Dealing with Racist Patients

Implementing the NCTSN Trauma-Informed Organizational Assessment (TIOA) for Improving Trauma-Informed Care in Inpatient Child Psychiatry

INTRODUCTION

Children and adolescents receiving inpatient psychiatric services have disproportionately high levels of exposure to trauma and adversity. The National Child Traumatic Stress Network Trauma-Informed Organizational Assessment (TIOA) is a comprehensive tool intended to guide implementation of trauma-informed care, but it has not yet been applied in inpatient settings.

AIMS

The purpose of this quality improvement project was to describe trauma-informed care in inpatient child/adolescent psychiatry with the TIOA, examine relatedness among trauma-informed care domains, and explore barriers or facilitators to applying trauma-informed care.

METHODS

This quality improvement project used mixed methods. We conducted a web-based survey in Summer 2022 with staff members (clinical and administrative) at two inpatient child/adolescent psychiatric units in California to assess trauma-informed care practices with the TIOA (87 items). Qualitative follow-up interviews were offered to interested participants. A correlation matrix and cluster analyses were used to examine relationships among TIOA domains; qualitative data were analyzed thematically.

RESULTS

There were 69 survey respondents and seven qualitative interviews. TIOA domain scores ranged from a low of 2.3 to a high of 3.2, indicating that practices were occurring only "rarely" to "sometimes." There were two major themes identified from qualitive interviews: (a) barriers to trauma-informed care in an inpatient context that can be resource-constrained or coercive; and (b) discovering strategies to provide trauma-informed care despite structural barriers.

CONCLUSION

Organizational interventions targeting any domains of trauma-informed care are needed in inpatient settings given limited uptake of trauma-informed care.

Let's Talk About Ethics: Addressing Ethical Tensions and Building Moral Resilience in the Occupational Therapy Profession

Health professionals across all care delivery settings, including occupational therapy practitioners, are experiencing high levels of moral distress. The mental, emotional, and physical consequences of unresolved moral distress are resulting in burnout, decreased quality of care, and poor patient outcomes. Moral resilience is a teachable and learnable skill that can nullify some of the adverse consequences of moral distress. To ensure quality care outcomes and improve the well-being of individual occupational therapy practitioners and the profession, it is essential that occupational therapy practitioners be provided with the education, training, resources, and strategies needed to address moral distress, foster moral resilience, and cultivate the skills necessary to cope with ethical tensions. In this column, we call the profession to action to address the phenomenon of moral distress as it relates to occupational therapy practitioner well-being. We also discuss resources and strategies for addressing ethical tensions and building moral resilience in occupational therapy practice.

The physician experience of patient to provider prejudice (PPtP)

Background

Patients can demonstrate prejudice and bias toward minoritized physicians in a destructive dynamic identified as PPtP (Patient Prejudice toward Providers). These interactions have a negative impact on the physical and mental well-being of both those who are targeted and those who witness such behaviors.

Study purpose

The purpose of this study was to explore the PPtP experiences of attending physicians who identify as a minority based on race, ethnicity, citizenship status, or faith preference.

Methods

Qualitative methodology was used to collect data using in-depth interviews. 15 attending physicians (8 male, 7 female, aged 33-55 years) who identified as minorities based on ethnicity, citizenship status, or faith practices were interviewed individually. Interviews were conducted using a guide validated in previous studies and content analysis was performed by two trained researchers to identify themes.

Results

Five themes were identified: A Continuum of Offenses, Professional Growth through Adversity, Organizational Issues, Role of Colleagues, and Consequences for Provision of Care. Findings suggest that although attending physicians learned to cope with PPtP, the experience of being treated with bias negatively impacted their well-being and work performance. Attending physicians also felt that white majority medical students sometimes treated them with prejudice but expressed a commitment to protecting vulnerable trainees from PPtP.

Conclusion

The experience of PPtP occurs consistently throughout a career in medicine, often beginning in the years of training and persisting into the phase of attending status. This makes it imperative to include strategies that address PPtP in order to successfully recruit and retain minoritized physicians.

Tackling discrimination in medicine head on: The impact of bystander intervention training

PURPOSE

A mixed-methods study to evaluate Bystander Intervention Training (BiT), a simulation-based small-group training programme designed to teach skills to tackle discrimination.

MATERIALS AND METHODS

Norwich Medical School delivered the intervention online between January 2020 and June 2023 to medical students, physician associate trainees, and qualified doctors. A sample of 569 participants was used in the main analysis. Participants completed pre- and post-training and follow-up evaluations.

RESULTS

Paired post-training scores were significantly different (all p < 0.001) from the pre-training scores for all 12 questions, in favour of the post-training scores. Of the 159 participants who completed follow-up questionnaires, 27 (17.9%) reported having the opportunity to be an active bystander; of those, 23 (85%) intervened. Scores in the follow-up questionnaire were significantly higher than those in the pre-training survey and significantly lower than those in the post-training questionnaire (p < 0.001). Participants had an increased sense of responsibility to be an active bystander and were empowered to challenge discrimination. Participants from marginalised groups expressed positive views about the training.

CONCLUSIONS

Interventions that allow open discussion and carefully supported personal disclosure in safe spaces, where difficult and uncomfortable discussions can occur, with an opportunity to change behaviour, must be developed to tackle discrimination.

It is Challenging to Shift the Norm: Exploring how to Anticipate and Address Microaggressions in Clinical Learning Environments

Purpose

Increased attention to improving a culture of belonging in clinical learning environments has led to various approaches to addressing microaggressions. However, most approaches in the literature focus on responding or reacting to microaggressions with insufficient attention to building trust before microaggressions might occur. Research on microaggressions in clinical learning environments suggests anticipatory or pre-emptive conversations about microaggressions may foster greater trust. In this study, the authors explored how diverse participants perceived the experience of anticipatory conversations about potential microaggressions. Overall, the authors sought to gain a deeper understanding of how pre-emptive and anticipatory conversations may influence an organization's approach to addressing microaggressions in clinical learning environments.

Methods

The authors utilized constructivist grounded theory methodology and conducted individual qualitative interviews with 21 participants in an academic department within a larger health sciences center in the United States.

