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 . 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.