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CME / ABIM MOC

Patient Prejudice? The Patient Said What?... and What Comes Next

  • Authors: Case History by Lois Snyder Sulmasy, JD and Paula Katz; Case Commentary by Thomas S. Huddle, MD, FACP and Lois Snyder Sulmasy, JD
  • CME / ABIM MOC Released: 11/15/2022
  • Valid for credit through: 11/15/2023
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for physicians caring for patients who may exhibit inappropriate speech, assumptions, or behavior regarding the healthcare provider.

The goal of this activity is for learners to be better able to describe appropriate responses to inappropriate behavior by patients in medical encounters, and associated ethical issues, according to an American College of Physicians (ACP) ethics case study and commentary.

Upon completion of this activity, participants will:

  • Describe how physicians may balance their obligation to treat patients with respect and serve their welfare and best interests with being treated with respect themselves, according to an American College of Physicians (ACP) ethics case study and commentary on appropriate responses to inappropriate behavior by patients in medical encounters
  • Determine potential solutions to reestablishing trust and respect in the patient-physician relationship, according to an ACP ethics case study and commentary on appropriate responses to inappropriate behavior by patients in medical encounters
  • Identify other ethical issues regarding the relationship between a physician and a patient behaving in an inappropriate manner, according to an ACP ethics case study and commentary on appropriate responses to inappropriate behavior by patients in medical encounters


Disclosures

Medscape, LLC requires every individual in a position to control educational content to disclose all financial relationships with ineligible companies that have occurred within the past 24 months. Ineligible companies are organizations whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


Authors, Case History

  • Lois Snyder Sulmasy, JD

    Center for Ethics and Professionalism
    American College of Physicians
    Philadelphia, Pennsylvania

    Disclosures

    Lois Snyder Sulmasy, JD, has no relevant financial relationships.

  • Paula Katz

    Center for Ethics and Professionalism
    American College of Physicians
    Philadelphia, Pennsylvania

    Disclosures

    Paula Katz has no relevant financial relationships.

Authors, Commentary

  • Thomas S. Huddle, MD, FACP

    University of Alabama at Birmingham

    Disclosures

    Thomas S. Huddle, MD, FACP, has the following relevant financial relationships:
    Consultant or advisor for: Boston Scientific Corporation

  • Lois Snyder Sulmasy, JD

    As seen above.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor

  • Lois Snyder Sulmasy, JD

    As seen above.

Compliance Reviewer

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.


Accreditation Statements



In support of improving patient care, Medscape, LLC is jointly accredited with commendation by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

    For Physicians

  • Ethics case studies are developed by the American College of Physicians Ethics, Professionalism and Human Rights Committee and the ACP Center for Ethics and Professionalism.

    Medscape, LLC designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™ . Physicians should claim only the credit commensurate with the extent of their participation in the activity.

    Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.25 MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

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For questions regarding the content of this activity, contact the accredited provider for this CME/CE activity noted above. For technical assistance, contact [email protected]


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This activity is designed to be completed within the time designated on the title page; physicians should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period that is noted on the title page. To receive AMA PRA Category 1 Credit™, you must receive a minimum score of 75% on the post-test.

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CME / ABIM MOC

Patient Prejudice? The Patient Said What?... and What Comes Next: COMMENTARY

processing....

COMMENTARY

Mutual agreement between patient and physician on establishing and maintaining a relationship is foundational to the delivery of medical care. So, too, is effective communication. Sometimes both can break down.

Mr Smith has just called Dr Jones an offensive epithet after a pain-inducing physical exam maneuver. His response to the exam indicates both a hot temper exhibited without filter and objectionable presumptions about Dr Jones. Patients, undoubtedly, have been unpleasant, demeaning, or worse to physicians for as long as medicine has been practiced; some physician speech or behavior may likewise fit that bill. Both patients and physicians sometimes make assumptions based on appearance and preconceived notions.[1]

Here, the patient and attending are male; the trainee, female. Would the interpersonal dynamic be different depending on sex or gender, race, or even other physical characteristics such as height? In a web-based survey, members of the public viewing photographs were less likely to identify as physicians female models in similar attire as male models and more likely to identify the female models as nurses or physician assistants.[2] Do perceptions of physical appearance contribute to expectations as to what a "typical" physician looks like?