Results

Findings suggest that anticipatory conversations about microaggressions were challenging due to existing norms in dynamic clinical learning and working environments. Participants shared that the idea of anticipating microaggressions elicited dissonance. Conversations about microaggressions could potentially be facilitated through leaders who role model vulnerability, organizational supports, and an individualized approach for each team member and their role within a complex hierarchical organization.

Discussion

Anticipating and addressing microaggressions in clinical learning environments holds tremendous potential, however, any conversations about personal identity remain challenging in medical and healthcare environments. This study suggests that any attempts to address microaggressions requires attention to cultural norms within healthcare environments and the ways that hierarchical organizations can constrain individual agency.

Ethics of identity concordance requests in patient-clinician encounters

Systemic injustice has resulted in significant baseline inequality amongst populations according to gradients of privilege. What is the ethical approach to situations wherein equity may require differential treatment to correct for baseline disadvantages as a necessary means to its attainment? We explore this concept through the issue of patient requests for clinician identity concordance, when patients request a clinician who matches their race, ethnicity, or gender. Firstly, we discuss ethical grounds for refusing requests by exploring the balance between patient autonomy, a physician's obligation to not abandon one's patients, and the right of a clinician to be free from violence of any form. Next, we explore the ethics surrounding conditional acceptance through the frames of intent and clinical outcomes. We note the legacy of trauma experienced by marginalized patients at the hands of medicine and the abundance of data suggesting that identity concordance can mitigate disparities.

Perceptions of healthcare professionals and students about interventions addressing implicit bias and microaggression: A mixed-studies systematic review

AIM

To consolidate and appraise available evidence on the experiences and perceptions of healthcare professionals and students about the interventions addressing implicit bias and microaggression in the clinical setting.

BACKGROUND

Patient-perpetrated acts of implicit bias and microaggression have profound effects on healthcare professionals' and students' mental health. However, the efficacy of interventions targeted at addressing implicit bias and microaggression requires further scrutiny.

DESIGN

Mixed-studies systematic review.

METHODS

A comprehensive search was conducted on PubMed, EMBASE, CINAHL, Scopus, Web of Science, PsycINFO, Cochrane Library, ProQuest (Social Science Premium Collection Database), ProQuest (Dissertations and Theses Global), and ClinicalTrials.gov. Study selection, quality appraisal using the mixed methods appraisal tool, and data extraction were performed. Narrative and thematic synthesis were used to analyze quantitative and qualitative findings respectively. A results-based convergent approach was employed to integrate findings from both research designs.

RESULTS

A total of 23 studies were included, involving 4667 healthcare professionals and students. There were 17 quantitative studies and six mixed-method studies of varying methodological quality. This review presented findings on healthcare professionals' and students' experiences and perceptions of the efficacy of the interventions targeted at addressing implicit bias and microaggression. Two themes were identified: 1) A safe space leading to enhanced confidence, and 2) what and why the interventions worked.

CONCLUSION

Our review findings found that healthcare professionals and students generally had a positive view of implicit bias and microaggression interventions in the realm of helping them gain knowledge and confidence to identify and respond to biased clinical encounters. This review could provide insights for administrators and institutions to provide such interventions in mitigating the impact of implicit bias and microaggression on healthcare staff and students. Future research should focus on comparing the views of participants from varied geographical and cultural backgrounds, and those with different healthcare disciplines.

Intersectional characterization of emergency department (ED) staff experiences of racism: a survey of ED healthcare workers for the Disrupting Racism in Emergency Medicine (DRiEM) Investigators

INTRODUCTION

The impact of racism on patient outcomes in Emergency Medicine has been examined but there have been few studies exploring the experiences of racism in health care workers. This survey aims to explore the experience of racism by interdisciplinary staff in a tertiary ED. By characterizing the staff experience of racism in the ED, we hope to inform the design of strategies to disrupt racism and ultimately improve the health and wellness of both staff and patients.

METHODS

We conducted a self-administered, cross-sectional survey to explore the reported experience of racism by healthcare workers in a single urban ED in an academic trauma centre. We employed classification and regression tree analyses to evaluate predictors of racism through an intersectional lens.

RESULTS

A majority (n = 200, 75%) of all ED staff reported experiencing interpersonal racism (including physical violence, direct verbal violence, mistreatment and/or microaggressions) in the workplace. Respondents who identified as racialized self-reported significantly more racism at work than white respondents (86% vs. 63%, p < 0.001). Occupation, race, migrant status and age were identified through intersectional machine-learning models to be significantly predictive of the experience of racism. Nearly all respondents felt that the disruption of racism in Emergency medicine is important to them (90%, n = 207) and (93%, n = 214) were willing to participate in further training in anti-racism.

CONCLUSIONS

Racism against interdisciplinary staff working in EDs is common and the burden on healthcare workers is high. Intersections of occupation, race, age and migrant status are uniquely predictive of the experience of racism for EM staff. Interventions to disrupt racism should be informed by intersectional considerations to create a safe working environment and target populations most at risk. ED healthcare workers are willing to take steps to disrupt racism in their workplace and need institutional support to do so.

Discrimination 911: A Novel Response Framework to Teach Bystanders to Become Upstanders When Facing Microaggressions

PROBLEM

Microaggressions are pervasive in daily life, including in undergraduate and graduate medical education and across health care settings. The authors created a response framework (i.e., a series of algorithms) to help bystanders (i.e., health care team members) become upstanders when witnessing discrimination by the patient or patient's family toward colleagues at the bedside during patient care, Texas Children's Hospital, August 2020 to December 2021.

APPROACH

Similar to a medical "code blue," microaggressions in the context of patient care are foreseeable yet unpredictable, emotionally jarring, and often high-stakes. Modeled after algorithms for medical resuscitations, the authors used existing literature to create a series of algorithms, called Discrimination 911, to teach individuals how to intervene as an upstander when witnessing instances of discrimination. The algorithms "diagnose" the discriminatory act, provide a process to respond with scripted language, and subsequently support a colleague who was targeted. The algorithms are accompanied by training on communication skills and diversity, equity, and inclusion principles via a 3-hour workshop that includes didactics and iterative role play. The algorithms were designed in the summer of 2020 and refined through pilot workshops throughout 2021.

