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Outside the Lab Profession, Training and education

Microscopes, Ambulances, and Humanity

When they don’t see the patients they serve, pathologists are uniquely exempt from appearance-based bias. Can other doctors – and other humans – learn from our approach of treating patients based solely on what they need from us?

I am a Muslim-American physician with brown skin and a trim beard. I have noticed that what I wear and how I carry myself in the hospital corridor can generate a highly variable response from the people around me – my patients, their families, our hospital support staff, even random strangers in my vicinity.

Here’s a scenario: I am running late for a meeting and the elevator is closing as I rush toward it. I press the button in the nick of time. Instantly, an elevator full of people re-opens. I sheepishly get in, apologizing for making everyone stop. Let’s say I am wearing jeans and have come in on a Saturday to catch up on work. Despite an obvious hospital ID bearing the title “MD,” the elevator opens to an almost hostile attitude toward me. I am a big inconvenience. Stopping again was a huge problem. No one smiles or says anything. So awkward.

Now imagine that I am wearing a suit or have my doctor’s coat on. The response from my own anecdotal cross-sectional analysis has been an outpouring of accommodation and smiles. “It’s no problem, Doc!” “No worries!” This sentiment typically extends throughout the hospital halls and common spaces. Random hellos, warmth, and smiles when I overtly look like “Dr. Mirza.”

How I look matters.

Moving beyond prejudice

My actual interaction with patients is indirect. As a pathologist, I see my patients through a microscope. Reviewing slides from patients’ tissues is analogous to a meme I saw recently – several skeletons in a row, labeled with descriptors of their former owners: white, black, gay, straight, Muslim, Christian, Jew, Hindu, atheist. They are all identical (obviously) – the point being that we are all the same inside. When seeing patient samples through the “microscope curtain,” the only thing I know about them is their names (from the requisition paperwork). I don’t know what they look like, what religion they practice, how they dress, whether or not they smell bad, whether or not they are prejudiced against my religion or gender – and I don’t care. All I care about is interpreting what their cells are telling me. I know it sounds like a cliché but, inside, we are all the same. No one can testify to this more than a pathologist. Wouldn’t it be amazing if all medicine were like this? If we all had the ability to look at our patients in this neutral manner, wouldn’t the world be a more humane and loving place?

What if our patients could all look at us the same way and not have prejudice against our race, religion, or gender?

The same could be said for the reverse. What if our patients could all look at us the same way and not have prejudice against our race, religion, or gender? Susan and Jack would both be referred to simply as “Dr. Simpson.” John wouldn’t have to worry about decorating his office with a picture of himself with his husband and how some patients might react. Mohammad wouldn’t have to care if a patient saw him walking out of the chapel after offering Friday prayers.

I think about my Muslim-American, head-scarf-wearing, ICU physician wife and wonder how her patients – very sick people with distressed families – look at her. She is an exceptional physician and a superlative human being. She has cried with patients, laughed with them, and bonded with their loved ones. But what if her patient’s family is not an understanding one? What if she loses a patient who was bound to die no matter what the intervention and, just maybe, the way she looked influenced the family’s response? What would she do then?

Lessons from the road

This business of what we look like and how it can influence others’ reactions reminds me of a commuting story. Coming home from work a few years ago, navigating the usual heavy traffic had me on edge. My day, like any day in the life of a resident, had been jam-packed. It was the usual stress combined with years of traveling the same roads, with similar traffic, unending construction, and the same congested spots. At one point, two lanes abruptly became one. Lonely signs from miles away tried to warn oncoming traffic of this union, but seldom did anyone pay heed – and the result was the ultimate display of road rage and disgruntled behavior. Instead of yielding to one another to merge into a single lane, people tried to stay in both lanes for as long as possible. If their car fit into the second lane, they stayed.

In my tiredness, I had a range of reactions to this process. Most often, I angled my car so that it forced people to merge into one lane. “What will you do now, buster?!” I would say into my mirrors, my face clearly visible to the other drivers. Or – if I was feeling particularly nice – I would let them whiz by, riding the shoulder, and justify it by saying maybe they weren’t local. Maybe they hadn’t seen the signs. Maybe they didn’t realize the lane closure would come so quickly. Maybe there was a family emergency. My physician training, I guess?

