DR MAX PEMBERTON: I’ve handled racists – so should each physician

The shocking case of two Filipino nurses attacked during the unrest in Sunderland last week prompted the Health Secretary, Wes Streeting, to announce that those who are racist to NHS staff ‘can and should’ be refused care.

While I agree with Streeting that those who attacked the nurses ‘brought enormous shame on our country’, when it comes to turning patients away, I couldn’t disagree with him more: it is not up to the doctor to make a moral judgment over who can and can’t have treatment.

Like Streeting, I was horrified by the scenes in Sunderland. It beggars belief that good, kind and caring people trying to get to work to help others should be subjected to such abuse.

But being racist should not mean you don’t get treatment on the NHS.

Over the 20 years I’ve been a doctor, I have come across many instances of patients being racist, homophobic or misogynistic. Some have expressed truly vile beliefs. While I wouldn’t say it’s regular, it’s certainly not uncommon.

I’ve treated murderers, rapists, paedophiles and terrorists.

But it’s a slippery slope to start standing in moral judgment over who can and can’t have treatment because of what they believe.

If we start excluding racists, where does it stop? What about other things the doctor might not agree with? What about climate change deniers, or people who eat meat, or don’t agree with abortion, or any other contentious area where one person finds the other person’s views offensive and unacceptable?

In my first year as a doctor, I remember a patient who refused to be treated by black members of staff. He went into urinary retention, meaning his bladder wasn’t working properly – an excruciatingly painful condition.

It was the middle of the night and I was called to insert an emergency catheter, but I had only ever practised on a plastic model.

The other junior doctor who was on duty with me, who was black, was very competent and the patient suddenly rethought his racism when confronted with the choice between having someone who was white, but a complete novice, jab something down his penis, or a black person who actually knew what he was doing. So I assisted my colleague and the man was very grateful to us both.

After we’d catheterised him, we talked to him about how everyone deserved to be treated with respect at work. We helped him see that, in refusing care from black members of staff, he was not only creating an unpleasant environment for them, but also affecting his own care. He later wrote a letter of apology to ward staff about his behaviour.

Wasn’t that a better outcome – both in term of medical ethics and in changing someone’s mind – than simply denying him treatment?

It’s not just white people I’ve witnessed being racist. I work in multi-cultural London and have seen Ethiopian patients abusing Eritrean staff, Pakistani patients attacking Indian staff and Muslim patients make awful comments about Jewish doctors. One Turkish patient refused to be cared for by a gay Turkish nurse, because he thought the nurse was bringing shame on his family and country.

I’ve had a number of patients say homophobic things in passing, using offensive slurs in conversation, and I always stop them, explain that I am gay and that it’s quite difficult to hear these things. They are often shocked.

‘Oh, but you are all right, Doctor,’ is a typical reply, as though this makes it OK.

I have a policy of talking to them about how these attitudes can be really harmful and upsetting. You don’t change minds by banning patients, as Streeting would have it – you change them by showing them unequivocal kindness, compassion and care

It’s not always easy. Only recently I was with a female member of staff talking to a patient who had been convicted of a violent sexual crime who described women who didn’t wear a hijab as ‘sluts’ and deserving of rape. Astonishingly, he was quite indignant that he had been convicted of rape, saying that it was the fault of the men of this country for allowing ‘their women’ out on the streets on their own, letting them wear what they wanted.

This kind of shocking misogyny is not uncommon. I always challenge it. Often these patients have never heard opposing views — it’s cultural for them and they simply don’t realise that women are treated equally in Britain.

Once, as a junior doctor working in surgery, it fell to me to examine a particular patient. Within a few hours he was on the ward, recovering from appendicitis – which would have been unremarkable were it not for the prison guards that chaperoned him and the handcuffs he was wearing. He was a convicted murderer. He had been transferred to hospital for treatment, and promptly returned to jail when he was well enough. The treatment he received was exactly the same as any patient with appendicitis. The fact that I and the other surgeons were morally opposed to murder didn’t matter.

Sometimes, yes, it tests your tolerance to the very limit. A friend of mine while working in A&E once had to stitch up a man’s hand after he had punched his wife repeatedly in the face. While she hated ever being in a room with him, she knew that, as his doctor, she must treat him regardless.

There is no place in medical practice for value judgments based on things outside of the clinical realm. Our role is to treat: not judge.

Pain like Kirsty’s is all too real 

The broadcaster Kirsty Young says she was made to feel like ‘a crazy lady’ by a doctor who said the condition causing her chronic pain – fibromyalgia – didn’t exist. This chimes with so many patients I’ve seen over the years who seek help for chronic pain.

It’s so easy to dismiss pain when there’s no clear underlying reason for it. Part of the reason, I think, is that pain is so complex – there’s no objective test for it, and it’s not clear why some people experience pain so differently to others. What’s more, sometimes no underlying cause for the pain can be found at all, yet the person is severely disabled by it.

We do know, however, that things outside of typical medication can help.

People with chronic pain who are lucky enough to see a specialist are often surprised to find they are being offered psychotherapy rather than simply more and more pain killing drugs. This isn’t saying their pain is ‘all in the mind’. Things such as sciatica, fibromyalgia and other chronic pain conditions can be the result of a complex interaction between physical and mental states. Studies have found that emotional and physical problems are processed in the same part of the brain, and it is likely that chronic pain is actually a ‘mind-body’ condition, with emotions playing an important part in triggering or exacerbating pain.

It’s not dismissing anyone’s genuine suffering to say how we feel mentally can have a big impact on how we experience pain.

For years, menopausal women were treated abysmally by the medical profession. They were denied HRT and their symptoms were downplayed. But have things swung too far the other way? Dr Sue Mann, the first NHS national clinical director for women’s health, has claimed there is now a perception that ‘everybody should be on HRT’ and that menopausal women feel they are ‘missing out’ if they are not prescribed the medication. I have to say, I agree. While I lament the fact that doctors have been so wary of HRT for so long, and that undoubtedly women have suffered as a result of this, the current trend for whacking everyone on this medication is just as wrong-headed.

There are a wide range of treatments and interventions to help women going through the menopause, from CBT to medications that target specific symptoms, such as Veoza which treats hot flushes and night sweats. These are just as valid as HRT. Everyone is different and we need to give women all the options to find what works for them.

Despite all the excitement surrounding new medications for Alzheimer’s like lecanemab and donanemab, experts warned last week that they are likely to result in a small improvement in symptoms, and only for those in the earliest stages of the disease. What’s more, they will require considerable resources to identify those eligible, give the medication which is by infusion and monitor them for side effects. While they are a great step forward in the battle against this dreadful disease, I’m afraid there has been a lot of hype surrounding them and the search for a cure continues.

Dr Max prescribes: Fruit and veg

You’d hope that these days the advice to eat fruit and veg wouldn’t be needed, but according to latest research the average Brit goes one month without eating a single piece of fruit and three weeks without eating a green vegetable. Honestly, this is shocking! We know that fruit and vegetables contain a wealth of disease-fighting nutrients and antioxidants, as well as fibre, which helps our bowels and protects against cancer. Come on, this summer let’s reach for the (green)groceries!