OUTCOMES

As of August 2022, 5 workshops have been conducted with 91 participants who also completed the post-workshop survey. Eighty (88%) participants reported witnessing discrimination from a patient or patient's family toward a health care professional, and 89 (98%) participants stated that they would use this training to make changes in their practice.

NEXT STEPS

The next phase of the project will involve continued dissemination of the workshop and algorithms as well as developing a plan to obtain follow-up data in an incremental fashion to assess for behavior change. To reach this goal, the authors have considered changing the format of the training and are planning to train additional facilitators.

Exploring the Professional Identity Formation of Racial/Ethnic Minoritized Physician Assistants

INTRODUCTION

The purpose of this article is to (1) describe how professional identity intersects with physician assistants' (PAs') and PA students' racial and ethnic identities and cultural backgrounds; (2) examine how sociohistorical contexts shape professional identity in racial/ethnic minoritized PAs and PA students; and (3) identify the role of PA program administrators and faculty to address the needs of racial/ethnic minoritized PAs and PA students.

METHODS

This study draws on elements of constructivist grounded theory to investigate the professional identity formation (PIF) experiences of 45 PA students and alumni from 3 institutions. Participants were recruited using a snowball method and identified as 23 Black/African American, 12 Hispanic/Latino, 6 mixed race, and 4 Native American/Indigenous. Interview data were analyzed using sociocultural theory as an analytic framework.

RESULTS

The results suggest that participants felt that their racial/ethnic identity was an important part of their identity, yet many indicated they experienced frequent micro- and macroaggressions from fellow students, faculty, lecturers, administrators, preceptors, patients, and supervisors. Additionally, they indicated that they need more support from their programs than what is currently provided.

DISCUSSION

The results of this study suggest that social experiences before, during, and after PA training strongly influence PIF development in racial/ethnic minoritized PAs. Administrators and professional PA organizations should evaluate methods to support those individuals who identify as a racial/ethnic minority throughout their careers.

Refusal of transplant organs for non-medical reasons including COVID-19 status

Transplant centers and physicians in the United States have limited guidance on the information which they can and cannot provide to transplant candidates regarding donors of potential organs. Patients may refuse organs for a variety of reasons ranging from pernicious requests including racism to misinformation about emerging medicine as with the COVID-19 vaccine and infection. Patient autonomy, organ stewardship, and equity are often at odds in these cases, but precedent indeed exists to help address these challenges. This work uses such cases to highlight the urgent need for uniform, national policy prohibiting informational requests unrelated to well-established risks.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors' actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a qualitative study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors' behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner's autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

Racial Discrimination in Patient Care-Preserving Relationships With Integrity

The following case study describes what is known as the health care system's open secret of allowing a patient or family to refuse care from a clinician of another race. This article explores the ethical tension between autonomy, nonmaleficence, justice, and duty to treat as it relates to racism and the potential harm to clinicians, health care teams, and organizations. When racism is experienced within the clinical setting, clinician knowledge, organizational training, and moral character are essential for identifying and addressing it effectively. Racial discrimination and related mistreatment are not part of a responsive and proactive moral community. This article explores creative solutions that preserve patient-clinician relationships without sacrificing personal integrity when racism is encountered.

Virtual Communication Across Differences: Development of a Workshop on Managing Patient Bias

PROBLEM

Despite the prevalence and detrimental effects of racial discrimination in American society and its health care systems, few medical schools have designed and implemented curricula to prepare medical students to respond to patient bias and racism.

APPROACH

During the summer of 2020, a virtual communication class was designed that focused on training medical students in how to respond to patient bias and racism. Following brief didactics at the start of the session, students practiced scenarios with actors in small groups and received direct feedback from faculty. For each scenario, students were instructed to briefly gather a patient's history and schedule an appointment with the attending whose name triggered the patient to request an "American" provider. In one scenario, the patient's request was motivated by untreated hearing loss and difficulty understanding accents. In another, it was motivated by racist views toward foreign physicians. Students were to use motivational interviewing (MI) to uncover the reasoning behind the request and respond appropriately. Students assessed their presession and postsession confidence on 5 learning objectives that reflect successful communication modeled after MI techniques.

OUTCOMES

Following the session, student skills confidence increased in exploring intentions and beliefs ( P = .026), navigating a conversation with a patient exhibiting bias ( P = .019) and using nonverbal skills to demonstrate empathy ( P = .031). Several students noted that this was their first exposure to the topic in a medical school course and first opportunity to practice these skills under supervision.

NEXT STEPS

The experience designing and implementing this module preparing students in responding to patient bias and racism suggests that such an effort is feasible, affordable, and effective. With the clear need for such a program and positive impact on student confidence navigating these discussions, including such training in medical school programs appears feasible and is strongly encouraged.

Anti-Black racism in clinical supervision: asynchronous simulated encounters facilitate reflective practice

Background Racist interactions in clinical practice remain a pervasive reality for Black healthcare providers. We sought to develop a framework to inform supervisors’ actions when confronting racism in clinical practice and protecting trainees under their oversight. Methods We conducted a prospective study in which experienced supervisors responded to seven short, videotaped interactions between: 1) Black trainees and a simulated patient (SP) in a racist role; 2) the trainees and their respective supervisors; and 3) the trainees and their supervisors together with the SP. The clinical exchanges exemplified different types of racist (entrenching) or antiracist (uprooting) behaviors by the supervisors. After viewing each clip, participants wrote their reflections confidentially; they later joined a structured debriefing together. We used thematic analysis to identify supervisors’ behavioral patterns when confronting racist interactions. Results Based on the input of 52 participants recruited into five two-hour-long sessions, we categorized the behaviors of supervisors facing anti-Black racial injuries involving learners under their oversight. We organized supervisor behaviors into five interlocking domains, each with a range of possible themes: 1) Joining: from conciliatory to confrontational in communicating with the aggressor; 2) Explicitness: from avoiding to naming racism; 3) Ownership: from individual to shared responsibility of the event and the response to it; 4) Involving: from excusing to including the aggrieved party when confronting the aggressor; and 5) Stance: from protective to paternalistic in supporting the learner’s autonomy. Conclusions Our qualitative findings can provide a framework for facilitated discussion toward reflective practice among healthcare providers who may have experienced, witnessed, or intervened in anti-Black racist interactions. They can also help medical educators to inform faculty development to fight anti-Black racism in clinical practice. The video materials we developed are available for viewing and download and can be used or adapted as springboards for reflective discussion or faculty development activities.

