A Plan to Move Forward
Report calls for hospitals to take a systematic approach
With the increasing diversification of the health care workforce, the issues arising from patients’ biases against clinicians must be addressed with a systematic approach by hospitals, states a U.S. report calling for action.
Despite the importance and prevalence of patient bias, many medical centres lack an organizational approach for addressing patient conduct, says the authors of the report that appeared in the July 14, 2020 issue of the Annals of Internal Medicine.
In fact, a recent U.S. study found 88 percent of the 426 hospitals surveyed had no policies for dealing with patients’ refusal of a physician on the basis of the physician’s sociodemographic characteristics.
“Policy development can be daunting because organizations may encounter various barriers, including reluctance of staff to have difficult conversations about race or other identity traits; uncertainty about what constitutes an appropriate response to the spectrum of demeaning behaviours and who should make this determination; what, if any, supports should be offered to targeted clinicians; whether these incidents should be reported and to whom; and whether the medical centres’ responses should differ depending on whether nurses, trainees or other clinicians are involved,” writes Dr. Kimani Paul-Emile (PhD), a lawyer specializing in biomedical ethics, who co-authored the report with Drs. Jeffrey Critchfield, Margaret Wheeler, Alicia Fernandez and Shalita de Bourmont.
However, “quiet acceptance of biased patient behaviour is not a defensible norm for medical centres,” write the authors. The need for a systematic approach is compelling, they write. A lack of policies in hospitals can undercut the therapeutic alliance necessary for the provision of care; undermine clinical standards; worsen patients’ health; and impair workflow, possibly at the expense of other patients.
Moreover, non-action can also impose hardship on targeted clinicians, particularly women and persons of colour, for whom explicit patient bias can exact a heavy emotional toll.
To help organizations develop policies that meet the needs of patients and health care professionals, the authors put forward the following recommendations to respond to biased patients.
Write a Policy that Explicitly Addresses Patient Bias
Addressing patient bias while supporting staff and respecting patients’ rights begins with writing a policy to establish implementation procedures; clarify expectations; promote consistency; and outline governing ethical principles, including justice and respect in health care delivery, adherence to relevant legislation, and protection of patients and staff.
The authors suggest that when faced with bias-based reassignment requests, it’s important the following considerations be incorporated into the policy: the patient’s medical condition, decision-making capacity and reasons for the request; the effect on the physician; and the options for responding, including accommodation.
In most cases, the authors recommend rejecting bias-based requests for clinician reassignment. However, they note that not all requests for reassignment are rooted in bias, such as a request for a physician who speaks the same language as the patient. The authors also recommend policies recognize patients’ past experiences, including discrimination in health care settings, and allow clinician reassignment for clinically indicated concordances.
Establish Procedures that Account for Clinical Roles and Services
Have specific procedures for every role in the health-care system — from nurses to physician assistants to doctors. The authors also recommend developing protocols specific to trainees. For example, if a student is targeted by a biased patient, that student should be allowed to opt out of taking care of that patient. If the student decides to opt in, they should work with physicians who can model behaviour for handling such conflict.
Also, procedures may need to differ on the basis of the clinical services and settings involved, such as psychiatric wards or emergency departments, where the patient’s capacity may be in question or clinical instability may be an issue.
Create Support for Reporting
To effectively address patient bias, incidents must be reported. But “written policies are only effective in a climate that supports reporting,” write the authors. Consequently, institutions should create mechanisms for reporting, while fostering a culture that supports it.
Designate a Team
“Identifying staff consultants to help with issues, such as deescalating encounters with recalcitrant patients, assisting in conflict resolution and offering legal advice, will ensure institutionally vetted procedures are followed,” write the authors. Use of this team resource, they note, would be helpful to clinicians who often lack the expertise and time to deal effectively with these situations.
Ensure Appropriate Tracking and Data System
Medical centres should track and collect data on encounters with biased patients, including how often and where they occur, the effect on staff, the support they received, and the institution’s response. The data collected can be used to gain a systematic understanding of the problem and help devise best practices.
Ensure Adequate Training
The authors say training can dispel the common belief that tolerating such behaviour is part of the job and instill the skills necessary to handle these incidents appropriately.