‘At the private hospital, the disrespect was just more subtle’: a tale of America’s two healthcare systems | Well actually

Walking into the main hospital building at NYU on my way to orientation on my first day, I passed through what’s known as the Hall of Portraits. This is a long bank of paintings in gilded frames hanging in a corridor off the main lobby at Tisch hospital. Every single one of the faces I saw in those portraits was that of a white man. Some wore glasses, some posed with microscopes, others held a pen in hand. Doubtless, these men in the pictures were physicians and surgeons who had made important scientific advancements in their respective fields over the past few centuries. Some of the paintings looked old enough that I wondered how many of their subjects had participated in and profited from slavery or had experimented on enslaved people. They certainly would have benefited from the racist and sexist admission policies that had excluded people who looked like me from medicine for centuries.

I was the very first Black woman faculty member in my department. It was 2010. I chose to keep my head high. I walked past the bank of portraits with a sense that my very presence was a rebuke to the white men in those paintings, that I did belong there. I reminded myself that it was important for me to be in these kinds of spaces so that Black students and residents could see someone who looked like them, came from the same communities as them, and cared deeply about our communities, who could mentor, motivate and inspire them.

My days as faculty were divided up between my clinical shifts in the emergency department, supervising medical students and residents, and my academic work. On the academic side, I was giving lectures to students, running workshops with residents and engaging in educational research in ultrasound, focusing on how this technology could be better leveraged as a tool to teach anatomy and physiology.

The other three or four days of the week, I was a practicing physician at one of two ERs. The first was at NYU Tisch, the private hospital that was part of the university. The other was at Bellevue, the public hospital affiliated with the medical school. These two ERs sit right next door to each other.

The private emergency room at Tisch was nothing less than a well-oiled machine. Named for the family of billionaires who endowed the institution, Tisch hospital was highly resourced in every way. No patient had to share a room with anyone else, every patient was accounted for, and arranging follow-up appointments was a breeze. When I put in my CT scan order, the order would magically get fulfilled – every time. Although we were dealing with a much smaller volume of patients than I had seen at Kings County, we had many more nurses per team and were much better staffed in terms of attending and resident physicians. As a result, I was able to care for many more patients on a given shift because I wasn’t caught up doing extraneous tasks.

But perhaps the biggest difference from Kings County was in the patient population. The people in the waiting room at Tisch were relatively wealthy, insured, with access to high-quality care outside the ER – and by extension, they were mostly white. Often, patients came to the Tisch ER because NYU specialists had referred them for an emergent issue. Even before they arrived at the ER, they were fully plugged into a medical system that they understood how to navigate and that understood them. These patients received rapid, individualized treatment, and immediate follow-up plans were made. Sometimes, we would get calls warning us that a “VIP” was on their way over. These VIPs were usually benefactors, board of trustees members or even members of the Tisch family.

My other shifts were spent at the Bellevue ER, part of the largest hospital in New York City and the oldest public hospital in the country. To say we saw a more diverse patient population at Bellevue would be an understatement. At Bellevue, patients came from every corner of the city – and the world. This was an ER with a reputation for being a place where no one would be turned away, regardless of their immigration status or ability to pay.

The year I arrived at NYU, the Affordable Care Act was passed, which created new health coverage options, with many uninsured becoming eligible for coverage when their states adopted Medicaid expansion under the ACA. This was excellent news and went some way toward addressing health insurance coverage inequities in our country. But at Bellevue, it didn’t seem to make any dent in the numbers of people we saw on a daily basis, most of whom lacked insurance.

Bellevue was a chaotic place. The ER sits right next door to a large men’s shelter for people who are unhoused, which meant we were taking care of people struggling with lack of safe and adequate housing and a host of physical and mental health problems, including substance use disorder. The hospital was also a level 1 trauma center, so we managed many of the city’s gunshot and stabbing victims, and we had a contract with the city’s department of corrections, so people who had just been arrested came to the ER to be medically cleared before being taken to jail. I had nights on the job when I was cussed out by intoxicated patients, and when patients lashed out at me not just verbally but also physically.

