Patient Mistreatment of Health Care Providers

doi:10.21203/rs.3.rs-1013756/v1

PDF

Research Article

Patient Mistreatment of Health Care Providers

https://doi.org/10.21203/rs.3.rs-1013756/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

Mistreatment of medical professionals by patients is an ongoing problem. We aimed to construct and evaluate a curriculum that would prepare medical professionals for mistreatment by patients.

Methods

Lessons learned from 15 interviews and 2 focus groups with medical professionals were distilled into a multi-modal curriculum including didactics, simulation videos and role-play scenarios aimed to improve confidence in addressing mistreatment. This curriculum was disseminated at five educational workshops to medical professionals of various training groups and experience levels. Pre- and post-surveys were distributed to assess changes in participant’s perspectives on readiness to address mistreatment. The signed-rank test was implemented to compare pre- and post- data.

Results

Participants were more likely to agree post-workshop that they had the right words to say, had a plan for what to do, and were more willing to speak up when they themselves or someone else was mistreated (p < .001). They were also more likely to agree post-workshop that there was something they could do to address patient mistreatment (p < .001).

Conclusions

Participant familiarity and confidence in responding to patient mistreatment increased. Our curriculum may serve as a foundation for institutions seeking to equip their educators, providers, and trainees with strategies for addressing this important issue.

Educational Philosophy and Theory

Internal Medicine

mistreatment

disrespect

curriculum

victim

bystander

Medical students enter training with a deep desire to care for patients well. Unfortunately, patients are becoming an increasingly recognized source of mistreatment directed towards healthcare providers, which is ultimately a threat to both patient and providers’ well-being. Mistreatment in the medical setting has broadly been defined as behavior that disrespects or disregards the dignity of another person [1]. Trainees are an especially vulnerable population given their place in the medical hierarchy, and recent literature would suggest addressing this issue is an urgent need [2, 3].

We now have extensive evidence that medical students suffer mistreatment throughout their training from a variety of sources [4]. —in fact, there’s little question that medical professionals across all training levels are exposed to such abuse. One recent meta-analysis quantifying harassment and discrimination against both medical students and residents found that 59.4% of trainees experienced at least one form of abuse throughout their training, most commonly verbal [5]. Experiencing such behavior has been shown to correlate with burnout, which is associated with suicidal ideation and thoughts of dropping out of medical school [6-8]. Attending physicians are no more immune than their junior colleagues, with one study stating 1 in 3 experience rudeness, dismissiveness, and aggressive behavior multiple times a week. A small fraction (7%) state that this behavior has led to medical mistakes [9].

One study out of the University of Alberta stated that of the 45% of respondents who had experienced intimidation, harassment, or discrimination during their family medicine residency training, 35% identified patients as the source of this mistreatment [10]. Several publications have offered strategies for how to address patient mistreatment of healthcare professionals effectively, with suggestions including depersonalization, exploring the patient’s perspective, and “calling it out [1, 11, 12].” To our knowledge, there are no studies to date that assess the effectiveness of training materials aimed at helping medical professionals respond to patient mistreatment. The authors aimed to address this issue by first constructing such a curriculum, then, by disseminating it to a range of medical professionals through workshops, and finally, by quantitatively measuring differences in attendee confidence before and after participating through surveys. By surveying medical professionals across several different levels of training, we hoped to assess the relative impact of such a curriculum (as well as mistreatment itself) over the natural history of a developing clinician. More broadly, we hoped that by recognizing and actively discussing these instances of mistreatment we would reinforce the importance of a culture of mutual respect within the medical system.

Study and curriculum design

IRB approval was obtained though Stanford University’s Research Compliance Office for all components of this study prior to initiation. The first phase consisted of a series of semi-structured interviews regarding patient mistreatment of medical staff (Appendix A: Semi-structured Interview Questions) with medical students, residents, attendings, nurses and other staff at Stanford Medical School, Stanford University Medical Center and Stanford Children’s Health. The interview template was written and reviewed by the primary research authors [DM, LO, RS-C,], and a single author [DM] conducted each interview. Participants were identified through a mixture of volunteer and purposive sampling—some individuals responded to paper advertisements posted throughout campus, while others were sought out for their expertise in this topic. Advertisements requested participation of individuals who had either personally experienced patient mistreatment or had witnessed it. The primary goal of each interview was to garner descriptions of instances of mistreatment, elicit what strategies were used to address mistreatment (if any), and evaluate if those strategies were viewed as effective or not by the participant. Fifteen individual interviews and two focus groups were completed between November 2017 and May 2018. Interviews were recorded with participant permission. Verbatim transcription of these interviews and focus groups were completed using an online service (Rev.com) and reviewed for accuracy by a single author [DM]. Transcripts were de-identified and stored on an encrypted, password-protected computer.

