Medical Racism: Why Dr. Susan Moore's Story Hits Home

The egregious and tragic experience of Dr. Susan Moore is one that hits close to home for me. As I noted in a part article, my family has experienced a range of bias and overt racism in healthcare, particularly in 2018 and 2019 when our mom had an unforeseen medical emergency. This critical—and often heart-wrenching—time spanned several months and included countless ER visits to the local Sutter Hospital. At one point she was actually hospitalized for close to eight weeks, including a two week transfer to UCSF Med Center.

The account below is a slightly edited version of an email I sent directly to Sutter's patient complaint desk. I received a generic reply saying the feedback was sent to the appropriate departments, with no clear accountability or regret expressed.

I'm sharing this very personal story in hopes of illuminating and giving both face and name to the inequities that Black and/or immigrant families face within our healthcare system.

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This is lengthy and detailed, but provides context as to why I both lack confidence in the care here, and would give Sutter Roseville a low satisfactory score.

• In August and September [2018], my mother had a few hospitalizations in close proximity. Finally in mid-September, she was admitted due to sudden onset of complete confusion and going days without sleep. After a few days in the hospital, Dr. Mohamadien wanted to discharge her saying there was nothing else to be done after her battery of tests came back clear. After I shared that this was not her baseline and something else must be wrong, he finally ran another test for ammonia and found it was three times the normal level—the direct cause of her impaired mentation. Had I not pushed, this test never would have been done.
• My mother was in your ER two nights back-to-back with blood sugar over 350 the weeks prior to her November 13 [2018] admittance. She was sent home without the core issue being addressed or without anyone ensuring that she had blood sugar supplies at home and nobody following up to ensure there was a plan in place for something that could potentially be life-threatening. When I asked one of your ER doctors (Dr. Nasr) about this on November 13, she stated “that was the role of the primary care doctor.” So what if someone didn’t have a primary care doctor? They’re just out of luck and their ER visit does nothing to fix a chronic issue? In my mom’s case, and unbeknownst to me, she didn’t have any supplies at home due to an error on the part of her pharmacy.
• On November 13 [2018], after I repeatedly told both ER doctors that my mother's behavior and mentation had been severely altered for the two weeks prior and especially that day (she’d become essentially catatonic) they told me that they didn’t have any medical reason to admit her. Even after talking directly to her primary care doctor (Dr. Caron Houston) they only begrudgingly admitted her, while trying me to feel as though they were somehow doing me a favor. She had the first seizures of her life hours within being admitted.
• Within days of her admittance, I was approached by both a case worker discussing her discharge plan as well as the palliative care team—all before there was even a diagnosis for her. The latter meeting was especially egregious when Dr. Zin said it was totally up to me whether we continued the discussion. I shared with him what my concerns were and that I’d like to table the meeting until there was a clear diagnosis for her condition. Directly following that, he actually found it acceptable to continue, while condescendingly asking me if I understood what it meant to be resuscitated, breezing past my reply that I did, then going into explaining it in elementary detail. It was the social worker who interceded on my behalf to wrap up the conversation during which I was visibly uncomfortable, having repeatedly shared my wishes only to have them ignored. The irony of this was not lost on me, given that this was the team I was supposed to entrust my mother’s wishes to.
• Multiple times over the past week [February, 2019], I have told two hospitalists (Dr. J and Dr. Zin) that my mom’s mentation was worse now than when she arrived and that 75% of what she was saying was incoherent in both English and her native language. This was not the case when she was first admitted. Even after voicing my concerns, never once (until I talked to infectious disease) did anyone tell me that this confusion and encephalopathy could have been a direct side effect of her antibiotic, Cefepime.
• On February 13 [2019], Dr. Zin told (me more than once) they could keep her a few extra days and, “it didn’t really matter too much” on his end if they did or not, implying there weren’t any reasons he’d be advocating so hard for her to be discharged. Yet, he then proceeded to do everything in his power to facilitate a discharge.
• Next, Dr. Zin sent Morlene (nurse case manager) and Tammy (nurse) to deliver the news of untimely discharge rather than delivering that message himself. I found myself in a moment of true fear, confusion, anger, and frustration for all these experiences we’d encountered at Sutter thus far. In a heated moment, I told them I was done with the conversation and that I wanted them to leave my mother's room. Truly, I needed a moment to collect myself. Rather than honoring my ask, Tammy further aggravated the situation by rolling her eyes and telling me I was being “very rude and aggressive.” I hadn’t raised my voice, at all but simply spoke in a stern and unapologetic tone while asking for what I need in that moment: to be left alone to process the situation. I told her that she had no idea what our family had been through thus far to which she replied that she’d, “been through it with her dad and didn’t act this way.” Needless to say, drawing a personal comparison and telling a family member they’re being rude and aggressive (even if it’s true in that moment) does not exhibit the care and compassion so many other nurses have showed us during our time at Sutter. 

I also highly doubt that if I were a man, particularly a white man, that Tammy would have seen it appropriate or her place to tell me I was being rude or aggressive in advocating for my mom.

• Never mind the fact that my mom had no water in her room when I arrived and was telling me she was thirsty. Never mind the fact that even after I asked for water from the nurse at the front desk, Tammy still hadn’t brought it by 20 minutes later, or asked someone else to. Tammy should have been more concerned with tending to her patients than attempting to scold me like a little Black child she caught talking back. She had a choice in that moment, and she chose to fan the flames rather than show any professional empathy for my mom’s mentation and my fear surrounding it.
• Morlene also stressed that she and Tammy were “patient advocates” but in my opinion patient advocates would have led with curiosity for our concerns in that conversation rather than simply towing the line and delivering the message of discharge.
• Lastly, there are intentional omissions from the discharge summary that I would like to formally dispute and want flagged.