Medicine Nonfiction Observations Reflection Systems

What Doctors Look Like.

I don’t remember her name, but I do remember her light brown hair, the simple nose ring that looped out of her left nostril, and the calm and centered presence she had with patients. She came across as unassuming, professional, and caring. We were both in medical school, though she was two years behind me. I admired how she treated people.

I don’t remember his name, but I do remember that he worked as a nephrologist (kidney specialist). He had a slight paunch and frequently wore dress shirts with short sleeves. The knots of his neckties were always loose. Students regarded him as an excellent teacher who revealed the mysteries of the kidney with tireless enthusiasm.

The nephrologist and I, among others, taught a course for junior medical students. Someone praised the bedside manner of this calm and centered medical student. The nephrologist interjected, “That might be true, but she doesn’t look professional. It’s the nose ring. Physicians shouldn’t have nose rings.”

I didn’t say anything in response. He was still an attending physician and I was just a medical student. His comment struck me: Did it really matter what doctors look like?

I have thought about that snippet over the years. Did he ever give her that feedback ? If he did, how did she take it? Did anyone else find his remark curious? Did any of the other attending physicians disagree with him? If they did, why didn’t they speak up?

After I became an attending physician and navigated ongoing perceptions of what I “should” look like, more questions have come to mind:

What if the medical student was a white male and had a nose ring? Would the nephrologist have made that comment? (Probably?)

What if the medical student was a stellar student and demonstrated clinical excellence? (My impression is that she did well in her coursework and that the comment about her nose ring was in the vein of, “If only she didn’t have the nose ring….”)

What if the medical student wore the nose ring for cultural reasons? Would that have mattered to the nephrologist?

What if the nephrologist learned that certain populations of patients were more likely to trust her than with him because of the nose ring?

What did the nephrologist think doctors should look like? (Clearly, he did not think they should wear nose rings.) How did he learn what doctors should look like? Who determined the definition of “professional” in the world of medicine?

Did it really matter what doctors look like? To medical students, of course it did. When we started our clinical rotations, we saw the attire of resident and attending physicians: Think Banana Republic or J. Crew, with the requisite long white coat on top. So what did we all do? We started shopping for “professional clothes”, except few of us had the money to buy stuff from Banana Republic or J. Crew. We cobbled together outfits from shops we could afford.

The pressure to conform, however, went beyond what we wore. There was only one female trauma surgeon who worked with medical students and, while students spoke well of her, resident physicians sometimes remarked that she was “too emotional”. During operations, male surgery fellows told female medical students, “You should feel this lung now, since you’re probably going to go into pediatrics or family practice.” Many of the attending physicians were heterosexual white males. Those of us who were not—men of color, women with or without nose rings, those who identified as LGBTQ—navigated how to conform to the values and behaviors of heterosexual white males, such as the nephrologist. Though some of these values and behaviors have no clinical relevance (e.g., wearing a nose ring does not affect how a physician washes her hands, gathers a history, or conducts a physical exam), they do affect how one goes through medical training. If enough attending physicians make comments about the nose ring, you might stop wearing it, even though the nose ring is something you value as a person.

What do you do, though, when the issue isn’t a nose ring, but your skin color? sex? accent? sexual orientation? culture?

When surveying the community, many people comment that they feel more comfortable working with health care professionals who look like and share the same experiences as them. Many women, for example, prefer to work with female gynecologists. People who speak languages other than English often feel more comfortable working with physicians who also speak the same language. Americans who are not white often comment that it is often easier to talk with non-white physicians about health concerns.

People with tattoos and nose rings may find it easier to talk with a physician with a nose ring. If the goal is to help keep people healthy and living the lives they want to lead, is it fair to say that nose rings are unprofessional? If the physician with a nose ring is able to connect with her patients and thus serves her community, should we indoctrinate her with the idea that nose rings are unprofessional?

Out of habit I still wear slacks and dress shirts when I see patients. I was trained that I should dress a certain way to both show respect to my patients and demonstrate that I am a professional.

The only time I did not routinely dress in slacks and dress shirts was during my time doing outreach to people who were sleeping outside. Part of this was due to function—it’s much easier to jump over puddles and slide past chainlink fences in jeans and a sweatshirt—but part of this was also because a doctorly outfit was often a liability in these settings.

How would you react if, while eating lunch outside, someone wearing a white coat and a stethoscope around her neck came up to you and asked, “Hi. How are you doing? Are you okay?”

