Challenges in Working with Patients
Clinical training includes how to help all patients, even those who present a challenge to the way you would like to help them. Skills that help reduce the number of challenges while working with patients include using a patient-centered approach to treatment including respecting their values, understanding what motivates them, communicating effectively, and recognizing and helping patients with their fears and anxiety. There will still be challenges in patient interactions, however. Depending upon the institution, you may learn to use skills to diffuse conflict if possible or request a patient stop inappropriate behavior. And if that fails, respectfully convey to the patient any policy in place on inappropriate patient behavior or seeking help from any staff assigned to handle it. Some of the situations that many medical students find challenging include:
- Patients with addictions who do not follow recommendations due to their addiction
- Helping patients who are known to have hurt others.
- Patients with personality disorders, including those who demand extra attention or seem to want to “pick a fight.”
- Patients who do not want to work with a medical student due to their low level of experience.
- Patients who do not want to work with a healthcare provider of a particular sex, race, ethnicity, religion, or sexual preference.
- Patients who make inappropriate sexual advances.
Some responses that may help in diffusing conflict with a patient, depending upon the situation, include saying:
- I understand your concerns. Of course, you want the best treatment. I can reassure you that’s what we work to provide for you.
- What questions do you have? I will do my best to make sure you get answers?
- I can reassure you that I am well trained, and they would not let me be here otherwise.
- I would like to hear your concerns. (Use reflective listening to show that you are listening carefully.)
- What would help you feel more comfortable at this point?
- Let’s talk and get this misunderstanding corrected.
Mistreatment by Patients, Medical Staff, and Peers of Medical Trainees
Biased and other inappropriate behavior by some patients takes the form of racial epithets, anti-gay slurs, offensive comments, belittling of medical opinion, and rejection of care (Wheeler et al., 2019; Weiner, 2020).
Patients and their families are the most common sources of gender and racial discrimination (Hu, 2019). However, sexual harassment and abuse also are reported to come from medical staff, in some instances more often than from patients. In a study of surgery residents, for example, sexual harassment and abuse were most often experienced from attending surgeons.
Groups of Medical Students Experiencing the Most Mistreatment
Some groups are targets of mistreatment more often than others, for example, AMC data found that the frequency of biased or inappropriate comments in the past year was 1 in 4 for gay physicians and 1 in 3 for black physicians (Weiner, 2020). Almost 30% of physicians have experienced rejection by a patient based on race, religion, gender, or other group membership or identity (Tedeschi, 2017). Analysis of data from over 72% of graduating medical students obtained via the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire found that mistreatment (including by administration, faculty, staff, patients, and peers) was reported more often by (one episode / two or more episodes):
- Females more than males: 40.9% / 28.2% vs. 25.2% / 9.4%, p<.001
- Minority students more than white students.
- Under-Represented Minorities URM: 38% / 23.3%
- Multiracial 32.9% / 11.8%
- Asian: 31.9% / 15.7%
- White 24% / 3.8% p<.001)
- LGB students more than heterosexual students: 43.5%/23.1% vs 23.6%/1%, p < .001
Mistreatment varied to a large extent by the training program.
Gender discrimination was reported by 65.1% of the women surgical residents in one study of multiple programs (Hu, 2019).
Impact of Mistreatment
Mistreatment, including, discrimination, verbal and physical abuse, and sexual harassment, was associated with increased risk for burnout and suicidal thoughts in a study of mistreatment of 7409 surgical residents (Hu, 2019). The impact of being treated with bias includes feeling anger, confusion, fear, and distraction. It often has a negative effect on learning and clinical practice and leaves the trainee feeling exhaustion, self-doubt, and cynicism (Wheeler, 2019).
In the study of surgical residents, the difference in distress experienced by gender was not evident after adjusting for reports of mistreatment, suggesting that, at least for this group, the difference in distress is largely attributable to mistreatment (Hu, 2019).
Response to Mistreatment on the Basis of Race, Sexual Preference, and Gender
Personal: Suggestions include:
Practice responses for each type of mistreatment by patients ahead of time, such as (Weiner, 2020):
- “Let’s keep it professional here.”
- (Respectfully) “The hospital’s policy is to not honor requests for a different provider based on race (or other groups a patient is biased against – Note, this is only true for some institutions).
- After making sure the patient is stable, say, “That type of behavior is not tolerated here.”
- If the patient’s situation is stable and institution policy permits it, walk away, return later, and ask if they are ready to behave.