The authors then constructed an educational curriculum for medical professionals to more effectively address patient mistreatment based on these interviews. Poignant narratives describing incidents of mistreatment were used as the basis for four video scenarios and one paper case to be used in the curriculum. Each video demonstrated one or more outcomes based on differing strategies utilized to address mistreatment, which mirrored strategies that were described during the interview phase of the study. The video scenarios depicted instances of racism, sexism, homophobia, and violent/threatening behavior. Scripts, discussion questions, and learning objectives were written collaboratively by the primary authors, with details sufficiently changed to maintain interview participant and patient anonymity. Learning objectives were based upon strategies that were uniformly described as helpful during the interview phase of the study. Actors for the video scenarios were health care workers from the Stanford Medical School community—a subset of these actors were financially compensated. Camera work, sound work, and video editing was completed by Stanford Video. The final curriculum consisted of a combination of background education on the topic via literature review, screening of video scenarios, and audience participation via group discussion as well as role-play exercises using the paper case scenario (videos available at this link: https://vimeo.com/channels/1659548). Mistreatment was broadly defined for participants as behavior that disregards or disrespects the dignity of another person. Physical violence was considered to be an extreme form of mistreatment and we shared de-escalation strategies in our curriculum and directed participants to individual hospital policies regarding violent behavior for further guidance [13].

Participants and sampling

The authors then distributed this curriculum to a wide range of medical professionals including medical students, residents, attendings, nurses, and other staff members between September 2018 and March 2019 via a series of educational workshops. There were five workshops in total spanning pre-clinical medical student didactic sessions, international conferences, and residency program didactic sessions. Workshops at the pre-clinical didactic sessions and residency program didactic sessions were completed following the request of the associated faculty supervisor or residency program director. The international conference workshop setting was applied to and accepted. Workshops lasted between 60 and 90 minutes.

Subjects were included in the analysis if they initiated both the pre- and post-test regardless of completing each question. A total of 172 subjects completed either the pre- or post-test questionnaire. Twenty-five subjects were excluded due to lack of either pre- or post-test data. Four subjects were excluded because they had identical subject-identifier numbers which prevented us from accurately pairing their pre- and post-test. A total of 143 subjects completed both the pre- and post-test and were used for this analysis. Of the 143 subjects, 62% were medical students, 12% were residents, 20% were attendings, and 6% were in another category (including nurse, nurse practitioner, psychologist, and case manager).

Data Collection

Pre- and post- workshop surveys were distributed to participants who agreed to participate in the research study. Surveys were constructed using a modified Delphi method completed by the primary authors. Ten Likert scale questions regarding knowledge and comfort around the topic of patient mistreatment of medical staff were included (See Appendix B for workshop survey), with 1 being “strongly disagree” and 5 being “strongly agree.” Pre- and post-surveys were paired using the participant’s date of birth (day/month) and the first letter of the city of their birth. The only other identifying information obtained from participants was their training level. Additional identifying information was not gathered to preserve participant anonymity.

Analysis

Descriptive statistics were used to describe responses to questions. Signed-Rank Test was used to compared pre- and post-test responses, both for the pooled cohort and also after stratifying participants by training group.

Pooled participants had a statistically significant increase (p < .001 for all questions) in post-response compared to their pre-test response for all questions six to fifteen (see Table and Figure 1). Question 16 asked whether participants preferred having an opportunity to address patient mistreatment themselves versus having their supervisor address the offending patient immediately. The percentage of respondents who preferred having an opportunity to address

mistreatment themselves prior to supervisor intervention increased 18% following our educational intervention, from 31% to 49%. Notable post-test responses in the stratified analysis that did not differ significantly (p < .05) from the corresponding pre-test response included: comfort bringing up instances of mistreatment with supervisors amongst attendings (Q8), willingness to speak up for one’s self during an instance of mistreatment amongst residents (Q12), comfort and knowledge about utilizing evidence-based strategies to de-escalate a hostile patient amongst residents (Q14,15), and impression that mistreatment has an impact on the quality of patient care amongst all non-pooled groups (Q10). Participants in the “other” category, which included several non-patient-facing health care workers, rarely had post-test responses that differed significantly from pre-test responses.

