I hope you’ve been doing well. I wanted to share an experience I recently had with you because it honestly haunted me for days. (No one died though so no ACTUAL haunting)
Some Background: One of my preceptors in Family Medicine I is a FM doc that got moved to a clinic in another part of DC (a poorer population in my opinion with a facility that definitely isn’t as nice as the one she came from). She had never worked at this facility before so now a lot of the continuity patients she has are patients who were assigned to other doctors that have since left. I’ll call her Dr. Karen White for the rest of this email. Dr. White definitely doesn’t phenotypically look like her patient population- many of the patients I see with her end up addressing me, even when she asks them a direct question, which I’m sure she subconsciously notes. I definitely noticed. The desire for a doctor that looks like you, speaks the same language, or one that you can tell fits the one drop rule with more than a few drops, is totally valid in communities that have reason to be distrustful of not just medicine but the ethnic majority. Unfortunately though, this definitely has made more than one of our encounters awkward.
Present scenario: An African American mother presents with her 2yo fraternal twin daughters for a well child exam. This isn’t atypical considering DC requires all children to have a physical before being allowed into school/the following grade/daycare. We find out she’s not only mother to these two girls, who I’ll name Dash and Violet, but 7 children total and she’s a single mother who has some occasional help from Dash and Violet’s father who is also father to one other brother. In this encounter, Dr. White takes the lead because these are our last patients of the morning and she’s running late. I sit down and eventually Dash comes over to sit in my lap to play with my stethoscope. Violet stays with the mom.
The mother brings concerns up about some odd behavior that she has noted from Violet- she rocks from side to side and front to back, sometimes so severely that the mother tries to protect her from hurting herself. Violet rocks when she’s nervous, when she doesn’t get her way and is not as outgoing or talkative as Dash. Dr. White asks her about having Violet evaluated which apparently the mother had already done at some point.
Dr. White ends up moving on to talk about how behind the twins are on vaccinations. She asks the mom if she got the kids vaccinated elsewhere and the mother replied that our clinic is her primary and sole place for care of the twins. Dr. White notes and says that the kids have been here only twice in their 2 years of life which is why they’re so behind. Dr. White tells her the vaccines each twin will need. And then the mother asks Dr. White about her opinion regarding vaccinations because the mother has a cousin who is completely antivax and who has advised her not to get the twins vaccinated. The cousin had even gone as far as to point out that one of the mother's older sons, who is vaccinated, has a learning disability. The cousin also noted that her own daughter was never vaccinated and had hardly ever been sick. So Dr. White kind of chuckles and then says something to the effect of: There’s nothing wrong with vaccines. People would rather listen to people like Jenny McCarthy who has no background in medicine which is narrow minded. No medical studies have proven this and I won’t even see patients who don’t vaccinate. She chuckles again and says yeah the twins will be fine.
The mother the whole time seems to be chuckling while nodding along with this almost nervous expression like she doesn't want to appear uneducated regarding the subject. The mother takes her word and says yeah the learning disability isn’t even the same and the twins can get vaccinated.
I’ll fast forward from this point past all the games I play with Dash, my conversation with the mother regarding non-Caucasian like hair regimens and my unsuccessful efforts to get Violet to smile at me.
I go to the office to talk to Dr. White like I do after all encounters and asked her about the rocking and potential differential for it. She says there’s a lot it could be but Dr. White would need to see it and still schedule another evaluation. She goes on to comment on how far behind the twins are and that she’s going to have to call CPS on this mother. I was taken aback and I am pretty sure that my face could not hide it because as we both know, hiding my facial expressions is not one of my personal strengths. I asked why we were going to have to call CPS and Dr. White stated that the mother did not bring her children in or vaccinate which means she is being neglectful medically and we have a duty to report that.
I had such a hard time with this. Like I was obsessed with this for days and I asked other providers, classmates, and I even called my mother about what she thought as a social worker. This whole thing haunted me.
I had 3 big problems with this encounter.
The first is that I did not feel the provider did a good job explaining vaccinations to the mother. Instead of using the moment to teach and provide education, she came off condescending and essentially called the woman's cousin narrow minded. There was a better way to do that and she definitely failed in that regard.
The second problem I had, was that I was offended by the first problem not just as a student of medicine who thought she did a bad job at educating her patient, but I don't think Dr. White realized how that interaction looked to me as a student of color. Dr. White came off condescending and almost judgmental to that patient. Laughing at the question, calling the differing viewpoint narrow minded, and bragging about not taking patients who don't believe in vaccinations- these are not ways to instill trust and respect with any patient but especially to a patient who belongs to a community that has been given plenty of reason not to trust medicine and not to trust those who lack vast amounts of melanin in their skin. I was offended that quite frankly, this white woman used her position of power to demean a Black mother asking a question that many patients in the US currently have. If I'm 100% honest, I don't think she would have had the same conversation with an affluent white mother, which is what burns me up. I definitely don't think she did this on purpose or maliciously, but ignorance and lack of intent can't be excused when we can do better. If she had just acknowledged the mother's concern, asked why she questioned the vaccines, what she believed, and offered some kind advice on safety of vaccines, this would not have been an issue, but she failed to do that.
The third problem I had with the encounter was the CPS call. Dr. White never asked why the mother didn't bring the twins in. She's a single mother of 7- there could be a million and one reasons she couldn't get in. Dr. White asked no context to the situation. If the mother did not have a reason for not bringing the twins in, Dr. White could have told the mother that she is mandated to call and at least give her a warning. Dr. White could have also told her that she needs to see the twins in a month for a follow up on vaccines and if she doesn't show, CPS will have to be called on the basis of neglect. I felt like she jumped the gun. I talked to my mom though and my mom said that this is a gray area but that technically Dr. White was right in the CPS call. She was explaining to me that Dr. White has to call if she has the suspicion at all. She also said Dr. White could have also gotten more context, gotten social work involved for like a consult and then made the decision on whether to call afterwards. She also explained that a lot of doctors will call at the slightest suspicion because they are protecting their license. I talked to another doctor though who said he would have tried to get context and contact social work before calling because a CPS call cannot be taken back. When CPS is called on the household, all children in the home are considered and he wants to keep families together as much as possible while still protecting the child because the reality of our foster system is traumatic.
So I bring up this extremely long winded story because maybe for the next class, you could do a little portion on what it is to have to make a decision regarding a CPS call. I think it would be beneficial because every provider does this differently and honestly it's a hard call to make. It's this weird tug of war between protecting yourself, protecting the child, and doing what's best for the family overall. I also think it would be great to prepare them for the fact that in clinical years and beyond, you will be with providers who do not practice as you would, who are fallible, who make mistakes, who make bad calls, and who do things you utterly disagree with- and as the student you feel powerless. You don't know what to do. You don't know what you can say. You don't know how to fight for the patient with your limited knowledge, respect your attending who has more experience, and still salvage a decent evaluation at the end of the rotation. I don't think I ever thought I'd be with providers that practiced in a way I absolutely did not want to practice. Most of last year I spent time picking up things I loved about different preceptor's styles of practice, but this year I am faced with a different challenge. I am faced with knowing just enough to disagree, having just enough knowledge about the hierarchy to know I am powerless and finding out the things that I absolutely do not want to do in my practice (If I ever eventually get there haha).
