Jax*, a junior registrar, is in my office to discuss a patient in the emergency department. It is only a few weeks since the start of the rotation and I am still getting to know the new cohort of junior doctors. But Jax has been hardworking, keen to learn, and gives a good account of the patient’s history and examination findings.
Something else strikes me more. We are in the middle of a heatwave severe enough that the State Minister of Health has sent an email urging all staff to stay cool. But Jax is sweaty, wearing an unusually high collared shirt buttoned to the top, even though he is not wearing a tie, as recommended for infection control.
We decide on a management plan for the patient. I decide to ask about Jax’s choice of work attire, framing it as concern for his wellbeing during a heatwave.
Jax gives me a strange look and tells me that another consultant has told him that his neck tattoo is unprofessional and that Jax must keep it covered up if he wants a good assessment.
Jax goes on to tell me that he started as a hospital orderly and put himself through medical school while working in a variety of health settings. This is the first time that he has been asked to cover up his tattoo. He adds that the consultant told him that covering tattoos was ‘the policy’ for doctors, and that the tattoo revealed Jax’s ‘background’. Jax seems to be taking this better than me. By now I am a ball of astonishment and indignation at the discrimination displayed towards Jax.
How does a tattoo affect his clinical performance, and why shouldn’t Jax be proud of his background? Has the consultant not been out into the ‘real world’ lately and seen how common and acceptable tattoos are? And are we to believe that doctors are on such a pedestal that a tattoo that was acceptable when Jax was an orderly is unacceptable now that he is a doctor?
I ask Jax what he would like me to do, and he says “Do nothing”.
Jax is concerned that making a big deal of this will cause hostility between himself and the consultant. Nevertheless I do a couple of things. I check with HR whether there is a policy regarding doctors covering their tattoos. There isn’t. There is a policy that all staff are required to cover tattoos which contain offensive words or images but Jax’s tattoo is an abstract pattern. I also contact the Medical Education Unit and discuss the issue, in case it affects Jax’s assessment later on. The Medical Education Unit are very supportive and make a note in their files. I tell Jax that I have done these two things but will not do anything else unless he wants me to.
I understand Jax’s predicament. Although I would dearly love him to unbutton that top button, cool down, and speak up to the consultant, I know that it is often easier to stay silent (and in this case, sweat). Existing hierarchies and dynamics work to continue this situation across a range of specialties. Even at consultant level, it is not easy to jeopardise a long term working relationship with another consultant for a problem that will be ‘geographically cured’ when the junior doctor rotates elsewhere. In some specialties, unacceptable behaviours have become so normalised that consultants who speak up become victimised themselves, even when the point they are making would seem reasonable to a layperson.
Discrimination is defined as ‘treating a person less favourably, including offending, intimidating, harassing or humiliating on the basis of legally protected attributes or personal characteristics.’ Legislation outlines a list of attributes and personal characteristics against which discrimination is unlawful, including sex, age, religious belief, political belief, pregnancy, breastfeeding, disability, impairment, marital status, family responsibilities, sexual orientation, gender identity, race and cultural background. Jax’s experience is an example of discrimination on the basis of cultural background.
Discrimination can be subtle, arising from an unconscious bias without malicious intent. In these situations, consider speaking up immediately, perhaps using gentle humour to avoid social embarrassment for the giver. “How lovely that you like my skirt. I like your pants too” (gender discrimination), or “Thanks for inviting my wife to the team party. Can my husband come as an honorary woman?” (sexual orientation discrimination). The intention in these cases is simply to raise awareness, and the response is usually favourable if the giver has the opportunity to change to a non-discriminatory stance without losing face.
In other cases the discrimination is deliberate and malicious. Repeated occurrences may constitute harassment or bullying. Examples include name-calling based on personal characteristics (“shortie”, “bonehead”), negative comments (“Of course you wouldn’t come to the team party. You Muslims don’t drink!”), exclusionary behaviour (“This procedure needs someone with muscles – not a girl like you”), and unfair rosters (“If you want to take maternity leave later on, you have to do all of your on call in the first half of the rotation”).
Indirect discrimination can occur where a requirement is universally applied, but acts to disadvantage someone on the basis of a personal characteristic. Indirect discrimination, just like direct discrimination, can be inadvertent, for example requiring everyone to use the stairs up to the wards ‘because it’s faster than the lifts, and better for your health’ which may be physically difficult for team members who have osteoarthritis or are pregnant. Again, consider speaking up immediately and gently in these situations. However, indirect discrimination can also be deliberate, for example ‘team bonding’ involving alcohol where those who do not drink are mocked.
What should you do if speaking up is not appropriate, or if you have spoken up and received an unfavourable response? The overall recommendation is to institute a response that is gradually stepped up and broadened, but the exact steps will depend on your personal setting and resources. But first, write down your experience and develop some clarity about what specific behaviours you consider discriminatory, and against which personal characteristics. It is much easier for others to help if they are acting on specific information, rather than a general feeling of upset, indignation or anger.
Have an idea of the outcome you would like, which may be as simple as ‘letting someone know’ but may also include specific outcomes such as ‘change in behaviour’ or ‘receiving an apology’. Then share your experiences with trusted colleagues, mentors, or seniors. They may be able to suggest further actions, or to take action themselves. These may include contacting the Medical Education Unit, contacting HR, talking to departmental leaders, contacting training agencies such as professional colleges, contacting employee support services, contacting medical indemnity organisations, or utilising peer support networks.
What should you NOT do? You should not engage in personal attacks or start a ‘trial by social media’. No one is perfect, and many unconscious biases reflect the generation of the giver, as views about issues such as gender roles, religious diversity, sexual orientation and tattoos, have changed over time. Vilification or public identification of a giver constitutes unacceptable behaviour in itself, and will make others less willing to help you resolve your problem.
A few days later Jax and I are chatting in theatre after Jax spent the day assisting the consultant. I ask about the neck tattoo, which is clearly visible because there are no items of theatre clothing that could fully cover it (have you ever seen high neck scrubs?) Jax simply says ”Well, he didn’t mention it today”. We remain hopeful.
* Names have been changed to protect the privacy of individuals.