Physician Health

Medicine’s “open secret”: What to do when patients hate

Patients who express ethnic, racial, sex, age or other forms of discrimination can present a dilemma for physicians: how to care for patients while also caring for themselves. A recent webinar provided real-life examples of discrimination in clinical settings and points to the need for best practices and formal training in dealing with intolerance.

“This topic is considered by many people … to be medicine’s open secret,” said presenter Anupriya Dayal, a fourth-year medical student at the Medical College of Wisconsin and a member of the AMA Minority Affairs Section Governing Council. “It’s also known very commonly to be something that is not well discussed.”

The webinar, “Upholding the Hippocratic Oath when Providers Face Discrimination from Patients,” (begins at 19:15) features numerous examples and notes the uncertainty that physicians can face in responding.

An Indian physician, Sachin H. Jain, MD, was confronted by a patient frustrated that he was unable obtain his usual type of insulin. “You people are so incompetent,” the patient said, adding, “Why don’t you go back to India?” Dr. Jain reacted angrily at first, asking the patient to leave the hospital. When he consulted with his colleagues, some made light of the patient’s behavior, while others suggested Dr. Jain apologize to the patient.

A Chinese-American physician, Pauline W. Chen, MD, felt intimidated and threatened by a patient she was treating in the emergency department. As the patient raised his arm as if to hit her, Dr. Chen noticed a swastika tattooed on his arm. When she mentioned the encounter to a fellow physician, the colleague recommended she make it a teachable moment and “educate [the patient] about racism.” 

An African-American medical resident, Tamika K. Cross, MD, while on a Delta Airlines flight from Detroit to Minneapolis, offered to administer emergency medical assistance to a fellow passenger. She was allegedly told by a flight attendant that an “actual physician” was needed. Publicity of the incident sparked a nationwide conversation about how physicians should establish their credentials in public emergencies.

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The uncertainty felt by many physicians in confronting discrimination is partly owed to a lack of best practices, Dayal said, noting that medical students often don’t receive any training on the subject.

The webinar features highlights of an article published in Academic Medicine that explores the perspectives of faculty educators seeking to identify strategies physicians and medical students can employ to address the issue. Their recommendations are to:

  • Assess illness acuity to determine whether immediate medical intervention is necessary.
  • Cultivate a therapeutic alliance to put attention on a shared goal.
  • Depersonalize the event to minimize heedless responses and negative emotional reactions that could interfere with patient care.
  • Ensure a safe learning environment by encouraging trainees to feel empowered to remove themselves from a discriminatory encounter.

 

What the AMA Code of Medical Ethics says

The AMA Code of Medical Ethics has guidance for physicians facing discrimination by patients. In Opinion 1.2.2, “Disruptive Behavior by Patients,” the Code explains:

The relationship between patients and physicians is based on trust and should serve to promote patients’ well-being while respecting their dignity and rights.

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.

Trust can be established and maintained only when there is mutual respect. Therefore, in their interactions with patients, physicians should:

     (a) Recognize that derogatory or disrespectful language or conduct can cause psychological harm to those they target.

     (b) Always treat their patients with compassion and respect.

     (c) Terminate the patient-physician relationship with a patient who uses derogatory language or acts in a prejudicial manner only if the patient will not modify the conduct. In such cases, the physician should arrange to transfer the patient’s care.

AMA Principles of Medical Ethics: I,II,VI,IX

In addition, the AMA Journal of Ethics® features a physician’s perspective on dealing with homophobia in the patient-physician relationship, as well as a commentary, “The Prejudiced Patient,” co-authored by Dr. Jain. The April issue of the AMA Journal of Ethics will be devoted to moral psychology and "difficult" patient-physician dyads. Sign up for email alerts.

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