In 2013, when Emily Whitgob, MD, MEd, was a resident, an intern reported an incident to her. A parent of a pediatric patient had looked at the intern's name tag and asked if she was Jewish, saying that he did not want a Jewish doctor.
When the intern told Dr. Whitgob, "I was taken aback and shocked," she said. "I turned to the attending and said, 'Did you hear this?' But that was the end of the discussion."
Dr. Whitgob said that she was disappointed but not surprised by the lack of support. There's an understanding, she explained, that trainees have to put up with such discrimination, ranging from the subtle dig of "You speak English so well" to more blatantly bigoted statements.
But awareness of this type of behavior has been gaining attention due in part to the country's political climate and in part to changing demographics and more racial and cultural diversity among physicians, said Bernard Lo, MD, FACP, who coauthored an article on the subject in the Feb. 25, 2016, New England Journal of Medicine.
Both Dr. Lo and Dr. Whitgob, who is now a clinical fellow in the division of neonatology and developmental medicine at Stanford University School of Medicine in Palo Alto, Calif., advocate the creation of detailed protocols to help trainees deal with discrimination by patients. Whether disparaging comments about race, gender, or religion are directed at or witnessed by trainees, they need to know what to do next and have confidence that the attending and administration have their backs, Dr. Whitgob said.
"You can't train the entire public how to be respectful, but you can prepare in advance to know what to do," she said.
Developing a plan
Dr. Whitgob was a coauthor on a recent article in the November 2016 Academic Medicine that explored potential strategies to combat discrimination. While previous studies found that trainee mistreatment and discrimination is widespread—between 17% and 95% of trainees report it—she and her colleagues found that none offered pragmatic advice that would help on the front lines with incidents such as the one she encountered as a resident.
While interns are often told to just leave the room if they don't feel comfortable, Dr. Whitgob said that doesn't help the trainee cope with the situation or with lingering feelings of inadequacy.
In her study, Dr. Whitgob and her coauthors interviewed pediatric faculty educational leaders at Stanford, asking how they would respond to scenarios of discrimination and how they would tell their trainees to respond. The faculty said that they were most concerned about protecting their trainees. Here are their four recommendations on the best ways to do that:
Assess illness acuity. Determine whether the patient has an emergency or can come back another day or wait for another physician. In an emergency, such as when a patient is having a heart attack, point out the risks for delay of care if the patient should choose to be transferred, Dr. Whitgob said.
In some cases, it may not be possible to find another clinician, and patients should be made aware of that as well. ACP Resident/Fellow Member Farah Naz Khan, MD, wrote an article for the Daily Beast in September 2015 about a patient's family member who didn't want care by an Indian doctor. Because everyone on the team was Indian, the patient had limited options. The patient and her family ultimately agreed to the care "only because one doctor was on call and that doctor was Indian. Otherwise she didn't want it," said Dr. Khan, a fellow at Emory University School of Medicine in Atlanta.
Cultivate a therapeutic alliance. Talk to the patient and/or family to build a relationship to relieve underlying fears and anxiety, if there's time and willingness. Ask, "Why? What concerns you?" Then redirect the conversation to focus on the patient's care.
Depersonalize the event. This is often difficult for residents who are already feeling scrutinized, said Dr. Whitgob. Dr. Khan agreed, noting an instance where a patient told the only white team member to "make sure none of these foreigners take care of me."
The key is depersonalizing in advance by knowing that the institution and team support the physician, Dr. Whitgob said. The self-talk should be: "I'm here. I should be here. I belong here. What happened is not OK."
Ensure a safe learning environment in the moment and with follow-up. Attendings can assure patients of the trainee's competence by saying, "I agree with this physician. What other questions may I answer?"
Having a general policy of supporting physicians isn't enough. "It has to be made explicit," Dr. Whitgob said. Involve risk management or other hospital administration if needed, and offer faculty development to help older physicians process their own past experiences that were never addressed.
The danger of jumping to conclusions
Assessing patient acuity is also the starting point of a flow chart Dr. Lo and his colleagues developed and published in their New England Journal of Medicine article. If the patient is stable, physicians should assess decision-making capacity. For example, the patient could be delirious, Dr. Lo said. If the patient has decision-making capacity, try to find out why the request is being made.
"We want to respect the ethical principles of autonomy and do no harm. We don't want to come to early closure and say it's prejudice when there may be something very valid to why the patient doesn't want a doctor of a certain color or background," said Mark A. Levine, MD, FACP. There may be an important historical context that needs to be understood. For example, Muslim women may prefer a female physician and someone with post-traumatic stress disorder may have a related request.
"Having that dialogue is a teachable moment," said Dr. Levine, professor of medicine and associate dean for graduate medical education at the Robert Larner College of Medicine at the University of Vermont in Burlington. "It allows residents … to have their emotional needs attended to or else be left with anger, confusion, or resentment."
While explicit prejudicial attitudes should never be condoned by either the attending physician or hospital, when valid instances are identified, they should be accommodated, Dr. Levine said. For remarks that openly show bigotry, Dr. Lo said, physicians should discuss the options (e.g., transferring) while setting limits on unacceptable conduct.
Because the attending is ultimately responsible for the patient's care, he or she should set the limits, Dr. Lo said. "When you say 'We're trying to help you, and it's not acceptable to talk to people that way,' a lot of people will pull back," he said.
Strategies to consider
The institution should make it clear that it is dedicated not only to good patient care but also to a good working environment, said Dr. Lo. He suggested that a facility's mission statement include patient responsibilities, such as, "You can refuse care, but you have an obligation to treat others with respect."
Dr. Khan said she'd like hospitals to have a zero-tolerance policy for patients refusing care from physicians based on race. "Nobody says call the patient or family racist, but acknowledging the discrimination for what it is could put a hardline stop to it," she said.
Dr. Levine said medical education doesn't specifically address this topic, but he would endorse something formal that could fit into an ethics curriculum. "Developing a process—a little didactic portion, some cases to stimulate discussion, then some scenarios with simulated patients—will elevate this to the level of importance it should have," he said. "It blends in with ethical principles like autonomy, beneficence, justice, and do no harm. Just a different angle from a different place." (For more on these topics, see the sixth edition of the ACP Ethics Manual.) .
Dr. Whitgob visualized how her situation as a resident might have played out had these strategies been in place. "The intern would tell me what happened; I tell the attending who says, 'This is not something we support here. It sounds like the intern has talked to you, and let's be sure we talk about it before we leave for the night,'" she said. "'Let her know faculty cares about it.'"