country, and truly I feel like it’s at the heels of this. We in the health care workforce are pretty much the first line and exposed to a lot of this, and a lot of comments I decided to ignore, but this one I decided not to.

So the story goes like this. I do a lot of endoscopy in my profession, and this is outpatient elective endoscopy. I walk into a procedure room, and the patient is ready to be consented. This is a gentleman in his 60s. He’s white, he’s from St. Cloud, which is a smaller city in Minnesota, and he’s here for an endoscopy. I greet him just like I greet every other patient: “Hello, sir. My name is Dr. Shaukat. We’ll be doing your endoscopy today. How are you doing?” And then I go through the whole consent process, which is pretty standard for us. There are four other people in the room with me, and at this time, everybody’s paying attention to the consent process. So there is a nurse, a tech, and another tech in the room, and they’re all listening to this conversation.

I finish my consent, and I ask, “Do you have any questions for me?” And out of the blue, the patient says, “Where’s your burka?” For the audience, a burka is a complete covering that highly conservative Muslim women wear. That took me aback. I thought I misheard, so I said, “Excuse me, can you repeat that? Where’s your burka?” And then I was completely floored and taken aback, because I didn’t know where this question came from. I said, “Why would I have a burka?” “Don’t women like you,” he said, pointing to my face, “don’t women like you from your part of the world wear burkas? And shouldn’t they be staying at home?” That again felt extremely inappropriate, and it was clearly meant to be an insult or to put me down for unclear reasons.

Our health care system also doesn’t prepare us how to respond to these questions, so I felt very embarrassed and very uncomfortable, particularly because there were three other people watching me. So I said, “Well, we’re not here to talk about me. We’re here to talk about you and your procedure. Any questions about the procedure?” “No.” And then we proceeded to finish the procedure. It really shook me that I was really put in my place, so to speak, and I really felt like an outsider.

And what bothered me is that I’ve worked in this same endoscopy center for 14 years, pretty much after I finished my fellowship training, and these are individuals who literally have known me for that long. Nobody spoke up during this conversation. An appropriate response may have been, “Sir, that’s not a nice thing to say,” or “That’s not an appropriate thing to say to our provider.” And then, even afterwards, it would have meant the world to me if somebody had come up to me and said, “You know, we saw that exchange, and we were just as speechless, and I’m really sorry, but that shouldn’t have happened,” or something along those lines.

So it was a mixture of embarrassment, feeling very betrayed, and just feeling I didn’t fit in. It kind of burst my bubble of feeling that here I am, feeling that I’ve contributed meaningfully to this society. I’ve been a citizen for over 20 years, my husband is white, my children are biracial, and I live in a nice suburb with a great neighborhood, but here somebody just put me in my place in a few seconds. And that’s not the only time. There are a lot of other instances where this continues to happen, and that’s truly when I decided to write about it, instead of doing what I usually do, which is just keep quiet, be embarrassed about it, and move on, hoping that it doesn’t happen the next time around.

Kevin Pho: Now, after reflecting on this, did you talk to anyone in administration, perhaps, about these incidents?

Aasma Shaukat: Yes, I brought it up to our nurse manager and the leader of our section, and they were very sympathetic. They said this kind of stuff should not be happening, and what can we do? We should brainstorm together to educate our staff, maybe even educate our patients, and send the message loud and clear that we support all our health care workers, no matter what they look like or how they speak, or their race, religion, or sexual orientation. So we should send that message loud and clear, and what else can we do?

And that got me thinking about strategies to improve this situation. Some of the things that came to mind are that we need to start early. This needs to be part of the curriculum in high school, in college, in medical school, nursing school, and tech school. And then we need to craft these training programs for all of our staff on implicit bias, diversity, and also standing up when you see something, things like “When you see something, say something.” Along the same lines, this should be really formally taught and propagated.

And then I would even venture as far as saying it’s not OK just because our patients are vulnerable and they need the help. There need to be certain boundaries put in. I know certain hospitals have taken on policies such as putting up posters throughout the hospital saying racial intolerance is not encouraged here, or tolerated here, or checking patients, whether they’re inpatients or outpatients, if they say something downright insulting, or extremely rude, extremely sexist, misogynist, or anything that makes an employee feel disenfranchised.

Kevin Pho: You mentioned this earlier, so let’s say you observe an interaction of racial intolerance between a health care worker and a patient. Now, just to be clear, what should these colleagues be saying or doing?

