Patients are not bitches: thoughts on medical othering
This post originally appeared on the Feminist Midwife blog February 10, 2017.
“Every woman has a well-stocked arsenal of anger potentially useful against those oppressions, personal and institutional, which brought that anger into being.” - Audre Lorde, National Women’s Studies Association Keynote Speech, 1981
Recently, I overheard fellow providers refer to a laboring person as a bitch.
Before we get into all of the ways this is problematic, and there are many, let's run through two values clarification exercises. Focus foremost on your initial reaction to the prompt "a provider called a patient a bitch." Is your response, “What the…?” Or, “That’s awful. I hope no one has ever called me that, because that would mean they aren’t taking care of me like I thought.” Or, “I can see how that might happen. Some patients really are rude and frustrating.” Or, “That’s so, so wrong and should never happen.” Got your initial thought? Okay, hold it tight.
Now, consider the following.
First, let's say you, as a care seeker or family member or provider, and are walking down a hospital hallway. As you pass by a patient's room, you overhear a man call a woman a bitch. How would that make you feel?
Would you feel the safety of the person being called a bitch was compromised? Would you feel like your own safety was perhaps compromised?
Would you identify that language as abusive, and perhaps think about ways in which the person saying that word might be aggressive in other ways beyond language?
Would you ever want someone in labor to be called that word, by anyone in their life, while in a physiologically vulnerable state?
Now, let's think about the possible circumstances under which I overheard colleagues using this word, and how it might affect your reaction to knowing a provider called a patient a bitch.
Does it change your response if a female physician called a female patient a bitch? And what if it was in the presence of only other female providers?
What if the physician was male, and he called a patient a bitch to other male physicians? What if there was also a female physician in the room?
What if the patient was a woman of color, and the provider was white?
What if the patient was a colleague?
What if the patient was 16 years old?
What if it was a midwife who called a patient a bitch?
If at the beginning of this post you felt anger at anyone being called a bitch by their healthcare provider, and felt equally about the circumstance with each changing scenario, I agree with you. Your first thought was the correct one: no patient should ever be called a bitch, and, ideally, no provider should ever think of someone they're responsible to care for, as one. No matter the people involved, no matter the scenario. It's offensive and abhorrent and wrong, period.
If at the beginning of the post you commiserated with the possibility that this could have happened and could be acceptable depending on the circumstance, and with certain scenarios it could be acceptable and in others not, I vehemently disagree with you. Hopefully I’ll have persuaded you by the end of this post.
This actual event happened quite a while ago, but it's taken me this long to separate my anger from the situation, to be able to calmly break apart all of the reasons why I felt that way. The exact circumstance was a room full of female Residents and one female midwife, referring to a patient who was disagreeing with a care plan and declining recommendations. Multiple providers in the room called the patient a bitch. They said it disparagingly toward the patient, and in camaraderie with each other.
Not only do I disagree with any provider calling a patient a bitch, but I've decided I disagree with any woman calling another woman a bitch. I took some time to figure out why exactly I disagree with that designation, particularly by women against other women. Here's what I came up with, and I'm looking forward to knowing what others would add.
I want to start with the idea that women shouldn’t call any other women bitches when speaking derogatorily. Then I’ll ramp it up to concerns for care provision.
What are the possible reasons that one person would call another a bitch? GURL does a great job of breaking this down: perhaps it’s because she’s speaking her mind, using defensive language, acting assertively, or that their actions or words were contrary to expectation. The summarized consensus seems to be that when a woman acts in any way outside of what would be predicted of her (too loud, bossy, assertive, opinionated, etc.) then the label “bitch” could apply.
To this idea that ‘she’s acting differently than expected,’ I question: what people are expecting of women? Compliance to all others in all situations? Quiet when no one wants to listen, but a patient and kind presentation of thought when warranted, but only to the extent that it’s welcomed? Who is this fictional non-bitch people are expecting, who fits into an acquiescent / quiet when others want / speaks only as much as others want / has only opinions that others agree with? SHE DOESN’T EXIST. Which means women are held to a fictional non-bitch standard, and any wavering should be called out and named. At any point in time, any woman who digresses from "what's expected" is labeled.
