Overcoming the Built-in Racism and Male Chauvinism of Doctors and Hospitals
Students tend to have little difficulty in describing many incidents of racism and male chauvinism: that they are mostly women suffices and that they are nurses adds meaning to the problem. Classroom discussion helps identify subtle incidents of racism. For example, students may realize that Black patients may be the last to receive morning or evening care, meal trays, and so forth. If this is a normal occurrence on a floor, it is an indictment in itself. Racism may take another tack. Is it an accident that the Black person is the last patient to receive routine care, or has he or she consciously been made to wait? Does the fact that the Black person may have to wait longest for water or a pill demonstrate rac- ism on a conscious level, or is it subliminal?
Nurses recognize the subtle patronization of both themselves and female patients. Once the situation is probed and spelled out, the students adopt a much more realistic attitude toward the insensitivity of those who choose a racist or chauvinistic style of giving care. Students have noted that, when they are aware of what is happening, they are better able to take steps to block future occurrences. Some have written letters to me after they have begun or returned to the practice of nursing, stating that knowing the phenomenon is common helps them project a stronger image in their determination to work for change.
■ Pathways to Health Services When a health problem occurs, there is an established system whereby health care services are obtained. The classical theoretical work that was developed in the mid-1960s and the 1970s continues to establish a viable framework for describing sources of patient problems. Suchman (1965) contends that the family is usually the first resource. It is in the domain of the family that the person seeks validation that what he or she is experiencing is indeed an illness. Once the belief is validated, health care outside of the home is sought. It is
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not unusual for a family to be receiving care from many different providers, with limited or no communication among the attending caregivers. Problems and complications erupt when a provider is not aware that other providers are caring for a patient. Let us not forget that, in rural and remote areas, compre- hensive health care is difficult to obtain. For patients who are forced to use the clinics of a hospital, there is certainly no continuity of care because intern and resident physicians come and go each year. This is known as the level of first contact, or the entrance into the health care system.
The second level of care, if needed, is found at the specialist’s level: in clinics, private practice, or hospitals. Obstetricians, gynecologists, surgeons, neurologists, and other specialists make up a large percentage of those who practice medicine. Recently, hospitalists have been added.
The third level of care is delivered within hospitals that provide inpatient care and services. Care is determined by need, whether long term (as in a psy- chiatric setting or rehabilitation institute) or short term (as in the acute care setting and community hospitals).
An in-depth discussion of the different kinds of hospitals—voluntary or profit-making and nonprofit institutions—is more appropriate to a book deal- ing solely with the delivery of health care. In our present context, the issue is “what does the patient know about such settings, and what kind of care can he or she expect to receive?”
To many students, the health care delivery problems of a given hospital unit are far removed from the scope of practice they know from nursing school and from what they ordinarily see in a work setting (unless they choose to work in a city or county public hospital). Many students assume that the care they observe and deliver in a suburban or community private hospital is the universal norm. This is a fundamental error in experience and understanding, which can be cor- rected if students are assigned to visit first the emergency room of a city hospital and then the emergency room of a suburban hospital in order to compare the two milieus. Unless students visit each setting, they fail to gain an appreciation of the major differences—how vastly such facilities differ in the scope of patients’ treatment. Students typically report that, in the suburban emergency room, the patients are called by name, their families wait with them, and every effort is made to hasten their visit. The contrast with people in urban emergency rooms— who have waited for extended periods of time, are sometimes not addressed by name, and are not allowed to have family members come with them while they are examined—is astounding. The noise and confusion are also factors that con- front and dismay students when they are exposed to big-city emergency rooms.
Figure 8–5 illustrates the maze of health care and the variety of obstacles a patient must deal with in attempting to navigate this complex system. Indeed, the patient not only needs to navigate an internal system of a given hospital but also needs to understand all the types of care available. Just to complicate mat- ters more deeply, many people are given information that contradicts itself—as with the diagnosis and treatment of breast cancer or the use of estrogen re- placement therapy—and then the patient is asked to make the choices.
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■ Barriers to Health Care There are countless factors, or barriers, in addition to financial that thwart a person’s or family’s ability to use the health care system to its greatest potential. The following are some examples:
Access A person is unable to enter into the system because he or she lacks money, health insurance, or the ability to get to a center where health care is delivered. Another access factor is that primary care physicians are leaving their practices, either to retire or to limit the scope of their practices to “concierge” services.
Age The person is too young or too old to enter into the system and is unaware of ways to overcome this.
Access Primary
Care Acute Care
Long-term Care
Who’s Who
Ownership
Technology
Insurance
Honesty
Where to go?
How to get there?
What do they mean?
How do I pay?