Researchers at the Stanford University School of Medicine have identified strategies that doctors can use when facing discrimination from patients or their families.
"We think so much about doctors mistreating trainees, and we also talk about clinicians mistreating patients and discrimination in that direction," said Emily Whitgob, MD, a fellow in developmental-behavioral pediatrics at Stanford. "But we don't talk about it in this direction, and it happens."
Indeed, a 2015 survey of Stanford pediatric residents revealed that 15 percent had experienced or witnessed medical trainees being mistreated by patients or their families.
A paper describing the strategies for dealing with discrimination will be published online Oct. 26 in Academic Medicine. Whitgob is the lead author, and Alyssa Bogetz, the educational program developer for Stanford's pediatrics residency program, is the senior author. Program director Rebecca Blankenburg, MD, is a co-author.
Galvanized by personal experience
Whitgob said a personal experience with discrimination spurred her to initiate the study. "An intern I was supervising came to me very disturbed one day: Her patient asked if she was Jewish -- because he didn't want a Jewish doctor," Whitgob said. "My intern isn't Jewish, but I am."
When Whitgob brought up this story at a weekly meeting to a roomful of doctors in training, she was surprised by their reaction. "Half of the room was in tears" as they talked about the difficulties of facing discrimination from patients, she said. "They're women, people of color, different religions -- and feeling very powerless."
The researchers recruited 13 physicians from Stanford's pediatric residency program evaluation committee, each with responsibilities for supporting and teaching doctors in training. "In the case of a discriminatory event, these people would be at the forefront," Whitgob said. "They are there for residents to go to, and they want to be there."
Bogetz conducted 75-minute interviews with these physicians on how they would advise their trainees to respond and how they would themselves respond to three scenarios of discrimination. One scenario involved racial discrimination, and the other two involved religious and gender discrimination.
When the researchers analyzed the responses, several themes emerged.
One was the importance of assessing illness acuity. In the case of an emergency, the participants agreed that doctors should ignore discriminatory remarks and focus on providing urgent medical care. "If this is a child who has a gunshot wound and is bleeding out, then none of the other approaches are appropriate because first you have to save this child," Whitgob said.
To validate or repudiate?
The participants also agreed that it is best for trainees to depersonalize the event. Rather than taking the discriminatory behavior personally, they recommended dismissing the remarks as the speaker's own problem.
Most, but not all, of the participants said that identifying, naming and validating the emotional experience underlying the discriminatory remarks was central to establishing trust with the families. They suggested that trainees "cultivate a therapeutic alliance" -- in other words, build a rapport with the patient's family to emphasize the importance of their child's health relative to all else, including their prejudice. This rapport may be established, these physicians asserted, through acknowledging the discriminatory remarks and exploring underlying reasons for them.
However, four of the physicians said it was best to simply focus on immediate medical needs and convey that discrimination of any sort is unacceptable. They believed that accommodating families' requests for alternative doctors would reinforce prejudicial thoughts and discriminatory behavior.
All of the participants expressed their hopes for ensuring a safe learning environment for trainees. While acknowledging the importance of discussing uncomfortable situations with colleagues and supervisors, they insisted that trainees should make their own decisions about how to deal with discrimination from patients or their families. They agreed that initial medical school training and faculty development could help to prepare for those situations.
"What's heartening in this study is that in a busy medical setting with a lot of demands, nobody really wants more trainings, but when we asked the participants if they would like to have more on this topic, everyone except for one person said absolutely," Whitgob said.
The next step
The next step is to create programs based on the study's findings to train both experienced and new medical staff to properly respond to discriminatory situations, Whitgob said. The participants recommended case-based discussions as one way to practice handling these scenarios.
"We recommend discussion of this type of mistreatment early in training so trainees feel equipped to respond and feel permission to remove themselves from care when necessary," the researchers wrote.
Whitgob hopes this study will first and foremost create a conversation. "These things will happen, and there's no way to prevent them," she said. "It's going to be shocking when someone says something horrendous, but previous training may help to have some kind of action plan in the back of your mind that you can employ." Advance preparation would give trainees time to ask questions such as, "What are my boundaries? What am I willing to hear? Where will I draw the line and say I'm not comfortable?"
Though this study was based on experiences at a pediatric hospital, the results are relevant to adult hospitals as well, and could provide a framework for training programs, the researchers said.
Stanford's Department of Pediatrics supported this work.
The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://med.stanford.edu/school.html. The medical school is part of Stanford Medicine, which includes Stanford Health Care and Stanford Children's Health. For information about all three, please visit http://med.stanford.edu.
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