Even authors, when writing fictional female characters, struggle with how to do so and still make the reader relate to their unlikeable, er bitchy, characteristics. Kameron Hurley reflects on that in this way:“...women have been so often cast as mothers, potential mothers, caretakers, and servants, assistants, and handmaidens of all sorts that’s it’s become a conscious but also unconscious expectation that anyone who isn’t—at least some of the time—must be inherently unnatural. And when we find a woman who doesn’t fit this mold, we work hard to sweep her back into her box, because if she gets out, well . . . it might mean she has the ability to take on a multitude of roles.Let’s be real: if women were “naturally” anything, societies wouldn’t spend so much time trying to police every aspect of their lives…”When women are assumed to be kind and caring and acquiescent and present for others, the moment they stand up for themselves and acknowledge their own existence and needs and individuality, the unnatural aspects of those actions are identified, called out, put down, and policed. And one act of policing is by calling them names, and push them back into the fictional box from which they strayed. Bitch, slut, cunt. Undo your behavior and get back to how society assumes you are to be.
So what of calling someone a name? As posted by the Momastery community to the person who called one of their writers a "cunt":"...You are actively creating a world in which it is okay to call those women cunts. You are releasing poison into the air that the women in your life WILL BREATHE BACK IN. You are poisoning your own people. You cannot hate a woman for speaking her mind without hating all of us. Women are a package deal..."Calling someone a name is an act of identifying what they "are" and assumes that the name-caller "is not." Further, part of the intention of calling someone a name in a degrading context is to separate oneself from that person, to show they are someone the name caller is not. Calling someone a “bitch” creates a “me” and “her,” scenario, an “other than me” scenario, an “othering” which facilitates a space in which overlapping humanity is undone, where someone who is a “bitch” is acting outside of what a similar person in a similar scenario, rather than being able to see the Venn Diagram of our overlapping existences in which we might express opinions or challenge power or act differently than expected given the chance. It's an othering mechanism, meant to break people down, make them feel badly, and control their future behavior according to societal presumptions. Children are reprimanded for name-calling, so I question how/why/to what purpose we would ever rationalize it as adults. I’ve written before about my struggle with women even light-heartedly negatively joking about other women in disparaging connotations: it’s an across the board topic for me.
When the word "bitch" is used in a derogatory way similar to how "cunt" was used in this scenario, it not only exists in the moment as a derogatory action, but it subsequently feeds into anti-woman vernacular and culture. In societies where women are the lesser, which is still the case everywhere, degrading and "othering" women by normalizing verbal abuse, i.e. calling them bitch or cunt, perpetuates cycles of structural and institutionalized violence against their humanity and their lives. This cycle underpins justifications of their existence as the lesser, and ultimately creates a foundation for rationalizations of physical violence. Verbal violence, including calling someone a 'bitch," exists on a spectrum with physical violence. The infrastructure of the cycle of violence and the spectrum from verbal to physical is so historically integrated into culture, that internalized "othering" is adopted by women and used against other women, which furthers any non-woman's justification to do so.
Women should never call other women bitches. We should work to see that our words and actions and lives exist in a society against which we are constantly pushing, a society in which we are fighting daily to be heard and exist, and within which we are working to survive and thrive and be uniquely our own. When another woman acts outside of what we would expect of her, celebrate that, examine the struggle and be present for her, acknowledge that minutes and hours and days are hard and sometimes our approach might be more intense to get our voice heard and the job done. And sometimes that struggle comes up against one another: lift each other up rather than tear down when our lives overlap. Welcome each others’ strengths, celebrate each others’ successes, and be kind when another one of us needs more support and grace and love. Support each other, period. Stop calling verbal abuse by any other name. Stop calling women bitches.
Now with that, I’ll get back to the issues of a provider calling a patient a “bitch.”
