Physician Health

Inside Mayo Clinic's 5-step process for handling biased patients

Timothy M. Smith , Contributing News Writer

Incidents of patient bias towards physicians and other health professionals are all too common, from subtle nonverbal actions to outright verbal attacks. Yet many health care organizations still lack policies, mechanisms and cultures to address them. Mayo Clinic recently developed a model for its staff to deal with racism, sexism, ageism and other types of patient misconduct while preserving patients’ rights and safety.

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The AMA Code of Medical Ethics provides additional guidance on dealing with inappropriate conduct, such as opinion 1.2.2, “Disruptive Behavior by Patients,” to help physicians establish and maintain mutual respect with patients.

Following are highlights from an article in the AMA Journal of Ethics® (@JournalofEthics) by Rahma M. Warsame, MD, assistant professor of medicine and diversity chair in the Division of Hematology at Mayo Clinic, and Sharonne N. Hayes, MD, professor of cardiovascular medicine and founder of the Women’s Heart Clinic at Mayo, highlighting their employer’s policies and procedures related to patient and visitor conduct.

“How health care organizations balance providing appropriate and necessary care to patients with maintaining a supportive, respectful work environment for staff can be a litmus test of organizational culture and leadership,” the authors wrote, noting that ignoring patient bias or taking a default patient-first approach can harm employee morale and open up organizations to legal liability. “Patients have a right to refuse care, but this right does not outweigh employees’ right to be free of discrimination.”

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Mayo Clinic convened a working group to develop its patient and visitor conduct policy after a growing number of reports that its patients had requested physicians with or without specific personal attributes. In addition, an organization wide assessment found that inappropriate behavior by patients and visitors disproportionately affected workers and students of color.

“Staff and learners reported feeling demoralized, marginalized, unsupported by their supervisory staff and without recourse due to the lack of policy guidance or a formal reporting mechanism to address bias incidents,” the authors wrote.

Mayo’s “SAFER model” was developed to address instances in which patients request care team members with characteristics unrelated to care, as well as when patients or visitors behave in a discriminatory, harassing or demeaning manner towards staff.

The Mayo SAFER model recommends the following responses:

  • Step in when you observe behavior that does not align with Mayo Clinic values.
  • Address (the inappropriate) behavior with the patient or visitor.
  • Focus on Mayo Clinic values (such as respect and healing).
  • Explain Mayo’s expectations and set boundaries with patients and visitors.
  • Report the incident to your supervisor and document the event using the patient misconduct form.

The model is reinforced by a decision tree for responding to inappropriate behavior and navigating requests based on care team members’ personal attributes, and an online reporting system documents inappropriate requests and episodes of misconduct.

Mayo also has a dedicated website with supportive resources—including videos, answers to frequently asked questions and tips for de-escalation—and training is available to all staff in distinguishing a patient’s needs from a patient’s preferences. Meanwhile, the working group remains in place to monitor the frequency and severity of bias incidents and assess adherence to the process.

In addition, Mayo revised its patient-responsibility policy preamble to state, “We won’t grant requests for care team members based on race, religion, ethnicity, gender, sexual orientation, gender identity, language, disability status, age or any other personal attribute.”

This policy does allow for several exceptions, such as when patients have had prior trauma, when they have cultural needs that inform their requests or if failing to accommodate the request would compromise the patient’s health.

An accompanying AMA Journal of Ethics case commentary explores, by way of a hypothetical clinical encounter, the ethical problems that emerge when physicians are subjected to racism from patients and the conditions under which these issues can best be addressed by individual staff and organizations.

The June issue of the journal features numerous perspectives on limits to patient preferences and gives you an opportunity to earn CME credit.