"When Appearances Matter: A Taxonomy and Ethics for Demographic-Based Provider Requests"

Requests by patients for providers of specific demographic backgrounds pose an ongoing challenge for hospitals, policymakers, and ethicists. These requests may stem from a wide variety of motivations; some may be consistent with broader societal values, although many others may reflect prejudices inconsistent with justice, equity, and decency. This paper proposes a taxonomy designed to assist healthcare institutions in addressing such cases in a consistent and equitable manner. The paper then reviews a range of ethical and logistical challenges raised by such requests and proposed guidance to consider when reviewing and responding to them.

Cultivating Anti-Racism Allies in Academic Medicine

Racial microaggressions, racially based remarks, or actions that negatively impact marginalized physicians of color (Black, Latino/a/x, and American Indian/Alaskan Natives) often go unaddressed. This article provides four strategies for how individuals and institutions can engage in anti-racism allyship: (1) be an upstander during microaggressions, (2) be a sponsor and advocate for physicians of color, (3) acknowledge academic titles and accomplishments, and (4) challenge the idea of a "standard fit" for academic faculty and research. Skills in academic allyship should be taught to all physicians throughout the educational continuum to mitigate feelings of isolation that racialized minority physicians frequently experience.

Patient perspectives of the climate of diversity, equity, and inclusion in the emergency department

Objective

Assessing the diversity, equity, and inclusion (DEI) climate of emergency departments (EDs) can inform organizational change to provide equitable, inclusive, and high‐quality care to their diverse patient populations. The purpose of this project was to investigate patient perspectives on the climate of DEI in an urban ED.

Methods

This was a cross‐sectional survey study conducted in a large‐volume, urban ED in Detroit, MI, from November 2018 to January 2019. The survey was developed by an experienced ED DEI committee via an iterative process and broad consensus.

Results

During their care in the ED, 849 patients completed an anonymous survey about their perspectives and experiences of DEI in that ED. Overall, the responses were favorable as most respondents reported that the ED staff treated patients from all races equally (75.8%) and made patients feel accepted (86%). However, some respondents felt that the ED staff's treatment of populations with greater complexity, such as patients who are mentally ill (16.8%) or lower income (14.3%), needs the most improvement.

Conclusions

This DEI climate assessment survey of ED patients’ perspectives revealed important insights that could guide strategic initiatives to advance DEI in the ED. This assessment may serve as a model for continuous evaluation of DEI over time and in multiple healthcare settings to help guide organizational change efforts.

A Scoping Review of Recommendations and Training to Respond to Patient Microaggressions

OBJECTIVE

Patient microaggressions affect practitioners in all fields of healthcare and especially psychiatry. In multiple studies, healthcare professionals reported high rates of patient microaggressions and discrimination. To date, this is the first scoping review of recommendations and trainings on patient microaggressions.

METHOD

A scoping review of articles indexed in PubMed, PsycINFO, Medline, ERIC, and MedEdPORTAL was conducted from July 2020 to August 2020 to identify recommendations and solutions for healthcare professionals on responding to patient microaggressions.

RESULTS

The review identified 27 studies that provide recommendations and trainings for healthcare professionals to address patient microaggressions. Twenty studies outlined recommendations for healthcare professionals and systems on how to respond to patient offenses. These 20 studies were grouped into establishing a supportive culture, addressing the microaggression, supporting the targets of microaggressions, discriminatory requests, and institutional responses. Six articles described trainings that equip providers with tools to address patient microaggressions, including the ERASE framework ("Expect/Recognize/Address/Support/Establish, Encourage"); Stop, Talk, and Roll; interrupting microaggressions; XYZ ("I felt X when Y because Z"); the ACTION model ("Ask/Come/Tell/Impact/Own/Next"); and the OWTFD tool ("Observe/Why/Think/Feel/Desire").

CONCLUSION

Recommendations and trainings for the response to microaggressions are emerging, and results of trainings are encouraging. However, more work is needed to evaluate the effectiveness of these trainings in clinical settings and longitudinally.

The Impact of Patient Prejudice on Minoritized Female Physicians

Background

Patient bias and prejudice directed against physicians from diverse backgrounds is a frequent occurrence in healthcare. Female physicians have long experienced discrimination in the healthcare system based on their gender alone. The dynamic known as Patient Prejudice toward Providers (PPtP) is disproportionately affecting female physicians because it is frequently compounded by sexism.

Aim

The goal of this study was to explore the impact of PPtP on female resident and attending physicians.

Methods

Using transcribed one-on-one interviews from a larger study of PPtP affecting resident and attending physicians, ten interviews with female physicians (resident and attending) from diverse ethnic backgrounds and countries of training at a large academic medical center were analyzed. The authors independently reviewed the interviews using an iterative process within and across interviews to inductively identify repeating words, phrases, and concepts relevant to the study aim.

Results

Demographics of the ten participants included age (mean 34.6 years), ethnicity (6 Asian, 2 Hispanic, 2 African), and country of training (10% IMG vs. 90% US trained). Four of the interviewees were residents and six were attendings. Themes that emerged from the analysis included experiencing "A Gendered Continuum of Abuse," "Establishing a Higher Standard of Competency," "Overcoming the Stereotype of the White Male Physician," "The Physicality of Self Identity," and "The Need to be Protective of Minoritized Trainees." All participants agreed that these perceptions created an adverse environment at the workplace and impacted on patient care.

Conclusions

Discrimination of physicians based on their gender or their race/ethnicity has been reported. This study highlights the compounded effects of patient prejudice on female minoritized physicians. Organizations and individuals should identify and implement strategies to address the impact of PPtP and sexism in order to create an environment where all women can thrive professionally.