In the last few years, speech or behavior in medical encounters deemed subtly hostile has been highlighted in the medical literature as coinciding more or less with the psychological construct of "microaggression."[3] Although the term goes back to the 1970s, its recent use stems from the work of the Columbia psychologist Derald Wing Sue.[4] Microaggressions are defined as subtle behaviors that communicate hostility, usually to members of historically stigmatized groups, whether intentional or unintentional.[4]

Mr Smith's language is not subtle or a microaggression as defined above. It may be aggression: social interaction aimed at inflicting harm,[5] in this case without nuance. It also signifies, of course, pain and perhaps fear. It is unclear if the patient would have said what he said if he had not been unexpectedly put in pain. It is also not clear if he is commenting on Dr Jones's trainee status. Although using profanity is common[6] and even associated with pain relief,[7] use of the word bi**h here is unacceptable.

Hostility in the context of the patient-physician relationship has complexities unique to that relationship. One such complexity is the power imbalance inherent in the relationship. By virtue of being a patient, Mr Smith warrants forbearance on the part of his physicians, forbearance that would not necessarily be demanded (or would be demanded less) in other contexts. The ACP Ethics Manual (Manual) notes that, "The patient-physician relationship entails special obligations for the physician to serve the patient's interest because of the specialized knowledge that physicians possess, the confidential nature of the relationship, the vulnerability brought on by illness, and the imbalance of expertise and power between patient and physician."

Further, the Manual states, "The physician must respect the dignity of all persons and respect their uniqueness" and "treat the patient with compassion and respect,"[8] but the physician should be treated with respect, as well. The physician's position in the relationship comes with ethical responsibilities to care for the patient in spite of what happened in this case if respect and trust can be reestablished.

Patients sometimes say offensive or demeaning things to healthcare professionals. They can give what they believe to be compliments or ask what they think are innocent questions that may not be innocent or taken as such. So too, of course, may healthcare professionals interact this way with patients, or with each other. Although all of this is a real, labeling the speech as "microaggression" can reflect a subjective assessment; lend it a kind of scientific reality that may be sharper than is warranted; or establish and even magnify a mistaken significance of a comment if it is unintentional. Usually, addressing a comment from a posture of giving the benefit of any doubt, establishing boundaries, and trying to reestablish a respectful environment will be called for. Sometimes the appropriate response may be to let a comment pass by.

Dr Jones's initial response should be acknowledgement and regret that she has inflicted pain (eg, "Mr. Smith, I'm sorry I hurt you.") How things might go from there would much depend on how Mr Smith responds to what may have been an outburst he immediately regrets. If he apologizes for his epithet, so much the better, but If Mr Smith does not somehow express regret for his epithet at least by immediately moderating his tone and language and exhibiting remorse, and especially if he continues to be verbally abusive or worse, Dr Jones should indicate that this is unacceptable and, if Mr Smith cannot be brought to agree, at least tacitly, Dr Jones should terminate the visit, seconded by Dr Lake.

Presuming the opportunity for forward movement together, Dr Jones's strategy should be to seek to lower the temperature while at the same time correcting his misapprehension (or deliberate misconstruing?) of her status. She should do so in as emollient of a manner as she can, such as by saying, "Mr. Smith, I'm really sorry that hurt so much, but you have a lot of inflammation in that tendon -- and I am your real doctor, even though Dr Lake here is my teacher."

