By Sarina Deb
In the midst of a mass movement against racial injustice, affiliates of Stanford Medicine are speaking out about how they respond to discrimination and maltreatment from patients and visitors.
“There is a challenge that has really been increasing nationally: the mistreatment of healthcare workers by patients, families and visitors,” Jeanie and Stew Ritchie Professor Tait Shanafelt, who is also Stanford Medicine’s chief wellness officer, told The Daily. “Historically, there has always been tension when, for example, someone assaults a physician, but what has really been the iceberg beneath the surface is the racially disparaging comments, the gender-related comments, the patients who won’t accept a doctor of a certain race caring for them and the patients who will only talk to the med student because they are the only man in the room.”
National data shows that healthcare workers are at high risk for workplace injury and encounter violence and discrimination on the job frequently. Shanafelt said that despite the pervasiveness of this issue, it often “flies under the radar” when evaluating the risks and challenges that come with working in the healthcare industry.
“We knew about physical violence occurring, but in 2017, we started to see a crescendo of anecdotal reports from our people who had experienced mistreatment at work,” Shanafelt added. “This is when we realized that we did not have a good organizational system and response to the behavior.”
‘I’ve been spit on, kicked and scratched’
Clinical assistant professor and emergency room physician Italo Brown shared his experiences with maltreatment from patients, pointing to incidents in which he was physically assaulted and threatened.
“I’ve been spit on, kicked and scratched,” Brown said. “I’ve had multiple patients tell me that they were going to kill me, I’ve had patients ask for my address so that they can come to my house and fight me and I’ve had patients wait outside after a shift to try to assault me.”
However, Brown said, experiencing discrimination and maltreatment based on his identity was nothing new to him.
“This is no different, in my opinion, than what it was like growing up as a Black man,” Brown said.
He added that he deals with this treatment through a combination of compassion and drawing from his past experiences of discrimination.
“I mix the street with the compassion that comes with providing care to patients that are maybe having their absolute worst day ever,” Brown said. “Out of those two things, what I find is an ability to interpret personalities and intent and ways to appropriately shift the energy in that conversation, so I’m able to redirect the patients.”
Brown said that the treatment he experiences in the emergency room is inextricably interconnected with the incidents of police brutality against Black people.
“It’s unique to be in this position as a physician and an attending [physician] and a Black man in America,” Brown said. “Black male medical students, residents and physicians are a rarity, and we’ve experienced both racism and the lack of police accountability in our country firsthand.”
“I grew up in communities and have lived in communities where over-policing was prominent,” he continued. “I’ve been pulled over and treated poorly by law enforcement. Now I’ve been treated poorly by my patients.”
He added, however, that his experiences as an ER physician have helped him learn to deal with maltreatment in and out of work, because physicians are expected to treat patients, even when patients act discriminatorily towards them.
“My vantage point as an ER physician where I have to treat patients helps me not only understand the complexity of these issues and the root of where the patients are coming from when they treat me poorly, but has also helped me find constructive ways to improve it,” Brown said.
‘We can’t prevent what comes through their doors of the hospital, but we can prepare to respond to it’
Affiliated clinical assistant professor in developmental-behavioral pediatrics Emily Whitgob ’02 is no stranger to the issue of patient discrimination. When she was a fellow in developmental-behavioral pediatrics at Stanford, Whitgob initiated a study that evaluated how physicians respond to patient discrimination and help their trainees navigate these difficult situations. According to Whitgob, the idea for the study was sparked by a personal experience.
“When I was working in the emergency department, an intern I was supervising came to me one day: Her patient asked if she was Jewish, because he didn’t want a Jewish doctor,” Whitgob said. “My intern isn’t Jewish, but I am.”
Whitgob said that when she brought up the story at a weekly meeting with 30 other residents and faculty members, half of the room was “tearful,” admitting that “this happens a lot but no one talks about it.”
“People brought up a variety of different stories,” Whitgob said. “They shared stories of being treated as if they were the interpreter because they were Latinx, of being asked where the food is because patients assumed they were a cafeteria worker, of being a woman and being passed up for cases because patients don’t think they are doctors.”
“We can’t prevent what comes in the doors of the hospital clinic, so we have to prepare to respond to it,” Whitgob said. She stressed the importance of talking about this issue as early as medical school so that trainees are prepared to react and process appropriately when discrimination occurs.
Whitgob also brought up the question of whether physicians should treat a patient directly if that patient discriminates against their trainees, one of the pivotal explorations of the study.
“When the supervisor says, ‘Let me go in for you, you don’t have to do that,’ because the trainees are already disempowered if someone discriminates against them, this just disempowers them further,” Whitgob said. The study ultimately concluded that sending in a substitute is not always the answer.
Whitgob’s study also examined the possibility of opening up a discussion with a patient who requests another doctor based on identity or who discriminates against their physician in another way.
“If someone’s in the ER bleeding out or if a baby’s being born and you have to rush in, you can’t have this long discussion, but if someone is coming into a clinic with a cough or cold you have a different opportunity to explore what the person is actually worried about and what the solution is,” Whitgob said.
She added that addressing the discrimination is important in preventing turnover and retaining trainees.