In the patient/provider example, the providers were in a charting room discussing patient care. The door to the room was open, though far away from the patient’s earshot. I heard angry voices, the word “bitch,” and then laughing. I heard this not as one of the providers involved in the patient’s care, but as a passerby, on my way to the call room. All the providers were women, and a mix of Residents and Physicians and Midwives.
After conversing with the providers involved, the reasons I have been able to surmise for their verbal abuse are as follows:
The patient asked a lot of questions.
The patient disagreed with the plan of care and declined the provider's recommendation.
The patient defended her choice(s) when challenged by the provider.
The provider felt like their authority was rejected by the patient's bodily authority.
The person was not acting the way the provider wanted, i.e. an "easy, compliant patient", and the provider was inconvenienced by time and charting more than otherwise would have been required of a compliant patient.
When met with a "no" response to their recommendations, the provider was uncertain of how to provide care other than what they knew as rote and had recommended. This led them to be made unexpectedly uncomfortable by the patient. To this physician, both their knowledge and ego felt directly impacted (which in the culture of Resident physicians in particular is a big deal, let alone the culture of medicine as a whole).
Perhaps when enumerated in an objective way like this, any reasonable person can say “that sounds like a challenge, but yes, calling someone a ‘bitch’ for any of those things would be out of line and inappropriate.” I guarantee, however, there are providers who have been in incredibly frustrating conversations or scenarios with patients, who feel the emotions rising up within themselves just remembering the details of when they might have called a patient a similar name, or just thought it.
None of those reasons should lead to a provider calling a patient a bitch.The job of the provider is to provide care to people: to recognize and respect their humanity, give full attention and care to their holistic well-being, to empower them as equal contributors to their care, and ultimately to be responsible for their lives. A provider calling a patient a “bitch,” first and foremost, shows a loss of respect for someone’s humanity. A provider calling a patient a “bitch” violates the underpinnings of medicine, “first do no harm,” by degrading someone who has entrusted their care and life to the name-caller. A provider calling a patient a “bitch” builds a space between the name caller and the called, rather than building rapport and relationship. A provider calling a patient a “bitch” substantiates power dynamics, rather than intentionally empowering patients in their care. Referring to someone within your care as a bitch is not only medical "othering," it is verbal abuse.
By calling a patient a “bitch,” the provider has chosen, consciously or subconsciously, to own the power in the interaction: they can now only see themselves as one thing and the patient as an-“other.” In this way, I would argue that the provider cannot again share power in conversation or care with that patient, and any attempt that the patient makes to re-establish their own power in interactions is fruitless. Their attempts to re-establish power will fail given that healthcare exists in an institutional system where the power is levied in hierarchical patterns, with providers at the top and care seekers at the bottom: when a provider name-calls a patient, it only solidifies this dynamic. To call someone "bitch" calls that flowchart into action, rather than seeks to break the power system and share power or, in midwifery care, make every attempt to give the patient power through information and decision-making. It allows one person to finish a conversation rather than continue it.
Similar to when women "other" women, what does "othering" mean in a a clinical care scenario? I would argue that it is a method by which providers dehumanize patients, even if unintentionally, and is oftentimes done as simply as calling them "the c-section in 8," or "the pre-eclamptic in triage." Or even saying "cut her" when referring to a c-section, or "break her" when referring to the bag of waters, which I've written about before. Perhaps these are more linguistic slights-of-hand than the directness of calling someone a "bitch," but the impacts are likely similar. My proposition is that once you've designated someone as an “other,” particularly as a "negative other” such as “bitch,” that blatant/flippant/seemingly no-big-deal process of “just” labeling someone starts a cascade of further devaluing, belittling, and enacting words/acts of aggression against that person.
In clinical care, once someone feels like a "negative other,” like “the bitchy patient in Room 3,” what are the possible impacts?
Would the impacts be "only" verbal?
Might that patient’s provider be less likely to provide full, if any, informed consent?
Might providers stop conversations before they start by only giving recommendations instead of options?
Could the impacts also be physical?
Would providers be less gentle with vaginal exams?
Would providers value self-reported pain the same?
Would providers in any way start to value the fetus' life over hers?
