Where is the Black doctor!?

I was a first-year resident in downtown Toronto when I got a page. The emergency physician started the conversation in a way that makes every resident’s heart sink. “I’ve got an interesting one for you.”

“Eighty-seven-year-old gentleman with an incarcerated hernia. I reduced it, but he continued to have pain, so I scanned him. Imaging shows a sigmoid volvulus. I told him he needs surgery, but he doesn’t want it. Will you talk to him?”

A sigmoid volvulus is an emergency; the colon twists on the axis that carries its blood supply, creating a closed loop obstruction. Without intervention, it can lead to perforation and death. “Time is bowel,” we say. I hurried to the patient’s bedside.

Through the doorway, I saw a frail, well-kept older Black gentleman accompanied by a man who looked to be about my age. Before I entered the room, a colleague in the emergency department called out to me, “Hey you’re gen surg right? Heads up in there, he’s a difficult patient.” He said the man didn’t want an intravenous line and had come to get his hernia reduced, get pain medication and go home.

I nodded and walked in. The patient’s eyes were as dark as mine, and in them I could see his immense pain. I introduced myself as the junior surgical doctor and saw a look of relief on his face. He spoke with a thick Guyanese Creole accent as he introduced me to his companion, his grandson, and told me his story. His vital signs were stable, but my physical examination revealed a tender and distended abdomen. I explained the critical nature of his condition and that he needed an urgent colonoscopic procedure to untwist his bowel.

“A suh yuh want mih fuh dead? A kill yuh want kill mih? Ail a mih family dem, dead out in dis place!”

I pause. Though not grasping every word that came from his mouth, his body language, expression and passion are something familiar to me. “No Granddad, I don’t want you to die,” I responded. “I understand your concerns and I want what is best for you. I know you are in pain. With this procedure, we can treat your pain and get you home as soon as possible. Without it, I worry it won’t get better on its own, and if it gets worse you may require an emergency surgery.”

We called his daughter on the phone and, together, we discussed the options. He asked me a question many patients ask: “What would you do if I were your family?”

“Granddad,” I told him, “the best option for us is to do the colonoscopy so we avoid a big surgery. I promise the whole team is going to do the best job we can to take good care of you.”

The patient consented, but as his grandson was not allowed to accompany him to the endoscopy suite, he felt uneasy about what was about to happen. He reached for my hand, clutched it and asked me to stay by his side, so I did. The porter walked into the room, looked at me with a smile and gave me a nod of recognition. I nodded back and together, we went off. We must have looked like a family of three generations.

A flurry of pages arrived as we got to the endoscopy suite. The attending surgeon was ready, and with the calm, confident and reassuring nature that comes with years of experience, reiterated to the patient the critical nature of his condition and the necessary procedure.

As the team prepared to start, I stepped out of the operating room to carry on with the rest of my tasks for the day, but was stopped by a loud shout.

“Where is the Black doctor!?”

The patient would not allow the procedure to begin unless I was in the room. I came back and offered him my hand. He held it so tightly it seemed our hands were bonded into one. As he drifted into sedation and vulnerability, his eyes remained locked on mine with an intense gaze that seemed to say, “Protect me.” The procedure went as planned and he went home later, as promised.

It never sat well with me that he was labelled a “difficult patient.” In the hospital, patients are afraid, vulnerable or in pain, and may behave in ways outside of what we define as “normal.” When I looked into that man’s eyes on that day, I didn’t see a difficult patient, I saw a man who was expressing his fear of being a racialized member of society, navigating a social system that has historically fallen short for Black people in Canada.

Black people in Canada come from diverse ancestral backgrounds that share a common history of colonialism, slavery and discrimination. I was born in Canada because my mother came as a child refugee of apartheid in South Africa in the 1970s. I inherited the last name Simpson from my father owing to British colonialism in Ghana. Our experiences and the those of our elders shape us. Black Canadians experience many inequalities that may influence health,1 and racialized health care users have been found to perceive race- and ethnicity-based discrimination as a central challenge when navigating the health care system in Canada.2

I think I saw a traumatized patient that day, not a difficult one. Perhaps seeing my face was a beacon of light on a scary day.

“Where is the Black doctor?”

I wondered the same as I sat in the lecture hall where all first-year residents in every surgical subspeciality gather weekly and found I was the sole Black face in the room.

A Filipino custodian I often chat with between cases in the operating room came up to me one day.

“I’ve worked here for 30 years, you are the third one,” he said.

“Black resident?” I asked.

“Black anything … surgeon, fellow, resident. A few years back, there was a fellow from Jamaica and before that a fellow from Botswana. You’re the first Canadian I’ve seen. I am so happy you are here.”

I get congratulated walking around the hospital. Black nurses (of which there are many in downtown Toronto and who have a rich history in our country)3 smile at me. The Black workers in the hospital give me strength, with a head nod, a wave or a smile, as they see me navigating a space not historically occupied by us.

“Where is the Black doctor!?”

I am glad I was there that day for that man with the sigmoid volvulus, but what if it was someone with a broken hip, a heart attack or a maternal–fetal complication? My patient spoke up that day, but how many of our patients don’t? How many patients who “refuse treatment” or “leave against medical advice” are silently asking this question as they remove themselves from a health care system in which they do not see themselves fitting? How does this exclusion affect their health outcomes and, therefore, their perception of the system’s effectiveness in a perpetual cycle of disparity? I’ve wondered.

In my few years as a resident, I have seen Black patients present to hospital with more advanced pathology than their nonracialized counterparts. This is not an isolated experience.4 In the trauma bay, I’ve seen young Black men over-represented as victims of assault and gun violence. But I have no data. How can we truly capture the entire picture of Canadian health if we turn a blind eye to some of its elements? As researchers and clinicians, as thinkers and practitioners, I believe we have a responsibility to explore these elements to understand the health of our society more accurately and improve outcomes for our patients.

Surgery is the most invasive treatment we have in medicine. It’s not a lifestyle modification, it’s not a pill, it’s not a procedure that can be done with your loved ones by your side. It encompasses one of the most vulnerable aspects of human existence. Creating a culturally safe space and fostering an environment of inclusivity should be part of our commitment to providing patient-centred care.

“Where is the Black doctor!?” I say, “We are here!”