“There are really talented trainees that come from different places, but if they’re discriminated against through their training, it’s not going to be motivating for them to stay on,” Whitgob said. “We need to figure out how we can support trainees in navigating these situations.”
According to Shanafelt, Stanford is in the process of creating streamlined processes for responding to incidents and experiences like Brown’s. In late 2018, Stanford Medicine commissioned a year-long task force including leaders from across departments at Stanford Medicine to evaluate Stanford’s processes for responding to these incidents and make recommendations for moving forward.
“The objectives of the task force were to evaluate the current state of this problem across all of Stanford Medicine, including the adequacy of our systems approach to dealing with mistreatment, and to identify gaps, as well as to make recommendations for the development of a system-wide approach to address this problem,” Senior Vice Chair of Medicine for Clinical Affairs Ann Weinacker, who served on the task force, told The Daily.
The task force came back with 15 recommendations for early identification of problematic individuals, prevention and de-escalation.
“We realized that some of our messaging around patient satisfaction being one of our top priorities was actually a barrier to speaking up for people,” Shanafelt said. “They were thinking about the risks of confronting a patient who was going to complete an evaluation on them that would factor into their salary. We had inadvertently baked in some things that were barriers to confronting inappropriate behaviors as a system.”
As a result, Shanafelt said, the task force and Stanford Medicine focused on creating a streamlined process for tracking and reporting; identifying higher-risk units; implementing robust de-escalation training; and creating rapid response teams of social workers, nurses and security officers to debrief incidents and come up with a plan for patients exhibiting problematic behavior.
“We ask ourselves how we can make a plan for this patient who we are obligated by law to care for,” Shanafelt said. “We think about how we set up appropriate safeguards and whether the healthcare worker can go into the room alone and, if not, how we can make sure that doesn’t happen.”
Stanford Medicine now tracks patients with a history of inappropriate behavior so that when the patient comes to any sector of Stanford Medicine, the providers know beforehand.
In addition to an immediate response and prevention strategies, Shanafelt said that going forward, supporting workers will also be a component of appropriately handling incidents of discrimination or maltreatment from a patient. This could include providing emotional support for a healthcare worker who is sexually harassed or considering dismissing a patient when the behavior gets out of hand.
“For outpatient ongoing care, for example,” Shanafelt said, “once we’ve had someone who has been mistreating our staff, we set the expectations and if they continue to do it, we eventually have to say to them that you need to seek care elsewhere.”
Ensuring that the process is easy and not traumatic for people experiencing the discrimination is another priority of the task force. Shanafelt said that in evaluating Stanford’s practices, task force members found that under current rules, the person dealing with the mistreatment had to personally write and send a letter to the person who was mistreating them, potentially making them even more of a target.
“The individual being mistreated should not be the one who is expected to confront the person mistreating them,” Shanafelt told The Daily. “If you are worried that confronting the patient will lead to more abuse, the leadership needs to step in.”
Weinacker added that Stanford’s response had historically focused on responding to incidents of physical violence, rather than other forms of mistreatment.
“In some cases of verbal mistreatment, including racially inappropriate or disparaging remarks made by patients or their visitors, victims or witnesses to verbal mistreatment were unsure exactly how to respond to the situation, and didn’t know what to say or do,” Weinacker said. “As a result, we have developed a list of potential responses, or ‘words that work,’ to provide the tools to victims or witnesses to this type of verbal mistreatment to help them respond respectfully but clearly in the moment.”
Refusing treatment due to identity
According to Shanafelt, another common challenge that healthcare workers face is patients who refuse to be treated by a person based on their race, religion or other identifier.
“There’s a historical legacy in a lot of medicine of ‘we need to respect the patient’s wishes’ and we often think that we’re a big center and have lots of physicians so we can transition them to a different doctor,” Shanafelt said. “But it goes without saying that in some ways this is profoundly undermining and invalidating to our own people when we say we’re going to honor this racist bigotry and move them to a different doctor.”
“The message that transmits from an organizational lens to the person who is experiencing the harassment is the antithesis of everything we stand for,” he added.
Shanafelt said that upon considering these circumstances, task force members realized that there are times when providers need to tell the patient that the physician they are refusing treatment from is the best person for the job.
“We say, ‘This is the best doctor for you, and this team-based approach is the best care we can offer you,’” Shanafelt said. “Sometimes the physician might say that they appreciate that policy but are uncomfortable treating a patient who doesn’t want them on their team, and we want to honor that request.”
“But ultimately, standing our ground is better than promulgating racism by telling the provider that the patient has a different view of their qualifications and that the institution is going to honor that by assigning a different provider for that patient,” he continued.
After the task force’s reports were released to Stanford’s hospital leaders in 2019, committees at each of the hospitals and health systems worked to implement recommendations.
“The task force made recommendations to develop a framework to address this challenge proactively across the entire Stanford Medicine enterprise, focused on prevention, early detection, triage, emotional support for healthcare workers, appropriate responses to episodes of mistreatment, secondary prevention and monitoring and tracking of events,” Weinacker said.
“All of this pre-dated George Floyd’s murder and all of the heightened conversation around disparities and racial injustice,” Shanafelt added. “So I think this is an example of Stanford being proactive: Needs were recognized and brought to us in 2017, a longitudinal effort occurred throughout 2019 and meaningful implementation has been underway since the start of 2020.”