DR MAX PEMBERTON: I am shocked by the riots, but being racist does not mean you cannot get treatment from the NHS

The shocking case of two Filipino nurses who were attacked during last week’s unrest in Sunderland prompted Health Secretary Wes Streeting to announce that people who make racist comments against NHS staff “can and should” be turned away.

While I agree with Streeting that those who attacked the nurses “brought enormous shame upon our country,” I strongly disagree with him regarding turning patients away: it is not up to the doctor to make a moral judgment about who should and should not be treated.

Like Streeting, I was shocked by the scenes in Sunderland. It defies belief that good, kind, caring people who are trying to work to help others should be subjected to such abuse.

But being racist doesn’t mean you can’t get treatment from the NHS.

In my 20 years of practice, I have come across many cases of patients who have been racist, homophobic, misogynistic. Some have expressed truly disgusting beliefs. While I wouldn’t say it’s normal, it’s certainly not uncommon.

I have treated murderers, rapists, pedophiles and terrorists.

But it’s a slippery slope when you start making moral judgments about who can and cannot receive treatment based on what someone believes.

If we’re going to exclude racists, where does it stop? What about other things that the doctor might disagree with? What about climate change deniers, or people who eat meat, or people who disagree with abortion, or some other controversial area where one person finds the other’s views offensive and unacceptable?

In my first year as a physician, I remember a patient who refused to be treated by black staff members. He developed urinary retention, meaning his bladder was not working properly—an excruciatingly painful condition.

It was the middle of the night and I was called to insert an emergency catheter, but I had only practiced on a plastic model.

The other junior doctor who was on duty with me, who was black, was very competent and the patient suddenly thought about his racism when he was faced with the choice between someone who was white, but a complete novice, sticking something up his penis, or a black person who actually knew what he was doing. So I helped my colleague and the man was very grateful to both of us.

After we catheterized him, we talked to him about how everyone deserved to be treated with respect at work. We helped him see that by refusing to receive care from black staff members, he was not only creating an unpleasant environment for them, but was also affecting his own care. He later wrote a letter apologizing to the department staff for his behavior.

Wouldn’t that have been a better outcome – both from a medical-ethical point of view and in terms of changing someone’s mind – than simply denying him treatment?

It’s not just white people I’ve seen being racist. Working in multicultural London, I’ve seen Ethiopian patients abuse Eritrean staff, Pakistani patients attack Indian staff, Muslim patients make horrible comments about Jewish doctors. A Turkish patient refused to be cared for by a gay Turkish nurse because he felt the nurse was bringing shame on his family and country.

I’ve had a number of patients who say homophobic things in passing, use insulting swear words in conversation, and I always interrupt them, explain that I’m gay and that it’s quite difficult to hear such things. They’re often shocked.

“Oh, but you’re doing fine, doctor,” is a typical response, as if that makes it okay.

I have a policy of talking to them about how these attitudes can be really damaging and disturbing. You don’t change minds by turning patients away, as Streeting would have it – you change them by showing them unequivocal kindness, compassion and care

It’s not always easy. I recently spoke to a female staff member who had a patient who had been convicted of a violent sex crime. She had described women who didn’t wear the hijab as “sluts” and deserving of rape. Surprisingly, he was quite indignant that he had been convicted of rape. He said it was the fault of the men in this country for letting “their women” walk the streets and wear whatever they wanted.

This kind of shocking misogyny is not uncommon. I always challenge it. Often these patients have never heard opposing views — it’s a cultural thing for them and they just don’t realise that women are treated equally in Britain.

Once, as a junior surgeon in surgery, I was assigned to examine a particular patient. Within a few hours he was on the ward recovering from appendicitis—which would have been unremarkable had it not been for the prison guards escorting him and the handcuffs he was wearing. He was a convicted murderer. He had been taken to hospital for treatment and promptly returned to prison when he was better. The treatment he received was exactly the same as that given to any other appendicitis patient. The fact that I and the other surgeons were morally opposed to murder did not matter.

Sometimes, yes, it tests your tolerance to the limit. A friend of mine who worked in the ER once had to stitch up a man’s hand after he repeatedly punched his wife in the face. Even though she hated ever being in the room with him, she knew that as his doctor, she had to treat him no matter what.

There is no place in medical practice for value judgments based on things outside the clinical domain. Our role is to treat, not to judge.

Pain like Kirsty’s is all too real

Broadcaster Kirsty Young says she was made to feel like a “crazy lady” by a doctor who told her the condition causing her chronic pain – fibromyalgia – didn’t exist. This is in line with so many patients I’ve seen over the years seeking help for chronic pain.

It’s so easy to ignore pain when there’s no obvious underlying reason for it. Part of the reason, I think, is that pain is so complex – there’s no objective test for it, and it’s not clear why some people experience pain so differently than others. And sometimes there’s no underlying cause for the pain at all, and yet the person is severely disabled by it.

However, we do know that other means than the usual medication can help.

People with chronic pain who are fortunate enough to see a specialist are often surprised to find that they are being offered psychotherapy instead of more and more painkillers. This does not mean that their pain is “all in your head.” Things like sciatica, fibromyalgia, and other chronic pain conditions can be the result of a complex interaction between physical and mental states. Studies have shown that emotional and physical problems are processed in the same part of the brain, and it is likely that chronic pain is actually a “mind-body” condition, with emotions playing a major role in triggering or exacerbating pain.

It is not ignoring someone’s real suffering.usHow we feel mentally can have a major impact on how we experience pain.

For years, menopausal women have been treated appallingly by the medical profession. They have been denied HRT and their symptoms have been trivialised. But have things gone too far the other way? Dr Sue Mann, the NHS’s first national clinical director for women’s health, claims that there is now a perception that ‘everyone should be on HRT’ and that menopausal women feel like they are ‘missing out’ if they are not prescribed the drug. I have to say I agree. While I regret that doctors have been so wary of HRT for so long and that women have undoubtedly suffered as a result, the current trend of pushing it on everyone is equally wrong.

There are a wide range of treatments and interventions to help women going through the menopause, from CBT to medications that target specific symptoms, such as Veoza, which treats hot flashes and night sweats. These are just as valid as HRT. Everyone is differentrent and we need to give women every option to find what works for them.

Despite all the excitement surrounding new Alzheimer’s drugs like lecanemab and donanemab, experts warned last week that they will likely result in little improvement in symptoms, and only for those in the earliest stages of the disease. What’s more, they will require significant resources to identify those who qualify, administer the intravenous medication, and monitor them for side effects. While they are a major step forward in the fight against this terrible disease, I fear that they have been overhyped, and the search for a cure continues.

Dr. Max prescribes: Fruit and vegetables

You’d hope that the advice to eat fruit and veg would be a thing of the past these days, but according to the latest research, the average Briton won’t eat a single piece of fruit for a month and no green veg for three weeks. It’s shocking, honestly! We know that fruit and veg contain a wealth of disease-fighting nutrients and antioxidants, as well as fibre, which helps our gut and protects against cancer. Come on, let’s reach for the (green) groceries this summer!