What are you? The art of asking patients about identity

It is not uncommon for patients seeing me for the first time to ask where I am from, usually meaning what “nationality” I am. “Canadian, why do you ask?” is my usual response.I am second generation Canadian; my parents being born in Canada also. At best, this is a quickly sorted out, minor “irritant,” at worst it is perceived as a challenge to somehow “prove” myself in the Canadian medical system. Where was I born? Where did I train? Am I competent? So . . . if this is even a small issue for me as a white cis male with a Eastern European sounding surname, I cannot imagine what this is like for any MD of colour, who speaks with an accent other than that of a Canadian radio broadcaster, wearing clothing of religious or cultural significance, not born in Canada, etc. This question can easily put people on the defensive. How do patients feel when we do the same to them? I imagine worse, a lot worse. Even if people see their heritage as a source of pride, it's natural to wonder why this is being asked. I am unashamed to be from a Polish/Ukrainian background, but I don’t speak either language and have only visited Poland briefly as a tourist. Why is this important? If we lead with this line of inquiry too early, patients can feel like they are being interrogated and don’t belong. The issue in question is captured in the term “othering.” Doing quick internet research, I found the following from very-well mind website on the subject of race and injustice. “Othering is a phenomenon in which some individuals or groups are defined and labeled as not fitting in within the norms of a social group. It is an effect that influences how people perceive and treat those who are viewed as being part of the in-group versus those who are seen as being part of the out-group. Othering also involves attributing negative characteristics to people or groups that differentiate them from the perceived normative social group. It is an “us vs. them” way of thinking about human connections and relationships. This process essentially involves looking at others and saying, "they are not like me" or "they are not one of us."As an MD seeing a patient for the first time, background information is important. Past medical history, past surgical history and family history are common areas that require exploring. Is ethnicity important? Probably not initially, unless we are talking about a few rare genetic medical diseases. "Just being friendly" may not be enough reason to instantly probe about ethnicity, religion etc. So the first question to ask ourselves: Is ethnicity important for the medical treatment of this patient? If not, then perhaps it can be left to a time when a solid therapeutic relationship is established and we are getting into more nuanced discussions. Even then, how to ask this question is controversial. While one person might not be bothered at all about being asked about ethnicity, others might take offense at the way they are being asked. Exactly how to ask, the precise wording, is much debated on social media. Here’s what I've found to be a general consensus, certainly open to discussion: AMONG THE WORSTQUESTION: What are you?POTENTIAL ANSWER: A patient who is contemplating seeing another doctor? ANOTHER POTENTIAL ANSWER: Hungry, overworked and tired of hearing this question.NOT MUCH BETTERQUESTION: What race are you?POTENTIAL ANSWER: Half marathon. I’m in a race to get out the door of this clinic.DEFINITELY NOT MUCH BETTERQUESTION: Where are you from?POTENTIAL ANSWER: You mean my home address? My mother’s womb, although I don’t remember the precise details exactly. NOT MUCH BETTER AGAINQUESTION: What is your background?POTENTIAL ANSWER: I prefer soft pastels or floral. You mean before I did my MBA?STILL NOT GOOD – Part 1STATEMENT: Let me guess where you are from!POTENTIAL ANSWER: Great to be a trivialized object for your viewing pleasure. Hope you enjoy the game. TERRIBLESTATEMENT: You look exotic. What combination produced you? POTENTIAL ANSWER: Are you asking what kind of not white person I am? SLIGHTLY BETTERQUESTION: Where did you grow up? POTENTIAL ANSWER: In a home on a wonderful street with lots of other kids that looked different, just like me!SLIGHTLY BETTER THAN LASTQUESTION: I am curious, where were your parents born? POTENTIAL ANSWER: I think they were both born in a hospital. If you are asking about location, my mom was born in Toronto and my father is from Jamaica. SLIGHTLY BETTER AGAINQUESTION: I am interested, where were your grandparents born? POTENTIAL ANSWER: Now that’s complicated! As far as I know, my mother’s side is all from Kenya and I think both dad’s parents were officially from Yemen. A POSSIBLE BEST?QUESTION: Some families and ethnicities carry higher risk for [insert condition here]—may I ask you how you describe your ethnicity?POTENTIAL ANSWER: Sure… My mother’s side is A and my father’s is Z, so I guess I am A to Z! Or some version close to this might work the best. It is easy to get this wrong even if well intentioned. So, we are challenged to try to get it right which every patient! I’ve certainly learnt in the practice of sexual medicine that asking permission and having a “preamble” as to why a line of questioning is important, is “best practice.” If permission is granted, straightforward questions asked in neutral (non-emotionally charged) language and terms generally is most acceptable. How might this same principle apply here? I am very interested in others’ experiences, both as MD and MD-patient. When has this line of questioning worked well and when did it fail miserably? We can all learn from each other. Dr. Ted Jablonski is a performing artist and writer who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta with two feet still on the front-line trenches of acute primary care.

What are you? The art of asking patients about identity

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