Next time, communication to the patient about roles upfront might be helpful. The Manual advises: "All trainees should inform patients of their training status and role on the medical team."[8]

Of course, Dr Lake may need to jump into the conversation depending on how things are going or if that is Dr Jones's preference. Once again, presuming that the epithet has been addressed, there are several helpful things he might say, depending on Mr Smith; that the Finkelstein test would have been just as painful had he performed it; that the premise of an academic setting is good care by trainees under supervision as in this case; and that Dr Jones is indeed his doctor.

How these points are made is as important as their substance. Drs Lake and Jones are seeking to care for Mr Smith by exhibiting care in spite of his seemingly aggressive outburst. Mr Smith might continue to rebuff Dr Jones (with or without hostility), and they would then have to terminate the interaction. He may ask for another physician, in which case a response demonstrating institutional support might look like: "We do not agree with you, and your request conflicts with the mission of our institution; we will try to accommodate you but understand that the best person to care for you may be someone you 'don't want or like'; and in an urgent situation, you will have no choice."

Sometimes, a conflict between a patient and a physician will escalate beyond individual physician powers of resolution. That may happen in the moment of difficulty during individual encounters, if a patient becomes uncontrollably abusive or violent, or later, if the conflict has not been resolved, and the patient brings a complaint to administration. Healthcare institutions should be prepared to respond to either situation, including having clear ways for physicians to initiate a rapid response by hospital security when needed and readily available procedures for fair review of formal complaints. Institutions should also try to recognize and address the potential psychological dimensions of such encounters for healthcare professionals who experience them.

Says the Manual, "On a teaching service, the ultimate responsibility for patient welfare and quality of care remains with the patient's attending physician of record. When a patient declines to have trainees involved in her or his care, efforts should be made to discuss this with the patient, explaining the function and supervision of trainees and exploring alternative options when possible."

An ACP ethics position paper on the hidden curriculum in medicine contains content on senior clinicians teaching physicians-in-training to contend with a range of patient interactions: "Modeling empathy and respect for patients and learners reaffirms core values of medicine as a profession. These behaviors have the power to influence the continuum of experiences from training through practice and foster lifelong reflection on ethics in the practice of the art and science of medicine. Experienced clinicians should be encouraged to share their emotionally challenging experiences."[9] Trainees should feel empowered by a supportive medical culture and training environment to raise ethical issues they may encounter[7] and to respond appropriately in specific instances. One survey found that "barriers to effective responses included lack of skills, insufficient support from senior colleagues and the institution, and perception of lack of utility associated with responding."[3]

Dr Jones might justifiably feel concern had Mr. Smith treated her as less than a real doctor even without his pain or anger. Presuming that his treating her so plausibly signified a genuine misapprehension on his part, a correction by Dr Jones (or by Dr Lake if Dr Jones wants assistance) would be the indicated response. Of course, sometimes subtle slights indicate real animus, expressed so as to seem facially innocuous, but it also can be easy to be mistaken about intent in such cases.

Unwanted compliments; flirtation; disagreements; hateful, derogatory or demeaning speech; sexual harassment; racism or other forms of discrimination; and physical violence or threats by patients or their family members/caregivers require different responses, stemming from the physician's responsibility to care for all, without prejudice. Not every individual will perceive comments in the same way (eg, male physicians report lower levels of sexual harassment than female physicians and "experience sexual harassment differently from women").[10] We must also recognize the potential for these forms of speech and behavior by clinicians and by clinicians to each other.

Respect is a two-way street, including during the patient-physician encounter. Both parties should exhibit it, but the physician also has a responsibility to serve the welfare and best interests of the patient, recognizing the power imbalance in the relationship along with the vulnerability of the patient that illness can cause. Physician termination of a professional relationship, if care is otherwise available, may be unavoidable, but the Manual counsels that only "[u]nder rare circumstances, the physician may elect to discontinue the professional relationship," and that "[p]hysician-initiated termination is a serious event, especially if the patient is acutely ill, and should be undertaken only after genuine attempts to understand and resolve differences."

Maintaining relationships, bridging differences and aligning expectations can be easier said than done.

Table of Contents

  1. CASE HISTORY
  2. COMMENTARY
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