Hey there, time traveller!
This article was published 3/3/2014 (1566 days ago), so information in it may no longer be current.
Three weeks ago I brought my youngest child to the hospital with a severe case of croup, a viral infection that causes swelling in the throat and vocal cords. She was quickly admitted and a colleague later told me he'd made the diagnosis before even arriving in the room. You see croup has a characteristic presentation — coughing sounds similar to a barking seal. Once you hear it, you never forget it.
Good clinicians see patterns. In training, we take seemingly unrelated symptoms and combine them into a diagnosis. These diagnoses are supported with patient history, blood work, imaging and other testing. Once confirmed, we move forward with the intention our treatment will help our patients.
I would wager there were other patterns at play in our situation. The triage nurse had worked with me previously and knew I was a usually calm anesthesiologist. My obvious concern was more than just an overprotective parent. My colleague was informed I had brought my child in and recognized the last name. Why would an anesthesiologist, a specialist in airway management, bring in a case of croup unless there was cause to be concerned?
Patient profiling — much the same as law enforcement is commonly accused of — is central to the practice of medicine. Early diagnosis, triaging the urgency of assessments and decisions on time to treatment all depend on how we profile patients.
Earlier this month, Brian Sinclair's family withdrew from the public inquest into the reasons behind his death. They believe the next phase of the inquest is disinterested in exploring systemic racism and discrimination against aboriginal people within the health-care system. Although the final report is not yet completed, the focus may be on the effect patient flow through the emergency room had on Sinclair's death. For Sinclair's family, the lingering question of racism as a causative factor in Sinclair's death remains unresolved.
The question of whether Sinclair was profiled is obvious. Of course he was profiled. The real question — and the one Sinclair's family wants answered — is whether he was profiled based on his medical presentation or whether it was because of the colour of his skin.
This is a much harder question to answer, but one I think we're obliged to explore. From testimony in the inquest, more than 14 health professionals worked over the period he could have been assessed. Four individuals in the waiting room stated they approached the triage nurse with concerns over Sinclair's status. As far as the inquest has found, no one ever evaluated Sinclair's medical status. No pulse, no blood pressure, no physical exam.
That's not to say he wasn't noticed. Rob Malo, a nurse working the weekend Sinclair died, told his lawyer he gave Sinclair's condition "10 seconds" of consideration — "if that." Interestingly, research studies estimate 18 seconds is all the time it takes health professionals to profile a patient. Once profiled, it can be very difficult to get a health professional to consider a new diagnosis.
In the case of my daughter, profiling worked to my benefit. Even before a physical exam began it was decided she was important to be seen.
In Sinclair's case, it worked against him. Time and time again he was profiled as unimportant — for more than 34 hours. This was not a case of being overlooked because of strained resources or hurried evaluation. Health professionals made a deliberate decision to classify him as non-urgent with disastrous results.
It is well established First Nations, Métis and Inuit people have poorer health in most measurements related to the general population. In the report Empathy, Dignity and Respect: Creating Cultural Safety for Aboriginal People in Urban Health Care, the Health Council of Canada further shares the feelings of aboriginal patients. One participant states aboriginal patients are "treated with contempt, judged, ignored, stereotyped, racialized and minimized."
If we are to be honest with ourselves as a medical profession, we must admit personal stereotypes can influence our patient profiling. Our awareness of those personal beliefs can make us better health-care professionals and better triage the limited resources we are given. If we ignore this reality, we shortchange the patients who come into our care.
Why 14 well-meaning health professionals profiled Sinclair's condition as non-urgent — with little supporting evidence other than his looks, his obvious double amputation, his demeanour and potentially his race — is cause for strong concern. If the second part of the inquest is not the place for this discussion, then so be it. It is foolish to believe, however, focusing on procedures and efficiency are going to fix inappropriate patient profiling.
In fact, we'll only profile faster.
Alika Lafontaine is an anesthesiologist practising in northern Alberta and is vice-president of the Indigenous Physicians Association of Canada.