Are providers more likely to cut an episiotomy rather than be patient with a slow crowning, to limit time spent with them in your care provision?
Would providers be more likely to cut an episiotomy despite explicit refusal?
I think one's words absolutely lead to their actions, and that verbal expression is a precursor to changes in physical behavior. Maybe you think I’m taking the safety concern too far? Obstetric violence is absolutely real, though what causes it is unknown. Linked above are two cases when women were violated in such an extreme way during their obstetric care that any other provider would wonder how another clinician treated them in such a way. I would argue that a cascade of othering, and negative othering, is one such possible cause. Let’s revisit the piece of the values clarification exercise where I asked how you’d feel if you heard a family member calling the patient a bitch. I asked whether you would feel if her safety, or even your own as a passerby, might be compromised. Why would that concern change if it was a provider calling someone a bitch rather than a family member / partner / spouse? Would you feel the level of safety compromise to be similar / more so / less so, if it was a provider calling the patient the name?
Kameron Hurley, when reflecting about the overlap between fictional characters and our relationship with nonfictional life interactions, delineates the unlikeability to those against whom we enact violence:“…This justification of violence against those who step outside of the roles the dominant culture puts them into can be reinforced or challenged by the stories we tell. Stories tell us not only who we are, but who we can be. They paint the narrow behavioral boxes within which we put ourselves and those we know. They can encourage compassion and kindness and acceptance, or violence and intolerance and reprisal. It all bleeds from the page or the screen into the real world. Who deserves forgiveness? I’d hope we all do.”There is no justification for calling a patient a “bitch.” None. Patients get to disagree, and question, and choose differently than a provider recommends. It's their body and their humanity. And when things go awry or when they are challenged, they get to "feel the feels" as Dan Savage says. They get to express their emotions.
The patient gets to be angry, a la Roxane Gay's question of "Who Gets to Be Angry?". Roxane elaborates:
"...I am an opinionated woman so I am often accused of being angry. This accusation is made because a woman, a black woman who is angry, is making trouble. She is daring to be dissatisfied with the status quo. She is daring to be heard. When women are angry, we are wanting too much or complaining or wasting time or focusing on the wrong things or we are petty or shrill or strident or unbalanced or crazy or overly emotional. Race complicates anger. Black women are often characterized as angry simply for existing, as if anger is woven into our breath and our skin.Black men, like black women, are judged harshly for their anger. The angry black man is seen as a danger, a threat, uncontrollable.Feminists are regularly characterized as angry. At many events where I am speaking about feminism, young women ask how they can comport themselves so they aren’t perceived as angry while they practice their feminism. They ask this question as if anger is an unreasonable emotion when considering the inequalities, challenges, violence and oppression women the world over face. I want to tell these young women to embrace their anger, sharpen themselves against it..."
The patient gets to be angry. As does any woman in any situation. This post started out with the Audre Lorde quote "“Every woman has a well-stocked arsenal of anger potentially useful against those oppressions, personal and institutional, which brought that anger into being.” Thus, anger from women should be understandable, rather than challenged. It should be supported and utilized and channeled into energy for change of the institutions which brought it into being, including, and importantly, medicine. Women have a right to be angry at medical institutions: eons of protocols and recommendations that challenge their physiologic process; giving them drugs to put them to sleep during labor without consent (including anesthesia doing so nowadays during c-sections); forced sterilization without consent. The underlining suspicion of whether healthcare providers truly have their best interests at heart is historical: we should be doing everything we can, every day, every interaction, to rebuild that trust. The humanity healthcare providers acknowledge and the respect we give to patients must be unwavering, which to me means the word “bitch” must never enter the conversation. They get to challenge the process. They get to push the boundaries of the institution to fit their needs. And the provider's job is to be present and support their needs, emotional and physical and otherwise, in a professional and ethical and caring way, including supporting their being angry. And never calling them names for it.