- Persuade the biased patient to keep biased opinions to themselves.
- Reassert your clinical role for those who doubt or belittle your ability.
- Explain any policies in place that inappropriate behavior will have the detrimental effect of delaying clinical care or talk with any staff assigned to communicate this policy.
Many healthcare professionals struggle with determining whether to proceed with care when there is poor control of behavior due to mental illness or being under the influence of a substance. Trainees wonder whether they will be considered unprofessional if they do not deliver care and turn for help from an immediate supervisor.
Institutional: Rather than expecting trainees to ignore biased or other inappropriate behavior based on the provider’s race, gender, sexual preference, or other group identification, there is growing consideration of the need for an institutional anti-bias policy. This needs to include a policy of patient responsibilities prohibiting such behavior and advising patients that if they behave inappropriately, they will be asked to leave (Weiner, 2020). For example, this includes rejecting requests for replacement of a provider based on bias. Solutions have even included delaying clinical care until behavior is improved. Patients may be required to engage in behavior contracts prior to resuming care. It is important that an institution determine who is responsible for responding to poor behavior.
External Readings on Mistreatment of Medical Trainees
- Paul-Emile K, Smith AK, Lo B, Fernández A. Dealing with Racist Patients. N Engl J Med. February 25, 2016;374(8):708-711. doi:10.1056/NEJMp1514939.
- Medical Schools Need to Get Better at Addressing Structural Racism article by Yoshiko Iwai, August 2, 2020, Scientific American, Policy & Ethics | Opinion.
- White Coats for Black Lives: Mission – An organization with the mission: “To dismantle racism in medicine and promote the health, well-being, and self-determination of Black and Indigenous people, and other people of color.”
- Patient Bias and Inappropriate Behavior
- Pushing Back Against Patient Bias – Stacy Weiner, January 17, 2020, AAMC.
- The Do’s and Don’ts of Calling Out Patient Behavior – Ethics, AMA, January 23, 2019
- How to Address Inappropriate Patient Behavior – By Healthleaders. 2018. Includes tips such as practicing phrases, such as, “‘let’s keep it professional”, so that you are ready to use them when needed.
- All Mistreatment
- The Prevalence of Medical Student Mistreatment and Its Association with Burnout – Research article by Cook et al., 2014.
- Patients with Criminal Activity
- Ignoring the Sins of Our Patients. Commentary by Amy Faith Ho, November 23, 2020. Medscape.
Hu Y-Y, Ellis RJ, Hewitt DB, et al. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. New England Journal of Medicine. October 31, 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759. PMID: 31657887.
Samuels EA, Gross CP, et al. Assessment of the Prevalence of Medical Student Mistreatment by Sex, Race/Ethnicity, and Sexual Orientation. JAMA Intern Med. May 1, 2020;180(5):653-665. doi:10.1001/jamainternmed.2020.0030. PMCID: PMC7042809. PMID: 32091540.
Tedeschi B. 6 in 10 doctors report abusive remarks from patients, and many get little help coping with the wounds. STAT. October 18, 2017.
Wheeler M, de Bourmont S, Paul-Emile K, et al. Physician and Trainee Experiences With Patient Bias. JAMA Internal Medicine. December 1, 2019;179(12):1678-1685. doi:10.1001/jamainternmed.2019.4122.
WebMD News Staff. Patient Prejudice Survey Results. WebMD. October 18, 2017.
Weiner S. Pushing back against patient bias. AAMC. January 17, 2020.
Well-Being Index. State of Well-Being 2021-2022. 2022.
Coping with Patient Death
Coping with Grief: How Physicians Can Heal After Patient Deaths – An article on the website Physician Practice.
- Create a safe space – It is important to acknowledge your emotions. Leadership can play a supportive role by creating opportunities for the expressing of emotions.
- Normalize grief support – Similarly, leadership can play a role in explaining that it is normal and accepted to access your organization’s formal grief support resources.
- Let go of guilt
- Prioritize self-care
(by Deborah Shute, September 23, 2019)
External Resources for Additional Reading:
- Doctors grieve, too – A lesson I did not learn in medical school – A blog by a Pediatric resident on MedPage.com
- Physician Grief with Death – A review of the literature article by Randy A Sansone MD and Lori A Sansone MD, published in Innovations in Clinical Neuroscience, 20(4), 2012. Includes an overview of grief responses in physicians and ways of resolving the grief response.