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

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 that Amy Nicole Cowan, MD, explored in a JAMA Internal Medicine essay, “Inappropriate Behavior by Patients and Their Families—Call It Out.” In her commentary, Dr. Cowan—an associate professor on faculty at the University of Utah whose clinical practice is at the George E. Wahlen, Department of Veterans Affairs Medical Center in Salt Lake City—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, along with guidance for doctors and physician leaders from the AMA Code of Medical Ethics.

“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.”

“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.”

Typically, medical students and resident physicians 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 Dr. Cowan conducts alongside more traditional clinical topics.

Dr. Cowan wrote that she 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,” Dr. Cowan wrote.

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, updated in 2020, addresses the question of unacceptable behavior from either side in Opinion 1.2.2, “Discrimination and Disruptive Behavior by Patients.”

“Disrespectful, derogatory or prejudiced language or conduct, or prejudiced requests for accommodation of personal preferences on the part of either patients or physicians can undermine trust and compromise the integrity of the patient-physician relationship,” the Code of Medical Ethics says.  “It can make individuals who themselves experience (or are members of populations that have experienced) prejudice reluctant to seek care as patients or to provide care as health care professionals, and create an environment that strains relationships among patients, physicians, and the health care team. 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 disrespectful, derogatory or prejudiced language or conduct can cause psychological harm to those who are targeted.
• Always treat their patients with compassion and respect.
• Explore the reasons for which a patient behaves in disrespectful, derogatory or prejudiced ways insofar as possible. Physicians should identify, appreciate and address potentially treatable clinical conditions or personal experiences that influence patient behavior. Regardless of cause, when a patient’s behavior threatens the safety of health care personnel or other patients, steps should be taken to de-escalate or remove the threat.
• Prioritize the goals of care when deciding whether to decline or accommodate a patient’s request for an alternative physician. Physicians should recognize that some requests for a concordant physician may be clinically useful or promote improved outcomes.
• Within the limits of ethics guidance, trainees should not be expected to forgo valuable learning opportunities solely to accommodate prejudiced requests.
• Make patients aware that they are able to seek care from other sources if they persist in opposing treatment from the physician assigned. If patients require immediate care, inform them that, unless they exercise their right to leave, care will be provided by appropriately qualified staff independent of their expressed preference.
• Terminate the patient-physician relationship only when the patient will not modify disrespectful, derogatory or prejudiced behavior that is within the patient’s control, in keeping with ethics guidance.

The AMA Code of Medical Ethics adds that physicians, especially those in leadership roles, should encourage the institutions with which they are affiliated to:

• Be mindful of the messages the institution conveys within and outside its walls by how it responds to prejudiced behavior by patients.
• Educate staff, patients, and the community about the institution’s expectations for behavior.
• Promote a safe and respectful working environment and formally set clear expectations for how disrespectful, derogatory, or prejudiced behavior by patients will be managed.
• Clearly and openly support physicians, trainees, and facility personnel who experience prejudiced behavior and discrimination by patients, including allowing physicians, trainees, and facility personnel to decline to care for those patients, without penalty, who have exhibited discriminatory behavior specifically toward them.
• Collect data regarding incidents of discrimination by patients and their effects on physicians and facility personnel on an ongoing basis and seek to improve how incidents are addressed to better meet the needs of patients, physicians, other facility personnel, and the community.

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.’”