When Communication Breaks Down: Handling Hostile Patients

Difficult patient encounters are common in clinical practice, with many arising from patient hostility owing to a breakdown in communication and the health care alliance. Patient anger may be a manifestation of fear, grief, or discontent with prior experiences in the health care system, but there may also be contributions from specific patient, physician, or situational factors. Physicians may intervene with specific actions based on these individual factors, while focusing on self-reflection to better understand their part in creating a hostile physician-patient dyad.

Addressing the Challenges of Cross-Cultural Communication

Cross-cultural communication has many challenges due to the complexity of culture, communication, and language. Improving cross-cultural communication in health care is critical to reducing disparities and improving health equity. Specifically, improving cross-cultural communication must be prioritized to overcome systemic barriers and to eliminate disparities that stem from stigma and biases. Communication must be improved, ideally via a cultural humility framework. Unconscious bias and communication training must be intentional. Culture is an attribute and should be celebrated and incorporated into health practice at all levels to prioritize health equity.

Applying Organizational Change Theory to Address the Long-Standing Problem of Harassment in Medical Education

Issue: Harassment is a common experience for medical and healthcare trainees. Experiencing harassment can have significant consequences for trainees in multiple domains, including mental, physical, social, and occupational well-being. Harassment remains entrenched in medical education despite efforts to address it. Evidence: Many articles have documented the prevalence of harassment in medical education. Likewise, articles have provided recommendations for how individuals or hospitals can attempt to reduce harassment. However, despite calls for reform, harassment persists, largely due to the hierarchical, paternalistic, high-pressure, and evaluative nature of medical culture. Most literature has emphasized the need for policies and reporting structures, yet such top-down initiatives have not had a sufficient impact on the attitudes and beliefs that drive culture change. Instead, change requires intervention at every level of an organization. Little, if any, literature has proposed applying a change management model to change the culture of medical training and therefore decrease harassment. Implications: This paper applies principles of organizational change theory, and in particular, the ADKAR model, in conjunction with a summary of the existing harassment literature, to propose a framework for addressing harassment by facilitating organizational culture change. Intervention is needed at all levels of the medical education system (the healthcare system, the supervisor or training program, and the individual), and the ADKAR framework can guide what interventions are offered and when to capitalize on the current level of change readiness. Recommendations go beyond the typical focus on formalized policies and procedures, which are necessary, but not sufficient, components of culture change. Implementation of these practices, as well as ongoing evaluation and refinement through research, should foster cultural change in medical education to address harassment.

Equity in medical education: Addressing microaggressions and discrimination on the wards

PURPOSE

Existing frameworks to address instances of microaggressions and discrimination in the clinical environment have largely been developed for faculty and resident physicians, creating a lack of resources for medical students.

METHODS

We implemented a workshop to prepare pre-clinical medical/dental students to recognize and respond to microaggressions. Participants in three cohorts from 2018 to 2020 completed pre- and post-workshop surveys assessing the prevalence of exposure to clinical microaggressions and the workshop's effect on mitigating commonly perceived barriers to addressing microaggressions.

RESULTS

Of 461 first-year medical and dental students who participated, 321 (69.6%) provided survey responses. Over 80% of students reported experiencing microaggressions, with women and URM students over-represented. After the workshop, participants reported significant reductions in barriers to addressing microaggressions and discrimination, including recognizing incidents, uncertainty of what to say or do, lack of allies, lack of familiarity with institutional policies, and uncertainty of clinical relevance. The workshop was similarly effective in-person and virtual formats.

CONCLUSIONS

Most medical/dental student respondents reported experiencing microaggressions in the clinical setting, particularly female and URM students. Our workshop mitigated most perceived challenges to responding to microaggressions. Future interventions across institutions should continue to equip students with the tools they need to address and respond to microaggressions.

Responding to patient requests for women obstetrician-gynecologists

Patients may request care from a woman obstetrician-gynecologist for various reasons, including privacy concerns, religious or cultural reasons, and in some cases, a history of abuse. They should be given the opportunity to voice their reasons for requesting a woman obstetrician-gynecologist but should not be compelled to do so. Respect for patient autonomy is a compelling reason to consider honoring a patient's gender-based request. When a patient requests a woman obstetrician-gynecologist, efforts should be made to accommodate the request if possible. However, medical professionals and institutions are not ethically obligated to have a woman obstetrician-gynecologist on call or to make one available at all times. If it is not feasible for a woman obstetrician-gynecologist to provide care because of staffing or other system constraints or patient safety concerns, accommodation is not required, and physicians do not have an overriding responsibility to ensure that patients receive gender-concordant care. Patients have the right to decline care and may choose to seek care elsewhere if their requested healthcare provider type is not available. Institutions and medical clinics should have policies and procedures in place for managing patient requests for women obstetrician-gynecologists, and patients should be made aware of these policies preemptively. These policies and procedures should include information about whom to contact for assistance and how to document the encounter. They should also be accessible and familiar to physicians and trainees. Care should be taken to ensure that adequate educational opportunities in obstetrics and gynecology are available for all medical trainees, regardless of gender.

Managing Challenging Patient Interactions in Breast Imaging

Managing challenging patient interactions can be a daily stressor for breast imaging radiologists, leading to burnout. This article offers communication and behavioral practices for radiologists that help reduce radiologists' stress during these encounters. Patient scenarios viewed as difficult can vary among radiologists. Radiologists' awareness of their own physical, mental, and emotional states, along with skillful communications, can be cultivated to navigate these interactions and enhance resiliency. Understanding underlying causes of patients' emotional reactions, denial, and anger helps foster empathy and compassion during discussions. When exposed to extremely disruptive, angry, or racially abusive patients, having pre-existing institutional policies to address these behaviors helps direct appropriate responses and guide subsequent actions. These extreme behaviors may catch breast imaging radiologists off guard yet have potentially significant consequences. Rehearsing scripted responses before encounters can help breast imaging radiologists maintain composure in the moment, responding in a calm, nonjudgmental manner, and most effectively contributing to service recovery. However, when challenging patient encounters do trigger difficult emotions in breast imaging radiologists, debriefing with colleagues afterwards and naming the emotion can help the radiologists process their feelings to regain focus for performing clinical duties.