Aasma Shaukat: Right. So the first thing is to check the person who’s making those comments, and that sometimes is enough to send a message and stop that behavior. This is something that I’m starting to do more and more, because as I round with, say, residents or trainees, sometimes I see remarks made to them from hostile patients or colleagues. The first thing to say is, “That’s not appropriate,” or “That wasn’t funny,” or “Did you really mean to say that? Could you please not say things like that?”

So the first thing is to just check them right in their place. I feel being an observer puts you in a position to be able to do that, rather than the interaction. It really helps the person who’s at the receiving end of those things, and that sometimes is enough. But we all just need to speak up for each other, and we just need to be upstanders for each other and set examples so that that behavior gets checked and hopefully doesn’t get repeated.

Kevin Pho: And of course, my next question: What if you are the recipient of inappropriate remarks from patients, especially if you’re an intern, resident, or medical student, or maybe even a junior attending? Sometimes it’s hard to speak up, especially if there are more senior clinicians in the room. So what kind of advice can you give them?

Aasma Shaukat: Absolutely bring it up to leadership. Often, and I’ve been guilty of this for many years, we get embarrassed. We feel we might be thought to be the root cause, that something we said might have provoked such behavior, and there’s just a lot of stigma in reporting these kinds of incidents. I think we need to be very vocal and go to our leadership and say, “This is what happened, and I would like for you to tell me how this would be remedied, and hopefully provide reassurance and also some concrete steps of how to not just mitigate this but prevent it from happening in the future.” So I would say be very vocal about it.

Kevin Pho: And at that moment, that clinician is the recipient of inappropriate remarks. Should the patient be checked at that moment, or should they wait and then report it later to leadership?

Aasma Shaukat: It might depend a bit on the circumstance, but if this is an outpatient encounter and you can pretty much tell what is behind the motivation for this, I think the patient should be checked right there and then: “Sir, what you said was very inappropriate,” or “Man, that was a very inappropriate remark.” Whether it’s directed towards you, or they’re talking about a colleague of yours, or a whole race category, or somebody else in general: “That was a very inappropriate remark,” or “That was a very racist remark. I just wanted to let you know that such remarks aren’t tolerated in this facility. Please, let’s just talk about your medical issues. That’s not a conversation I wish to have.”

Kevin Pho: We’re talking to Aasma Shaukat. She’s a gastroenterologist, and she wrote the KevinMD article “Be an upstander and not a bystander.” Ever since you told your story, what has the response been?

Aasma Shaukat: Overwhelmingly positive. All my colleagues have read the post, and thanks to its wide circulation and its reach, a lot of people have come across it. The response has been, “We had no idea this happens,” or “I feel really bad. I will always stand up for you,” or “Thank you so much for reminding us to stand up for each other, because it looks like we just don’t do it often enough.” So I think that was a very, very positive response.

I also got responses from younger trainees and students that say, “Thank you so much. We don’t feel empowered enough to bring this to attention, because we’re so low on the totem pole of hierarchy. It’s good to know that these things can be brought to light, because we have similar experiences.” A lot of individuals reached out with similar experiences they’ve had, where they’ve had remarks: “Oh, yes, I had something similar happen to me.” There are a lot of remarks out there.

But then there have also been a couple of individuals who wrote to me and actually tried to defend that behavior, and said, “Oh, the patient might have just been curious. You misunderstood, you misinterpreted. He might have just been curious where you were from, or maybe he was just nervous and trying to make light of the situation.” And that bothered me a little bit. Being right there, and being in this profession for 20 years, I think I’m a pretty good judge of when somebody has good intentions and truly is curious, versus when somebody’s truly saying things to put you down.

Fortunately, that was a minority of the reaction, but there are people willing to defend and stand up for this. Ignoring that, everybody else was overwhelmingly positive, and I think these are stories we need to get out there so we can truly start changing the narrative and changing the culture around this.

Kevin Pho: And my final question: Do you have a take-home message that you want to share with the KevinMD audience?

Aasma Shaukat: My message is for every immigrant, any person who doesn’t fit the standard mold of a place where they work or live: If you see something and it doesn’t sit right with you, speak up. Say something. Either challenge it right there and then, or bring it up later, but don’t sit with it, because, you know what, then that behavior just gets perpetuated. Also, there’s a lot of support out there, but unless we get our message out, we can’t really solicit that support and that help. And I’m very encouraged that this is what will cause the cultural change.

Kevin Pho: Well, thank you so much for sharing your story and insight, and thanks again for being on the show.

Aasma Shaukat: Thank you so much for having me.

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