Post-workshop, the pooled cohort of participants were more likely to agree that they had the right words to say, they had a plan for what to do, and they were willing to speak up when faced with mistreatment by patients (Figure 1). Pooled participants also were more likely after the educational intervention to feel comfortable de-escalating a hostile patient and be aware of evidence-based de-escalation strategies. In addition, they were more likely to desire the opportunity to address mistreatment themselves rather than request immediate supervisor intervention following our educational intervention. These results suggest our curriculum bolstered the confidence of medical professionals across a range of training levels to find their voice in addressing patient mistreatment and feel prepared to address patient mistreatment.

Regarding our stratified analysis, there are several possible explanations for lack of pre- and post-test responses differing significantly amongst various groups. Regarding question 10, lack of significance is most likely explained by the ceiling effect, as groups already strongly agreed that mistreatment impacted quality of patient care. Regarding question 8, it’s possible that attendings don’t have an identified supervisor that is appropriate for discussing instances of mistreatment with compared to residents or medical students. Regarding question 12, lack of significant increase in resident willingness to speak up for oneself may be explained by the relatively low number of resident participants, and we are reassured by the trend of increased agreement. Similarly, lack of increase of resident comfort and knowledge surrounding hostile patient management was likely secondary to the very small number of residents that participated in workshops addressing this issue, with only 6 resident participants amongst 120 total respondents.

Our results suggest that mixed curricula like ours, which utilizes video depictions of simulated mistreatment, role-play scenarios, and development of planned responses to prejudice and inappropriate behavior, may be an effective option for medical institutions seeking to prepare medical professionals for the unfortunate inevitability of facing mistreatment. In our time holding these workshops, we frequently heard participants describe feeling frozen or paralyzed during instances of mistreatment, which oftentimes led to a sense of shame or regret for not being able to say something in the moment. Debriefing these scenarios may help participants find the words that feel right to them—such preparation may help overcome the initial shock of inappropriate behavior and “call out” mistreatment in a more timely (and potentially more satisfactory) manner [13]. This could be true both for the targets of mistreatment and for bystanders hoping to protect their peers or learners. Ultimately, we recommend that the individual being mistreated be given agency to determine what the response to an instance of mistreatment looks like—this boosts the victim’s autonomy in addressing the event, and permits an educator or peer to tailor their support in a way that is most effective for the person being mistreated. Figure 2 summarizes some of our lessons learned. Educators may wish to incorporate other tools aimed towards addressing microaggressions, such as the GRIT mnemonic, or mindfulness tools such as BREATHE into their practice [14, 15].

The following limitations to our study should be noted. Questions 14 to 17 were on the back of a two-sided survey sheet and were left blank by 23 of our post-survey respondents. We suspect they were left blank because they were not seen by participants. We would not expect the respondents who did not see these final questions to have differed substantially from those who completed the survey, decreasing the likelihood this would bias our analysis. The post-intervention responses were obtained right after the educational intervention, and therefore it is unknown if these results would be sustained with time. It is possible that the participants over time would become less comfortable or would feel less prepared to address patient mistreatment of providers as time goes on and repeating the post-test questionnaire at a later date to determine if the effects of the educational intervention are longer lasting would be a valuable assessment.

Using trigger videos with patient mistreatment scenarios and role-playing these with medical trainees and faculty can prepare both trainees and faculty to more confidently handle these events when they occur. This has implications for improving patient care, given the ripple effect patient mistreatment of providers has on quality of care. Further assessment of the longevity of increased confidence following curricular intervention, assessment of actual capability to address mistreatment following intervention, assessment of alternative tools, and assessment of the detrimental impact of mistreatment on healthcare professional wellbeing is warranted.Of utmost importance, institutions should have robust infrastructure and processes in place to not only address patient mistreatment, but support their trainees, educators and staff who experience this type of abuse. Building a culture of mutual respect is critical for the well-being of both patients and the providers caring for them. It is particularly important to have a heightened awareness for the potential for mistreatment of marginalized individuals given this population is at higher risk of being mistreated both within and beyond the medical setting. Future research in this area should include a dedicated exploration of the experience of marginalized health care providers and their assessment of the effectiveness of the above strategies in addressing mistreatment.

Not applicable

Ethics approval and consent to participate:

IRB approval was obtained though Stanford University’s Research Compliance Office for all components of this study prior to initiation. Subject participants were consented.