Effects of Race, Workplace Racism, and COVID Worry on the Emotional Well-Being of Hospital-Based Nurses: A Dual Pandemic

Persons of color in the US experience the worst COVID-related outcomes and account for the majority of COVID-19 cases and hospitalizations among healthcare workers. In a pandemic where minority populations and healthcare workers are among the hardest hit, nurses of color are undoubtedly taxed. Moreover, their workplace racism experiences represent a dual pandemic in that the effects of COVID-19 worries and workplace racism may synergize to the detriment of their emotional well-being. The purpose of this study was to examine the direct, indirect, and interactive effects of individual (race, COVID worry), interpersonal (workplace racial microaggressions), and institutional (racial climate) factors on hospital-based nurses' emotional well-being. A sample of 788 registered nurses who worked in New Jersey hospitals completed an electronic survey. Compared to White nurses, nonwhite nurses reported higher emotional distress, more negative racial climates, more racial microaggressions, and higher levels of COVID worry. Nurses' worry about getting sick from COVID and multiple racial microaggression experiences had the largest effects on the likelihood of high emotional distress. Racism variables and worry about COVID mediated indirect effects of nonwhite race on emotional distress. Racial microaggressions mediated an indirect effect of racial climate on this outcome. Nurses who were worried about getting sick from COVID and experienced multiple microaggressions and/or the most negative racial climates had severe emotional distress. There is a need for sustained investment in a racially diverse nursing workforce. Mitigating workplace racism in hospitals is crucial, particularly during public health crises that disproportionately threaten minority populations and healthcare workers.

Racial and Gender Differences in Patient Satisfaction Scores Among Oncologists

BACKGROUND

Patient satisfaction scores (PSS) have been adopted in health care reimbursement and faculty promotion metrics. Oncology patients face a challenging prognosis, where PSS may be perceived differently. We hypothesized that PSS differed based on gender and racial demographics of oncologists.

MATERIALS AND METHODS

This was an institutional review board exempt cross-sectional study utilizing PSS data for outpatient oncologists within a large comprehensive cancer center. Patient demographics included age, gender, race/ethnicity, geographical residence, and disease site. Characteristics of oncologists included gender and race/ethnicity. We used PSS ≥95 to make comparisons. The association between patient and physician characteristics were evaluated using the t test and χ2 test.

RESULTS

A total of 15,849 oncology patients were identified between 2011 and 2020. Survey respondents were predominantly female (53.2%), white (93.4%), between 50 and 70 years of age (55.3%), and living in an urban setting (63.6%). There were 303 oncologists with the majority being male (64.4%) and white (58.1%). Compared with white oncologists, Asian and Hispanic oncologists received lower PSS (P=0.001 and 0.0085, respectively). On subset analysis, these differences were significant among patients older than 50 years, living in rural counties, and reporting white or non-Hispanic race/ethnicity, or among patients of either gender (all P<0.05). Patients with genitourinary malignancies provided lower PSS for female oncologists (P=0.005).

CONCLUSIONS

Asian and Hispanic oncologists were more likely to receive lower PSS. In addition, female oncologists treating genitourinary malignancies received lower PSS. Appropriate statistical adjustments are needed for PSS among oncologists to account for race, gender, and physician subspecialization to allow for equitable professional opportunities across demographics.

Emergency Medicine Nurse Practitioner and Physician Assistant Burnout, Perceived Stress, and Utilization of Wellness Resources During 2020 in a Large Urban Medical Center

The objectives of this study were to measure perceived stress, burnout, and utilization and perceived benefit of wellness practices among emergency medicine (EM) nurse practitioners (NPs) and physician assistants (PAs). An additional aim was to evaluate attributions of stress to racism and the COVID-19 pandemic. A 28-item electronic survey of ED NPs/PAs at 3 hospitals was used to measure respondents' perceived stress (Perceived Stress Scale), stress attributed to COVID-19 and systemic racism, burnout (2-item measure), and utilization and helpfulness of wellness practices. The sample consisted of 53 ED NPs/PAs respondents (response rate 42.4%). More than one half (58.5%) reported burnout from their job, and a majority (58.5%) reported moderate to high stress. Burnout was reported by 70% of female respondents compared with 30.8% of male respondent (p = 0.002). A large majority (70%) of Black respondents reported concerns about experiencing racism at work, and 58.8% reported higher levels of stress attributed to racism. Respondents reported meals during shifts, community donated personal protective equipment, flexible work hours, and societal offerings of financial support (e.g., Internal Revenue Service stimulus check) as helpful. The COVID-19 pandemic and the impact of systemic racism are significant contributors to the stress and burnout of NPs/PAs. Female ED NPs/PAs disproportionally share the burden of burnout. Strategies to reduce burnout should be prioritized by institutional leadership. In addition, a majority of Black ED NPs/PAs are concerned about experiencing racism at work and report moderate to high stress associated with racism in general. There is an urgent need to address racism in the workplace with training on implicit bias, systemic racism, and allyship behavior.

Taking the VITALS to Interrupt Microaggressions

INTRODUCTION

Microaggressions are subtle statements or actions that reinforce stereotypes. Medical students, residents, and faculty report experiences of microaggressions, with higher incidences among women and marginalized groups. An educational tool utilizing the acronym VITALS (validate, inquire, take time, assume, leave opportunities, speak up) provided a framework for processing and addressing microaggressions encountered in the academic health center environment.

METHODS

We developed a 60-minute workshop designed to raise awareness of microaggressions encountered by medical students and trainees. The workshop consisted of a didactic presentation and multiple interactive exercises shared in small- and large-group formats. Participants also completed pre- and postsurvey instruments to assess changes in their knowledge and attitudes about promoting an environment that prevents microaggressions from occurring.

RESULTS

There were 176 participants who completed our workshop. In comparing anonymized pre- and postworkshop responses submitted by attendees, an increase in recognition of one's own potential stereotypical beliefs about social identity groups was observed. Participants also expressed a greater sense of empowerment to foster mutual respect in health care settings. After completing the workshop, attendees indicated a greater likelihood to engage in difficult conversations, including responding to microaggressions, which both peers and superiors encountered in both academic and clinical environments.