I found myself wondering if these people’s upbringing, their socioeconomic status, race, religious background, or age played a role in their behavior.

Witnessing this event every day allowed me to look at the faces, races, ages, and expressions of the drivers who participated in this undignified behavior. I found myself curious about who they were and what they might be possibly going through based solely on their driving. Less commonly, I found myself wondering if these people’s upbringing, their socioeconomic status, race, religious background, or age played a role in their behavior. I wondered if some drivers felt more entitled to the road than others. In this crazy demonstration of commuter aggression, did how they look matter? Did how I look matter?

Once, while driving, I raised my hand to thank someone for letting me change lanes. (I do a little handwave as a gesture of gratitude.) This time, the car behind me sped up, cut across me, stopped dead in its tracks, and the driver stormed out and started banging on my car and window with his fists. He was irate! I hesitantly pulled down the window and realized that he thought I had shown him the middle finger. I was just thanking him! He was so angry that he even said “people like me” weren’t welcome in his country. I guess how I looked mattered.

As a legal, law-abiding, tax-paying physician-immigrant with over a decade of being ’Murican and harboring a profound love for this country, these events stay fresh in my memory. I lost my first pathology residency spot due to a two-day visa delay. I had traveled, interviewed, matched, and done everything that was required of me. But the visa was late by one day and, just like that, my spot was rescinded. Did how I look matter?

Although I have successfully completed graduate and post-graduate education in the US, I have spent countless hours at O’Hare airport undergoing extreme scrutiny and ‘random’ security checks.

Since then, although I have successfully completed graduate and post-graduate education in the US, I have spent countless hours at O’Hare airport undergoing extreme scrutiny and “random” security checks. I guess how I look matters. In 2006, my wife and I – two resident physicians with paystubs and proof of employment – had to wait for two weeks before our Toyota dealer approved our secondhand car purchasing process because of the “Patriot” Act. What we believed mattered. When we bought our current home, old neighbors warned us that the area was not very “diverse.” Nowadays, even when I am feeling lazy and don’t want to rake leaves, I still go out and do it. Why? Because I don’t want anyone to think “the Muslim family” doesn’t rake the yard. Is this normal for all Americans – or is it because of how we look or what we believe?

Nevertheless, it isn’t all doom and gloom. Despite having a ways to go as a country, these few instances are outnumbered by many wonderful moments. Although my wife, like all of us, has lost terminal patients, she has never had a negative, racially charged moment at work. Road rage is just that – silly road rage. Most people can mask their prejudices long enough to have a meaningful doctor-patient interaction (and, hopefully, educate themselves). My elevator experiences have been variable, but not malignant. Despite friendly warnings of “lack of diversity” by concerned friends, 90 percent of the people in our neighborhood are the best neighbors we could have asked for.

What of the ambulance?

But why do I mention the ambulance in the title of this article, you ask? Well, not everyone can understand the example of the microscope curtain – so let’s discuss ambulances for a minute. If we were to take road rage, external bias, and general traffic happenings as a metaphor for bias in life then I want to bring your attention to the passing of an ambulance. Guess what? Everyone – white, black, brown, gay, straight, Muslim, Christian, Jew, Hindu, racist, xenophobe, tree-hugger, flat-earther, anti-vaccine dad, pro-vaccine mom, climate change activist, gun owner, anti-gun protestor, Democrat, Republican, independent – everyone slows down and moves to the side when an ambulance passes by. Does it matter what the patient looks like? Can they even see this patient? Do they know whether it’s a boy or a girl – gay or straight – cisgender or transgender? Do they know about body shape, partnership status, presence or absence of body odor, or whether they wear headscarves, skullcaps, or have Nazi symbols tattooed on their bodies? No, they don’t. And, just like pathologists making a diagnosis without one iota of bias, humanity comes to a standstill out of respect for a human they don’t know passing by in an emergency vehicle.

As long as humans continue to slow down and move to the side for ambulances, I have hope that humanity will wake up and see how ridiculous they can be when basing their opinions on looks alone. May all physicians be like pathologists – making unbiased diagnoses from behind a “microscope curtain.” And may all humans respond to others like those drivers who slow down and move aside for an ambulance.

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About the Author
Kamran Mirza

Professor of Pathology and Director of the Division of Education Programs, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States.

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