How Physicians Can Combat Discrimination by Patients

Nicola M. Parry, DVM

October 26, 2016

Mistreatment of physician trainees by supervisors and other team members is well documented. But the prevalence and appropriate responses to mistreatment by patients and patient families has received less attention. Now, researchers identify four specific strategies that doctors can use when facing discrimination from patients or their families.

As a first response, doctors who find themselves in this situation should "1) assess illness acuity; 2) cultivate a therapeutic alliance; 3) depersonalize the event; and 4) ensure a safe learning environment for trainees," write Emily E. Whitgob, MD, MEd, from Stanford University, and colleagues in an article published online October 26 in Academic Medicine.

"We believe these approaches begin to form a model that can be taught to trainees and faculty alike to ensure adequate preparation for these events."

Mistreatment of medical trainees is a widespread problem According to studies over the last 5 years, trainee mistreatment and discrimination have been reported by 17% to 95% of medical trainees. One meta-analysis identified verbal harassment as the most common form of mistreatment, with discrimination based on gender (4%) and race (19%) most prevalent.

Medical schools must now document all incidents of trainee mistreatment, and, in 2013, the Accreditation Council for Graduate Medical Education was also called upon to address cases of resident mistreatment, according to the authors.

Only one study, however, has investigated the prevalence of mistreatment of trainees by patients, finding that patients accounted for nearly 40% of all mistreatment encounters experienced by residents. Further, in a 2015 survey of pediatric residents at Stanford University by Dr Whitgob and colleagues, 50% of respondents indicated a lack of knowledge about how to respond to mistreatment by patients and their families.

With this in mind, Dr Whitgob and colleagues conducted a study to identify strategies for trainees and doctors to use if they experience discrimination from patients and their families, and to identify specific educational strategies to help address this issue.

The researchers interviewed 13 physicians from Stanford University's pediatric residency Program Evaluation Committee who covered a range of roles within the residency program.

The 13 physicians each underwent a 75-minute, one-on-one interview in which they discussed how they would advise trainees to respond, and how they would respond as the supervising physician, to scenarios of discrimination involving race, gender, and religion.

After analyzing the physicians' interviews, the researchers identified four themes in how participants would respond to discriminatory remarks and parents' requests to see a different provider.

Assess illness acuity. Participants agreed that providers should first assess patient acuity: in cases of emergency, providers should ignore or avoid responding to discriminatory comments, and should not grant parents' requests to see an alternative provider.

Cultivate a therapeutic alliance. In nonemergency cases, however, participants emphasized that providers should cultivate a therapeutic alliance with patients and families as a constructive response to discriminatory comments.

Participants believed that parents' anxieties about their children's medical situations could drive their mistreatment of providers. As a consequence, participants therefore recommended that providers build rapport and trust with parents, empathizing with their anxiety to distract parents from their personal prejudices. Providers should have parents focus on a shared goal of managing the child's immediate medical needs, highlighting the qualifications of the medical team as a whole.

"Participants believed identifying, naming and validating the emotional experience underlying the discriminatory remark was an important step in establishing trust with families," the authors write.

Depersonalize the event. Participants also suggested that providers not take parents' discriminatory remarks personally, and instead focus on professional values and patient care as a strategy to avoid reacting to the mistreatment. Providers should realize that such comments reflect more about the parents than about the provider, the participants agreed.

Ensure a safe learning environment for medical trainees. Although all participants wanted to protect trainees, they acknowledged that not all incidents of mistreatment could be prevented, and therefore emphasized the importance of ensuring a safe learning environment for trainees. However, participants also expressed the need for providers to make their own decisions about how to deal with discrimination from patients or families. In particular, if a discriminatory encounter threatened to compromise patient care, participants hoped trainees would remove themselves from the situation, because waiting for faculty to make this decision would further undermine trainees' autonomy.

Participants emphasized that medical trainees need education early in training to help them cope with discriminatory encounters with patients and families because such incidents cannot be completely prevented. Case-based discussions are particularly useful educational tools to help providers work through such encounters and identify what behaviors they are willing to accept, how best to respond, and when they should remove themselves from a situation.

Based on the results of this study, Dr Whitgob and colleagues emphasize the need to create institutional policies, at all levels, for addressing the issue of patients who discriminate against providers.

"Processes must be in place to ensure protection of trainees and the faculty who train them, and to ensure continuity of care for patients needing transfer when they refuse to be treated by the team," they conclude.

The authors have disclosed no relevant financial relationships.

Acad Med. Published online October 26, 2016. Abstract

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