DISCUSSION

The workshop provided an interactive format for medical students and trainees to gain awareness, knowledge, and tools for addressing microaggressions encountered in health care settings.

Addressing Mistreatment by Patients in Geriatric Subspecialties: A New Framework

Mistreatment by patients is unfortunately common in clinical medicine, including geriatric subspecialties. Despite the prevalence of this problem, there are few standardized approaches for addressing it at both interpersonal and institutional levels. The "ERASE" framework is a novel, practical approach for addressing mistreatment by patients. "ERASE" includes Expecting and preparing for mistreatment by patients, Recognizing mistreatment, Addressing mistreatment in real time, Supporting members of the healthcare team who have been mistreated, and Establishing a positive institutional culture. The framework may prove particularly helpful and applicable to providers specializing in geriatrics and can be used by administrators, educators, and all members of the healthcare team to promote safe, dignified clinical care and learning environments.

The Stereotype Content Model as an Explanation of Biased Perceptions in a Medical Interaction: Implications for Patient-Provider Relationship

This experimental investigation uses the stereotype content model (SCM) to explain the biases associated with the perceptions of healthcare providers and the subsequent impact of such biased perceptions. Specifically, the 2 (gender: male, female) by 2 (race: Arab, Caucasian) between-subjects experiment examined the impact of physician race and gender on people's perceptions regarding physician's communication competence, trust, and intentions to visit. The findings indicate that female physicians are considered not only warmer but also more competent than male physicians. White physicians are considered less competent overall than their minority counterparts, though no differences in perceived patient-centered communication behaviors were observed. In addition, perceived competence and warmth mediated the effect of physician gender and race (only warmth) on the perceptions of trust, physician's use of patient-centered communication, and intentions to visit. The theoretical and practical implications of the study are discussed.

Are You Really the Doctor? Physician Experiences with Gendered Microaggressions from Patients

Background: In contrast to physician implicit bias toward patients, bias and microaggressions from patients toward physicians have received comparatively less attention. Materials and Methods: We captured physician experiences of gendered microaggressions from patients by conducting a mixed-methods survey-based study of physicians at a single academic health care institution in May 2019. A quantitative portion assessed the frequency of gendered microaggressions (microaggression experiences [ME] score) and the association with measures of perceived impacts (job satisfaction, burnout, perceived career impacts, behavioral modifications). A one-tailed Wilcoxon rank sum test compared distributional frequencies of microaggressions by gender, and by gender and race. Chi-square tests measured the associations between gendered microaggressions and perceived impacts. Welch two-sample t-tests assessed differences in ME scores by rank and specialty. Linear regression assessed the association of ME scores and job satisfaction/burnout. A qualitative portion solicited anecdotal experiences, analyzed by inductive thematic analysis. Results: There were 297 completed surveys (response rate 27%). Female physicians experienced a significantly higher frequency of gendered microaggressions (p < 0.001) compared with male physicians. Microaggressions were significantly associated with job satisfaction (chi-square 6.83, p = 0.009), burnout (chi-square 8.76, p = 0.003), perceived career impacts (chi-square 18.67, p < 0.001), and behavioral modifications (chi-square 19.96, p < 0.001). Trainees experienced more microaggressions (p = 0.009) and burnout (p = 0.009) than faculty. Higher ME scores predicted statistically significant increases in burnout (p < 0.0001) and reduced job satisfaction (p = 0.02). Twelve microaggressions themes emerged from the qualitative responses, including role questioning and assumption of inexperience. The frequency of microaggressions did not vary significantly by race; however, qualitative responses described race as a factor. Conclusions: Physicians experience gendered microaggressions from patients, which may influence job satisfaction, burnout, career perceptions, and behavior. Future research may explore the multidirectionality of microaggressions and tools for responding at the individual and institutional level.

No One Size Fits All: A Qualitative Study of Clerkship Medical Students' Perceptions of Ideal Supervisor Responses to Microaggressions

PURPOSE

This study explores medical students' perspectives on the key features of ideal supervisor responses to microaggressions targeting clerkship medical students.

METHOD

This single-institution, qualitative focus group study, based in an interpretivist paradigm, explored clerkship medical students' perceptions in the United States, 2020. During semistructured focus groups, participants discussed 4 microaggression scenarios. The authors employed the framework method of thematic analysis to identify considerations and characteristics of ideal supervisor responses and explored differences in ideal response across microaggression types.

RESULTS

Thirty-nine students participated in 7 focus groups, lasting 80 to 92 minutes per group. Overall, students felt that supervisors' responsibility began before a microaggression occurred, through anticipatory discussions ("pre-brief") with all students to identify preferences. Students felt that effective bystander responses should acknowledge student preferences, patient context, interpersonal dynamics in the room, and the microaggression itself. Microassaults necessitated an immediate response. After a microaggression, students preferred a brief one-on-one check-in with the supervisor to discuss the most supportive next steps including whether further group discussion would be helpful.

CONCLUSIONS

Students described that an ideal supervisor bystander response incorporates both student preferences and the microaggression context, which are best revealed through advanced discussion. The authors created the Bystander Microaggression Intervention Guide as a visual representation of the preferred bystander microaggression response based on students' discussions. Effective interventions promote educational safety and shift power dynamics to empower the student target.

Ethics and multiculturalism in pediatric surgery

The concept of culture includes many defining characteristics such race, ethnicity, gender, identity, socioeconomic status, beliefs, traditions, and habits. Multiculturalism is a concept that allows for respect, understanding and acknowledgement of a diversity of identities. The cases discussed in this manuscript indicate the importance of multiculturalism in the practice of pediatric surgery.