Particularly for the exact scenario in which I overheard providers calling a patient a bitch, knowing the circumstances in which that occurred, a compassionate and empathetic response to that would be, "I'm so sorry the labor process is not going how you desired or expected. Sometimes bodies and babies do things differently than what they should or what we want. I can understand how this feels out of your control, and how that is scary and infuriating. You have every right to choose what you want for your body and baby. My best recommendations are what I have discussed, and I'm open to finding other options within those based on your needs. Please let me know how I can best care for you going forward given where we are right now. Would you like some time alone, and I can come back in a few minutes to check-in?"
Providers who work long hours / in incredibly busy settings / with complex issues / ride emotional roller coasters for themselves and the people for whom they provide care often experience moments where they feel like they're out of capacity to be their best self, and may say things or approach clinical scenarios in less-than-perfect ways. Providers also, reasonably, may become frustrated in challenging clinical scenarios in which they feel the patient is making choices dangerous to their health or to the health of others, and respond in a less-than-professional way. Perhaps this is a component of compassion fatigue, whereby a provider has essentially run out of compassion or sympathy or empathy. Compassion fatigue is being identified more recently as a form of traumatic stress, and providers are receiving information to promote self-care and identify and address burnout in its early stages so it doesn't progress to significant degrees. The inconvenience of "difficult" patients particularly when in the presence of provider exhaustion or patient acuity leads to minimalist and immature responses, such as childish retorts through name-calling. While this is understandable and compassion fatigue is absolutely something to be addressed in the provider community, the possible impact on patients cannot be ignored. It is verbal abuse, plain and simple.
In a recent episode of the podcast “Only Human,” physicians discussed back-stage versus front-stage medicine. Back-stage medicine was reviewed as the place where clinicians can discuss patients without their knowledge, whether to laugh about a funny care scenario, or vent about frustrations. These two spaces are important to define and exist within: providers need a place to discuss the lived experience of providing healthcare. It's a hard job, often. But even then and there, question the validity of verbal abuse toward patients, and the subsequent environments of care that could be affected by welcoming verbal abuse toward patients in any setting. Hard moments should be embraced, and conversations opened, for exchanges of power and moments of universal empowerment, rather than unilateral enforcements of power to shut down the conversation.
I anticipate many providers responding to this piece and saying, "Some days are hard, some patients are challenging. We are human, too, and need to be able to vent." I'm not saying I haven't had hard days. I'm not saying I haven't vented to colleagues about people in my care who have frustrated me and I've struggled to find language to understand why. I'm not saying that finding and existing in safe outlets for processing, with language true to our own experiences as clinicians and humans is hard, exhausting, and infuriating. I have identified my own compassion fatigue at times, and found myself saying or doing things I wouldn't do in any other scenario. I remember that feeling scary for me as a provider, knowing that I wasn't my true self in a moment when I was responsible for caring for someone else.
A few years ago, a midwifery student called me out in clinic for calling a patient "crazy": I immediately realized the depth of my words, the possible impact on how I would provide that person care once I had "othered" them, and re-examined my depths of empathy that I was able to bring to their needs that day. I am encouraging others to identify if and when they've done the same, and to find ways to see it in others, and then find ways to not do it again in the future.
As Roxane Gay concludes in "Who Gets to Be Angry?":
“Anger is not an inherently bad thing. Most of the time, it is a normal and even healthy human emotion. Anger allows us to express dissatisfaction. It allows us to say something is wrong. The challenge is knowing the difference between useful anger, the kind that can stir revolutions, and the useless kind that can tear us down.”
I would argue that in the scenario at my own workplace, it would seem the patient showed healthy anger at the process and institution and provider, and engaged in a personal revolution by claiming her words and needs. I would then argue that, by using the word bitch, the provider chose an anger outlet that tore down the care process, herself, and sought to devalue the patient. She likely succeeded.So what can you do, when you overhear verbal abuse about patients in the medical background?
Possible script:
"I will not participate in a conversation that labels patients in a negative way. It creates an environment that ultimately compromises their health by verbally othering them and negating their role as equal contributors in their care. It's unprofessional and unethical, and is verbal abuse even if they can't hear us. That's not how I practice."
Thoughts welcomed.
In solidarity,
Stephanie