Feedback I often received throughout my medical training (and continue to receive now) is that I do not speak up enough during rounds and related meetings.[1. Even though this post is over one thousand words, it’s true: I actually don’t talk much when working.] My seeming reticence partly reflects my introversion; it also reflects Chinese Confucian values. Medicine has trained me to talk more. I will never know if my taciturn tendencies have caused more problems for my patients (I hope not), though we all appreciate someone who is willing to listen.

And while I am sure that the nephrologist would have disapproved of unnatural hair colors, I can’t count the number of times vulnerable people with significant psychiatric symptoms were willing to talk to me simply because of my locks of curious color. This holds true even for people without any psychiatric symptoms.

I trust that the medical student who wore the nose ring has become a fantastic physician. I wonder if she still wears a nose ring. I hope she still does.

One way we recognize physicians is by their white coats. The rest of it—sex, skin color, accents, nose rings, tattoos, hair color, age, height, weight, etc.—shouldn’t matter.

Consult-Liaison Informal-curriculum Lessons Medicine

You Don’t Have to Like Everyone.

You don’t have to like everyone under your care. And you probably won’t, which is okay.

Own how you feel. If you insist on telling yourself that you should like someone when, in fact, you don’t, it will come out in other ways: The tone of your voice, the expressions on your face, the way you position your body.

There might completely understandable reasons why you don’t like the person under your care. Maybe he never seems to hear what you say. Maybe he doesn’t follow any of your recommendations, but he blames you for lack of healing. Maybe he expresses opinions you find offensive. Maybe he calls you racial slurs. Maybe he’s thrown things at you. Maybe he threatens to rape you. Maybe he’s told you that he will kill you and your family.

People do things like that for reasons that make complete sense to them. You may disagree with or misunderstand their reasons, but despite that, they are still people. Even though you may dislike some people under your care, you must still recognize that they are still human beings. The moment you refuse to recognize the humanity of the other person, you are at risk of inflicting violence upon them. Violence can manifest in many ways, including neglect.

First, do no harm.

It is possible to dislike someone and do no harm.

When we don’t like someone, it is much easier to assign blame entirely to the other person (e.g., “He’s an annoying @$$hole”). While it is possible that the problem has nothing to do with you and everything to do with the other person, that doesn’t change the fact that you cannot control other people. You can’t make someone less of an @$$hole. You, however, can make yourself view the situation in a different perspective.

Own how you feel. Let’s say he is, in fact, an @$$hole—something you cannot change. What if you focused instead on yourself?

“I really don’t like him. I feel dread whenever I have to see him.”

The reasons behind your dread make complete sense to you. When you acknowledge your dread and dislike to yourself, you give yourself more options as to how to proceed. You now have more control over the situation.

When you don’t like someone who is under your care and you acknowledge this, you can:

  • get support from your trusted colleagues. You can tell them how much you don’t want to see this person, how anxious and annoyed you feel about having to do this, and how much you don’t like this person. Get it out of your system ahead of time so you can be the professional you want to be when you actually see this person.
  • activate your internal coach. You can take some deep breaths and say a silent prayer before the interaction begins. You can rehearse some evacuation plans in case things start to run off the rails. Your internal coach can recruit your internal cheerleaders afterwards if the conversation goes well.
  • pause and remind yourself of your purpose. Your job does not include judging or shaming the person under your care. Your job isn’t to like the person under your care. Your job is to help the individual improve his health. Sometimes the people you care for have terrible life circumstances that contribute to the behaviors that you don’t like.
  • ask a colleague to see the individual so you don’t have to. Sometimes it is clear that the clinical relationship won’t work out at this time. We can’t be effective with 100% of the people we see (though we can try). Sometimes, the best way we can help the people under our care is to remove them from our care. (Sometimes, though, this isn’t an option.)

It’s often helpful to focus on the behaviors of an individual. When you focus on behaviors, you are more likely to remember and respect the person’s humanity. This keeps us professional and kind, even if we aren’t warm and smiling.

Indeed, he may do things that you don’t like… but he may also do things that you do like. And when we offer genuine thanks to people when they do things we like (e.g., “Thanks for your patience while I was asking you all of those personal questions,” “Thanks for summarizing your story quickly for me,” “Thanks for not calling me names today”[1. I have actually said, “Thanks for not calling me names today!” to people under my care and, no joke, the vast majority of them never address me with bigoted phrases ever again.]), people are almost always going to do those things more often.

You don’t have to like everyone under your care. Once you start owning how you feel, though, you might find that, most of the time, you do.