Consent for publication:

No individual person’s data is contained in the manuscript

Availability of data and materials:

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests:

"The authors declare that they have no competing interests"

Funding:

This study was supported financially by the Stanford Vice Provost of Diversity and Inclusion Grant and the Stanford Nurse Alumnae Legacy Project Grant, Stanford Health Care, Stanford, CA, USA. The first author was financially supported by the Medical Scholars Scholarship offered to medical students completing research, Stanford University School of Medicine, Stanford, CA, USA.

Authors’ contributions:

D.M. and D.G. wrote the main manuscript. Study concept and design done by D.M., L.O., R.S-C.; teaching sessions done by D.M., L.O., R.S-C.; acquisition of the data done by D.M., L.O., R.S-C.; Figures 1 and Table done by M.N. Figure 2 done by D.M. and D.G.; data analysis and interpretation done by D.M., M.N., L.O., R.S-C.. All authors have critically reviewed the manuscript.

Acknowledgements:

None

Whitgob, E. E., Blankenburg, R. L. & Bogetz, A. L. The Discriminatory Patient and Family : Strategies to Address Discrimination Towards Trainees. 91, 64–69 (2016).
Olayiwola, J. N. Racism in Medicine: Shifting the Power. Annals of family medicine 14, 267–269 (2016).
Okwerekwu, J. A. The patient called me ‘colored girl.’ The senior doctor training me said nothing. StatNews.com https://www.statnews.com/2016/04/11/racism-medical (2016).
Mavis, B., Sousa, A., Lipscomb, W. & Rappley, M. D. Learning About Medical Student Mistreatment From Responses to the Medical School Graduation Questionnaire. Academic Medicine 89, 705–711 (2014).
Fnais, N. et al. Harassment and discrimination in medical training: A systematic review and meta-analysis. Academic Medicine 89, 817–827 (2014).
Cook, A. F., Arora, V. M., Rasinski, K. A., Curlin, F. A. & Yoon, J. D. The Prevalence of Medical Student Mistreatment and Its Association With Burnout. Academic Medicine 89, 749–754 (2014).
Dyrbye, L. N. et al. Burnout and suicidal ideation among U.S. medical students. Annals of internal medicine 149, 334–341 (2008).
Dyrbye, L. N. et al. Burnout and Serious Thoughts of Dropping Out of Medical School : A Multi-Institutional Study. Academic Medicine 85, 94–102 (2010).
Bradley, A. V. et al. Sticks and stones : investigating rude , dismissive and aggressive communication between doctors. Clinical Medicine (London) 15, 541–545 (2015).
Crutcher, R. A., Szafran, O., Woloschuk, W., Chatur, F. & Hansen, C. Family medicine graduates ’ perceptions of intimidation , harassment , and discrimination during residency training. BMC Medical Education 11, 88 (2011).
Wheeler, D. J., Zapata, J., Davis, D. & Chou, C. Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner. Medical Teacher 0, 1–6 (2018).
Cowan, A. N. Inappropriate Behavior by Patients and Their Families—Call It Out. JAMA Internal Medicine 178, 1441 (2018).
Richmond, J. et al. Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. WestJEM 13, 17–25 (2012).
Warner, N. S., Njathi-Ori, C. W. & O’Brien, E. K. The GRIT (Gather, Restate, Inquire, Talk It Out) Framework for Addressing Microaggressions. JAMA Surg 155, 178 (2020).
Eva, A. L. & Thayer, N. M. Learning to BREATHE: A Pilot Study of a Mindfulness-Based Intervention to Support Marginalized Youth. J Evid Based Complementary Altern Med 22, 580–591 (2017).

Due to technical limitations, table 1 is only available as a download in the Supplemental Files section.

No competing interests reported.

PDF

Editorial decision: Major revision
21 Jan, 2022
Reviewers agreed at journal
14 Jan, 2022
Reviews received at journal
05 Jan, 2022
Reviewers agreed at journal
20 Dec, 2021
Reviewers invited by journal
15 Nov, 2021
Editor assigned by journal
15 Nov, 2021
Editor invited by journal
03 Nov, 2021
Submission checks completed at journal
03 Nov, 2021
First submitted to journal
24 Oct, 2021

You are reading this latest preprint version

Patient Mistreatment of Health Care Providers

Status:

Version 1

Abstract

Figures

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Version 1