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Exploring how physicians can handle discrimination by patients

Katherine Hill, MD, a Stanford clinical instructor of pediatrics, was an intern on rotation in the ER when the father of a little boy asked her a question: “I see your last name is Hill. Is that a Jewish name?”

Hill told the father it was not and asked why it mattered. He said that if she were Jewish, he didn't want her seeing his son.

Feeling uneasy about the encounter, Hill approached Emily Whitgob, MD, a fellow in developmental-behavioral pediatrics who was a third-year resident at the time. Whitgob was appalled and motivated to act. She relayed the story during the resident’s morning report, which elicited tears from some residents and prompted others to share their own stories of patient bias and discrimination. Discovering that she had tapped into something real but not talked about, Whitgob decided to devote her residency research project to exploring strategies for handling discriminatory patients and families towards trainees, the results of which are published today in Academic MedicineRebecca Blankenburg, MD, and Alyssa Bogetz, MSW, are co-authors.

The authors wrote, “Our political and social climate is such that discrimination is at the forefront of many human interactions. As medical professionals, our duty is to prepare our trainees, faculty, staff, administrators, and ourselves to appropriately navigate these situations.”

Right now, Whitgob believes the most valuable strategy we have is encouraging a dialogue. “Obviously, discrimination is happening all the time in the grocery store, everywhere else," she commented during a recent interview. "But do we think: 'Oh, we’re in medicine, we’re above that?' It’s absolutely not true.”

In fact, a 2015 survey of Stanford pediatric residents found that 15 percent personally experienced or witnessed patient or family mistreatment; yet, 50 percent of respondents reported not knowing how to deal with these issues and 25 percent believed no action would result if they alerted hospital leadership. Whitgob went on to interview 13 pediatric faculty educational leaders: She presented them with three scenarios of family discrimination against trainees (involving race, gender, religion) and asked participants how they would address the scenarios as a trainee and also the supervising physician. These discussions led to four major recommendations: 1) assess illness acuity; 2) cultivate a therapeutic alliance; 3) de-personalize the event; and 4) ensure a safe learning environment for trainees. Above all, participants stressed caring for the child was their top priority.

Surprisingly, one of the recommendations in the paper where the participants' opinions differed starkly was on how much doctors should try to validate the emotional experience underlying the discriminatory remark. Four faculty interviewed said they would be less likely to cultivate an alliance and would opt for a more pragmatic approach, redirecting the focus back on the child’s health. Others believed it was important to lean in.

“See if you can speak to the person’s emotions, not to their words. If someone says, ‘I don’t want a Jewish doctor,’ I might say, ‘Gosh, you must be really worried about your child,’” suggested Heidi Feldman, MD, PhD, who now advises Whitgob in the developmental-behavioral pediatrics section. “Don’t run away from the situation. The more you run away the more I think it validates the behavior.”

Whitgob's report shows that faculty educators unanimously agreed on one point: that case-based discussions should be a part of resident training. Feldman agrees. She participated in a communication course when she was an attending at the University of Pittsburgh. It involved simulated scenarios between doctors and actors who were playing pre-assigned roles as patients. Physicians had a safe environment where they could get immediate feedback and advice from the actors and their peers, and they were able to replay a scene until it worked better for all parties. While no such training is offered at Stanford specifically addressing discrimination by patients and families, Whitgob has led a formal workshop where a group of residents and attendings discussed the scenarios presented to the participants in her research study. The group brainstormed ways to respond.

Says Whitgob, “We can’t prevent it, but we have to be prepared for it. That’s the big goal: Start talking about it and let trainees know this will very likely happen. Here’s who you talk to when it happens. Please don’t keep it to yourself.”

Laura Hedli is a writer with the Division of Neonatal and Developmental Medicine in the Department of Pediatrics.

Previously: Racism inside the clinic: One physician's story
Photo by Mike

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