Ethics

The do’s and don'ts of calling out a patient's bad behavior

Most physicians will encounter patient comments that are rude—or worse. Be prepared with a ready reply and an understanding of the ethics involved.

It’s a clinical curveball, though in this case a physician in training can’t turn to science for help. What does a doctor do when a patient’s biased, disrespectful or hateful language threatens to get in the way of necessary treatment?

It’s a situation Amy Nicole Cowan, MD, explored in a JAMA Internal Medicine essay, “Inappropriate Behavior by Patients and Their Families—Call It Out.” In her commentary, she described an end-of-life situation for an elderly patient whose family members very vocally found fault with apparently everything, including the treatment team.

They didn’t want to work with the Muslim medical student, the intern (“whom they felt was not a real physician”), the dark-skinned senior resident, or Dr. Cowan herself.

“To say that this family was disappointed when they learned that I, the attending physician, was a woman would be an understatement,” she wrote.

Dr. Cowan made clear to the family that this was the team they would be working with, but the incident brought to mind similar situations that had left her feeling “stunned, feet weighted, mouth paralyzed.”

She has since developed effective ways of dealing with those incidents. Here are the three key takeaways from her commentary.

Have a reply ready. “I have a quick response I can make with minimal thought,” she wrote. “‘We don’t tolerate that kind of speech here,’ or ‘Let’s keep it professional,’ or ‘I’m leaving because I don’t feel comfortable’ are my standard lines.” It allows her to call out the objectionable behavior, “set a clear limit, and seamlessly move to the task at hand.”

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Be firm in the face of unacceptable behavior. “While in the moment I use plain language—no arguments, no apologizing or negotiating—when the situation later deserves to be explored, I will circle back to the bedside on my own.”

Trainees and medical students need to have this taught to them. Typically, they are at a loss on how to handle such situations. Roleplaying about how to address unacceptable comments and boundary issues are now part of the hospital hallway learning she conducts alongside more traditional clinical topics.

Dr. Cowan plays the role of the aggressor and her trainees have a chance to try out a ready response. It can still be an uphill battle. “Sometimes when they cannot overcome their paralysis, I gently remind them they will not die from being uncomfortable.”

Answers from medical ethics

Patient provocations are bound to happen from time to time, but professionalism is always the expectation for physicians.

Also, while clinicians are often on the receiving end of inappropriate language, some patients also report disrespectful treatment from doctors. Guidance from the AMA Code of Medical Ethics addresses the question of unacceptable from either side in Opinion 1.2.2, “Disruptive Behavior by Patients.”

“Disrespectful or derogatory language or conduct on the part of either physicians or patients can undermine trust and compromise the integrity of the patient-physician relationship. It can make members of targeted groups reluctant to seek care, and create an environment that strains relationships among patients, physicians, and the health care team,” the Code of Medical Ethics says. “Trust can be established and maintained only when there is mutual respect.”

The Code says that in their interactions with patients, physicians should:

  • Recognize that derogatory or disrespectful language or conduct can cause psychological harm to those they target.
  • Always treat their patients with compassion and respect.

If a patient “uses derogatory language or acts in a prejudicial manner only” and refuses to “modify the conduct,” the Code says, then “physician should arrange to transfer the patient’s care.”

Dr. Cowan’s commentary captures, in practical terms, how that guidance plays out in face-to-face encounters with patients: “My message to whomever I am correcting is always the same, ‘I care about you as a person, but I will not tolerate offensive behavior. Now let’s focus on how I can help you today.’”