Impact of racial microaggressions in the clinical learning environment and review of best practices to support learners

Microaggressions are brief, commonplace, and daily verbal, behavioral, and environmental slights towards marginalized groups. Underrepresented in medicine (UiM) learners experience a barrage of microaggressions in the pediatric clinical learning environment. Literature demonstrates that microaggressions are detrimental to the mental and physical well-being of the recipient. There is an urgent need to bring greater awareness and understanding of how microaggressions operate in the clinical learning environment, the impact they have on UiM learners and the educational and institutional strategies needed to best support learners. Several databases were searched using combinations of subject headings and keywords as described. While "microaggressions" is not yet an official medical subject heading (Mesh term) for the National Library of Medicine's databases, nonetheless there are numerous studies using the term microaggressions in the research literature about health care, medical education and learning environments. Items were limited to English language publications from the past 10 years. Microaggressions are rooted in power differentials and indirect assertion of power. The clinical learning environment contains learners at all levels along with patients and families. The impact of microaggressions leads to (1) othering (2) stunted professional identity formation and (3) racial battle fatigue. Both educational initiatives targeted at recognizing and responding to microaggressions and institutional anonymous reporting systems and policies are best practices to combat the negative impact of microaggressions. Institutions-at-large and graduate medical education need to create safe spaces for anonymous reporting, robust policies for addressing bias and educational initiatives for responding to microaggressions. Together these will begin to create safe spaces for our UiM learners in a system that so often perpetuates they do not belong.

Becoming Active Bystanders and Advocates: Teaching Medical Students to Respond to Bias in the Clinical Setting

INTRODUCTION

Incidents of bias and microaggressions are prevalent in the clinical setting and are disproportionately experienced by racial minorities, women, and medical students. These incidents contribute to burnout. Published efforts to address these incidents are growing, but gaps remain regarding the long-term efficacy of these curricular models. We developed and longitudinally evaluated a workshop that taught medical students a framework to respond to incidents of bias or microaggressions.

METHODS

In October 2019, 102 Vanderbilt core clerkship medical students participated in an hour-long, interactive, case-based workshop centered around the 3 D's response behavior framework: (1) direct, (2) distract, and (3) delegate. Participants were surveyed before and after the training, and both qualitative and quantitative data were collected. A refresher workshop was offered 8 months later, which added two additional D's: delay and display discomfort.

RESULTS

After the workshop, respondents' knowledge of the assessed topics improved significantly, as did their confidence in addressing both personally experienced and witnessed incidents. Respondents initially indicated a high likelihood of using response behaviors to address incidents. The workshop did not consistently modify behavioral responses to experienced or witnessed incidents. Ninety-one percent of respondents agreed the workshop was effective.

DISCUSSION

This workshop provided an effective curriculum to sustainably improve participant knowledge and confidence in responding to incidents of bias and microaggressions. This resource can be adopted by educators at other institutions.

Racial Discrimination from Patients: Institutional Strategies to Establish Respectful Emergency Department Environments

n/a

Responding to Discriminatory Patient Requests

CASE

Julia is a 13-year-old White adolescent girl who was referred for psychological counseling given concerns related to mood, nonadherence, and adjustment secondary to her new diagnosis of type 1 diabetes. The family lives in a rural town located several hours from the academic medical center where she was diagnosed. After several months on a waitlist, the family was contacted to schedule a telehealth appointment with a predoctoral psychology trainee. When the scheduler informed the mother that her daughter would be scheduled with Ms. Huang, the mother abruptly stopped the conversation stating, "I do not want to waste everyone's time" and initially declined the appointment offered. When the scheduler asked about her hesitance, the mother disclosed previous interactions with doctors at the hospital who were "not born in the United States" that she felt were "textbook" (e.g., smiling even when discussing a new chronic medical condition) and "hard to understand" (i.e., because of different dialect/accent). The mother shared that she found these experiences to be stressful and felt the interactions had negatively affected Julia's care. When informed about the length of the waitlist for another clinician, the mother agreed to initiate services with the trainee.The supervising psychologist shared the mother's concerns and comments with Ms. Huang. After discussion, Ms. Huang agreed to provide intervention services, "as long as the family was willing." During the initial telehealth sessions, Ms. Huang primarily focused on building rapport and strengthening the therapeutic alliance with the family. During this time, Julia's mother was reluctant to incorporate suggested parent management strategies at home. Julia also made minimal improvement in her medical management (i.e., A1c levels remained high), had difficulty using behavioral coping strategies, and experienced ongoing mood symptoms (i.e., significant irritability, sleep difficulties, and depressive symptoms). Ms. Huang began to wonder whether the family's resistance and inability to implement recommendations were in some part because of the family's initial concerns and reluctance to engage in therapy with her as a clinician.Should Ms. Huang address the previously identified concerns with the patient and her family? What should be considered when determining how to approach this situation to ensure provision of both the best care for this patient and support for this trainee?

Healthcare professionals' encounters with ethnic minority patients: The critical incident approach

Ethnic minority patients face challenges concerning communication and are at higher risk of experiencing health problems and consuming fewer healthcare services. They are also exposed to disparaging societal discourses about migrants which might undermine healthcare institutions' ambitions of equitable health care. Therefore, healthcare professionals need to critically reflect on their practices and processes related to ethnic minority patients. The aim of this article is to explore healthcare professionals' experiences of working with ethnic minority patients by using the critical incident (CI) technique. In two focus group sessions, participants discussed challenging events in their encounters with patients. The critical incidents show that healthcare professionals may experience unfamiliar situations related to their work performance, prejudice toward patients, and labeling by patients the professionals do not identify with. The professionals' reflections are discussed in relation to social discourses on migration and their work conditions, and the possible influence on the professionals' preconceptions and the patient-professional relationship in health care. Reflections about work experiences with ethnic minority patients and aligned societal discourses should be included in healthcare workers' professional development. Critical incident reflections at work may contribute to better-coping strategies for healthcare professionals and improved patient-professional relationships with ethnic minority patients.

Professionalism: microaggression in the healthcare setting

PURPOSE OF REVIEW

Microaggressions are daily commonplace, subtle behaviors and attitudes toward others that arise from conscious or unconscious bias. Not only can microaggressions affect one's access to power, resources, and opportunity, but they could also contribute to the persistent disparities faced by marginalized groups among healthcare professionals as well as patients.

RECENT FINDINGS

Physicians, especially those in perioperative specialties, commonly have distress during their medical training. Workplace mistreatment, such as discrimination, has been commonly reported by residents across multiple specialties. Microaggressions also impact patient care as they can influence decisions of medical professionals toward a person or group of people.

SUMMARY

This review offers education on the correlation of microaggression and unconscious bias to health disparities, provides tools to address microaggressions as a bystander, and outlines processes for institutional improvement.