On any given shift, we were seeing people who had slipped through the cracks of a system that was simply not built to serve them. I can still remember the pain-stricken features of a young Black man who came in with a broken leg that had become dangerously infected. He had been hit by a car several weeks back and had been taken to one of the other ERs in the city, where he was diagnosed with a tibia-fibula fracture in his leg. He had been discharged with a splint, but because the hospital staff there hadn’t arranged for proper follow-up for him, he had been sitting at home suffering in increasingly unbearable pain. Eventually, he came to us, where we diagnosed him with necrotizing fasciitis, an infection of the tissues beneath the skin, a very serious and potentially life-threatening condition that could have been avoided if he’d only been able to see a doctor many weeks ago. We would often care for patients like this who had been “lost to follow-up”, which meant that although they had been treated at the time of their emergency, they hadn’t been able to access care beyond that point.

Often, I was dealing with patients battling substance use disorders; many were suffering with mental illnesses. I knew at the start of a shift that there was a chance I was going to be called the N- or the B-word. One time I was on shift with my senior resident, a young Black woman. She told me that she had just come from seeing a psychotic patient, a white woman, who was yelling the N- word repeatedly at the top of her lungs.

“The patient says she doesn’t want me to see her,” the resident explained, visibly shaken.

I told her I’d go and see the patient myself. As I walked into the room, the patient started screaming the same epithet, demanding that I leave the exam room. She was disheveled, her hair was a mess, her clothing stained as she paced around her stretcher. She was clearly in a bad state mentally, but as I didn’t sense she was a danger to me, I went over and tried to engage her in a conversation to see if I could get her to cooperate with us. Perhaps I should have been upset at being called the N- word, but instead, I stayed calm.

I knew that the number of patients needing psychiatric treatment in the city was far greater than the number of inpatient psychiatric beds available, which is why so many people like this woman ended up on the streets and in the city’s emergency rooms.

At the private hospital, although the patients presented as polite and well-spoken, I also experienced a certain level of disrespect; it was just a lot more subtle and insidious. I could sense as soon as I entered a room if my white patients were going to have problems with me; I had learned to detect a flicker of confusion in their eyes as they sized me up, trying to figure out how I fit in. Some supposed misunderstandings became almost routine.

One time, the chief of service in the emergency department called to tell me there was a problem with one of my patients.

“Really?” I asked. “What’s going on?”

The chief explained that this patient had complained he hadn’t seen the supervising doctor yet.

“But I was just with that patient,” I explained. “I saw him, examined him and recommended treatment.”

It didn’t take us long to figure out what had happened. Although I had spent a full 20 minutes with this patient, this white man had refused to believe that a Black woman could be his supervising doctor.

One night, I had been on my shift for nearly eight hours and was getting ready to go home. My last visit was to a woman with pain in her calf. She had come to the ER with her daughter. After I’d examined the patient and told her it was a sprained muscle, the daughter asked me for a second opinion. “And it’s not because you’re Black,” she added.

It had been a tough shift and I was exhausted. All I wanted to do was to go home. But now I had to arrange for a second opinion demanded by my patient’s daughter. I asked my colleague, a white woman, to go and take a look. She came back and said: “I completely agree with you, it’s a strained muscle.”

To this day, only 9% of the discharged patients at Tisch are Black, compared with 26% from Bellevue. Across the nation, studies show that Black patients are two to three times less likely than white patients to be seen at private academic medical centers, which have a reputation for providing superior care. Uninsured patients are five times less likely than patients with private insurance to be seen at these types of hospitals.

Working at NYU, we knew that when EMS picked up unhoused patients in an ambulance, they would never bring those patients to the private hospital. They only brought them to the public hospital. This was the unspoken rule. We all knew that interns weren’t allowed to work at Tisch ER because that would mean a wealthy private patient might complain of inadequate care. Instead, if you were an intern, you went to work at the Bellevue ER, where the assumption was that people would be grateful for your help, no matter how inexperienced you were.

In my 10 years working at Tisch and Bellevue, I can count on one hand the number of times anyone broke the silence about the existing segregated system of healthcare. When someone did, it was usually a Black person or person of color.

“How come the FDNY guys are so rude to the patients they bring to the ER at Bellevue?” one of my residents, an Indo-Caribbean woman, asked one night. “They would never speak that way to a Tisch patient!”

She was right. The paramedics would routinely shout at the public hospital patients and treat them roughly, while remaining courteous with the private patients in their care.