Incidents of identity-based patient bias are disturbing for all health professionals, but they can present especially intense challenges for physicians in training due to the number of patient interactions they experience. A lawyer specializing in anti-discrimination and health law recommends a five-step approach to helping colleagues during a real-time discrimination incident and addressing discrimination organization-wide.
Following are highlights from an article published in the AMA Journal of Ethics® (@JournalofEthics) by Kimani Paul-Emile, PhD, a professor at Fordham University School of Law, with recommendations based on lessons drawn from grand rounds she conducted at U.S. medical organizations.
“Despite the startling statistics regarding patients’ treatment of trainees, data and overwhelming anecdotal evidence show that organizations are not adequately supporting their trainees in dealing with these abusive patient encounters. Indeed, 50% of surveyed residents who experienced or witnessed patient discrimination didn’t know how to respond, while 25% believed that nothing would be done if hospital leadership were notified,” Paul-Emile wrote, citing a 2016 study.
She suggests five protocols that together “constitute a clinically, ethically and legally appropriate means of supporting trainees while protecting the interests of patients and health care organizations.”
Assessment. When an incident occurs, a supervisor should immediately acknowledge the patient’s misconduct and determine whether the resident wishes to handle the situation on her own.
“If the trainee doesn’t, then the supervisor must intervene to inform the patient that the trainee is qualified to treat patients and that bigoted conduct will not be tolerated,” Paul-Emile wrote. “After conferencing with the trainee, it is imperative that, whatever is decided, the supervisor model appropriate behavior and not force the trainee to accede to the patient’s biased demands, as this may violate both employment and education anti-discrimination laws.”
Debriefing. After the event, an affected resident should have an opportunity to talk frankly about it, preferably with someone he trusts.
“It’s also important that supervisors and the organization not minimize the encounter and instead commit to understanding how the trainee may have experienced the harassment or rejection with an eye towards crafting a meaningful future response,” Paul-Emile added.
Team meeting. A bias incident can affect onlookers too, but it’s possible that coworkers are unaware of the incident. A supervisor should convene a meeting to enable all clinical team members to discuss their experiences and how to address similar situations.
“Bringing these incidents to light can not only inform the team but also help prevent affected staff from internalizing the bias; since these encounters can feel like an assault, internalizing the experience is more likely to happen if staff feel alone in the experience, that they won’t be supported or that they will be accused of being overly sensitive,” Paul-Emile wrote.
Tracking and data collection. Baseline information—such as the frequency of incidents, the organization’s responses, the effects on targeted workers and the departments most affected—can further a systemic understanding of the issue and guide responses.
Organizational culture change. As evidenced by the recent #TimesUp and #MeToo movements, many who brought sexual misconduct claims against coworkers worked at organizations that had sexual harassment policies but lacked a norm of coming forward.
“Even with the best policies in place, a culture of non-reporting will undermine meaningful change,” Paul-Emile wrote. “Supervisors must be sensitive to this dynamic and work with the organization to create a norm of reporting and a culture of supporting staff members who have experienced discrimination.”
The AMA Council on Ethical and Judicial Affairs is currently reviewing existing guidance on disruptive behavior by patients in light of increasing reports of incidents in which patients discriminate against physicians.