Intolerance Will Not Be Tolerated
“Those people… the problems of this country start with those people. Send ’em all away is what I say! Round ’em up and get ’em outta here!” Her face was scrunched up, cheeks aflame, and she was practically spitting. My patient’s demeanor had transformed from unpleasantly dour to frighteningly enraged in less than ten seconds.
Her ranting continued despite my soft murmurs of “Ooookay. Let’s not get distracted from the purpose of your visit. Let’s stay focused now…”
She had long suffered from mental illness, but when her ranting turned uglier and frankly bigoted, I couldn’t consider her psychiatric diagnosis an excuse. I felt my hackles rising, though I kept my voice low and tried to calm her. She didn’t stop, and she kept railing against “those people”, gesturing wildly in the air, almost rising from her chair.
So I actually slapped my hand down on my desk as I rose my voice:
“Enough! That’s enough. This is no place for that kind of talk. You are here to discuss your health, and that is what we will focus on. Now, let’s get back to the reason for your visit.”
My patient stopped and melted back into the chair, arms folded across her chest, subdued, for the moment.
It doesn’t even matter who “those people” were. Bigotry, racism, intolerance… It’s all the same. It’s anger and hate, plain and simple. “Those people” is just an excuse for spewing pent-up emotion out like nasty vomit. And I wasn’t going to allow that in my office.
It’s harder to know what to say when the spewing is subtle. Sometimes a patient makes an underhanded comment about “those people”, a quiet and unexpected emotional deposit that I usually end up ignoring or working around, as if they had casually pooped out a smelly little turd in my exam room. The problem is, it fouls up my whole day.
I wonder what other providers do when confronted by bigotry, racism, intolerance, hate… When do people speak up, and what do you say?
I often play dumb. “‘Those people’? You mean Americans?” If goaded more, “Americans who don’t look like you?” I make it clear that my white skin does not mean I align with their bigotry or racist spew — most of the time they are white.
I like it- but I wonder if that response would trigger more emotion and potential violence (at least in patients like this)
I don’t try to shut down ranting in people who are mentally ill; I sometimes say “I can’t help you if you keep yelling” but I don’t say anything about the content. In others…I try hard not to engage. Every now and then I get hooked, though, like the long-time patient of mine who said Barack Obama wasn’t an American citizen during the 2008 campaign.
Jay I often stay quiet as well, especially if the patient is calm. But I wonder if that’s not always correct. Got to read that NEJM article another commenter mentioned
I will! CME from blogging. I love it.
Pretty much what you did.
One of the things that is upsetting to me in that type of situation is that it’s clearly an expression of bigotry that at least some people still feel but don’t articulate. In other words, it’s not random, it’s rooted in history. This person is saying it out loud because she is mentally ill, but it reflects a more common sentiment. (If she hated short people, say, it would more bizarre then upsetting.) My husband and I are not the same race, and while I’m pretty confident that most people around me are genuinely comfortable with that, it kind of threw me when a mentally ill homeless woman approached me and angrily whispered horrible things about my husband, and me for being with him (we were holding hands). Trump’s presidential race is so freaky because now, you don’t even have to be mentally ill to get a pass.
Thanks Lara, it was exactly that- the shocking and very scary open expression of racism and bigotry we are witnessing- that prompted her outburst and my post…
“Dealing with Racist Patients”, NEJM 2016; 374:708. What you did was appropriate. A combination of assess the patient medically and mentally/emotionally, limit unacceptable conduct, and accommodate but always keep your own feelings in mind. (If she had made you unacceptably uncomfortable, it’s perfectly reasonable to try to transfer care to someone else.)
Ooh I’m printing the article out now to read later thanks!!