How do you deal with a toxic patient who is racist, misogynist and full of hatred?

'Let anyone among you who is without sin be the first to throw a stone…' As a kid, I only went to one professional hockey game with my father, seeing the Winnipeg Jets on Feb. 14, 1975. Why do I remember this so well? Bobby Hull scored a hat trick that night to score 50 goals in 50 games, a rare and amazing feat. The crowd in the arena literally erupted and this was one of the most exciting nights of hockey I have ever witnessed to this day. One of the most famous Canadian hockey players of his era, leaving Chicago and the NHL and moving to Winnipeg was already unbelievable. Most of the boys in my school idolized the “Golden Jet” and it was contagious. He was a star. A phenomenon. Mr. Hull died recently, at the age of 84. And the hockey world seems to be divided as to how to honour his death. If we view him as a hockey player alone, he’s an iconic hall-of-famer, who revolutionized aspects of the game with a blistering slapshot and an unmatched flare. He was one of a kind, the stuff of legend. If we view him as a man, he was deeply flawed and a miserable example of toxic masculinity. We’re all flawed. But there are lines that, when crossed, bring on a hailstorm of condemnation. Bobby allegedly beat his wives, assaulted a police officer and was quoted in a 1998 interview as saying the Black population in the U.S. was growing too fast, that eugenics was a good idea and that Hitler, for example, had some good ideas. It’s hard not to be disgusted. Yet, there are fans and sports-casters who want to ignore the human being and venerate the god he was on the ice. Should he be extricated from the Hockey Hall of Fame? Should we take down the statues and banners that celebrate him? Should we stand up and speak the truth because anything less is being complicit? In the last few days, I’ve read opinions on all sides and it’s gotten me thinking. Bringing things closer to home, the COVID pandemic has brought a lot of nastiness out of some people. Patients spewing vitriolic polarized views and conspiracy theories that are viciously directed against us, the medical community. My work with trans folks occasionally gets me an email full of insults and hate. My work with harm reduction in post-steroid-abusing bodybuilders sometimes brings me face-to-face with masculinity full of anger and rage, which I know has involved violence against women. I am a white male, so can only imagine how this could be magnified if I were of a different gender or racialized. How can I willingly be an empathetic doctor to a patient who is unapologetically racist? How can I support a patient who actively fights against equity and inclusion; who blatantly violates the Canadian Charter of Rights and Freedoms? How do I forge a therapeutic relationship with a patient whose ethics are flagrantly opposed to everything I stand for? If a patient is physically or verbally aggressive towards staff, we have every right to discharge them from our clinic, particularly if they have been warned and this is a repeated offence. These situations can be “ugly” and very unpleasant to deal with but are generally black and white in regards to a definitive decision, that is, termination. The COVID pandemic has seemingly brought out an unprecedented host of physical abuse and violence against physicians and this is another issue altogether. But what if this patient is polite, charismatic and even well-liked by staff? A celebrity of sorts. They might even be a “good patient” who listens and is compliant with our advice. And yet they have a repulsive flaw. We might be the only one who is privy to the dark side of their character that only comes to light behind closed doors. This type of patient tests us to our core as human beings and as doctors whose job it is to treat all in a non-judgemental and caring manner. Clearly, if I’m drawn to treating convicted criminals, I can choose to work in a prison setting or halfway house. I can choose to provide medical services to individuals or groups who are “pariahs of society” because of their misaligned views. But what if I really don’t want to engage? How do I deal with a racist patient? A BMJ article just published takes a stab at this. There is a lot of medical literature on the patient who displays racism against the doctor and demands to be seen by someone else or “reassigned.” Typically the advice is some variation of a “four-step approach for physicians confronted with a patient’s racism: 1) ignore such comments in an emergency; 2) focus the encounter on the shared goals of treatment; 3) depersonalize the event; and 4) foster a community of support within the hospital.” This quote was taken from a 2017 article written by Harvard’s Lachelle Dawn Weeks for STAT on-line magazine. How do I personally manage these few “toxic” patients that I have? I take a few deep breaths and try to: see them as human and empathize if possible with this deal with the medical issues at hand first and foremost defuse and take the emotion out of the situation initially later explain how I feel (put my emotions back in) if safety is not an issue find some common ground that we both agree on and focus on this clearly communicate my beliefs if they are in conflict and where there will be no compromises made be clear, factual and specific talk through consequences of problematic attitudes and behaviours set expectations (if there is to be a future therapeutic relationship) give patient viable alternatives to my involvement in their care in the future (ideal if their medical concerns are of non-urgent nature), which could involve a list of resources or a referral These are challenging situations for us and I certainly don’t profess to be an expert. We must speak up, stand our ground and hope that the patient sees the line in the sand, moves on to someone else who might be more sympathetic to their noxious viewpoint without abuse or violence against us. Not a lot of winners in these scenarios. And so must we leave our childhood heroes/villains and become mature adult doctors in the complicated and not always friendly world of medical care. Dr. Ted Jablonski is a singer-songwriter, emerging playwright and neophyte poet who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta. He finds himself advising medical students at the Cumming School of Medicine and still on the front-line trenches of acute primary care.

How do you deal with a toxic patient who is racist, misogynist and full of hatred?

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