Many Patients Perceive Discrimination at ED Visit
By Stacey Kusterbeck
Is a patient unhappy with the way they were treated in the ED? Some patients might assume they received poor care because of their race, gender, or age, or because of their appearance, income, or health literacy level. “ED care is fast-paced and time-sensitive, so healthcare providers may not have enough time to build trusting relationships with patients,” asserts Brittany Punches, PhD, RN, CEN, FAEN, an associate professor in the The Ohio State University College of Nursing. This can lead to unconscious biases interfering with patient care. “It is important for ED care teams to understand patient perceptions of discrimination and microaggressions, as they may be unaware of how their behaviors and words make the patients feel,” offers Punches.
Punches and colleagues sought to understand how patients perceive ED care, and also whether patients perceived discrimination or microaggressions. The researchers asked 52 patients at two urban academic EDs to complete the Discrimination in Medical Settings (DMS) scale. The study participants were from a wide range of backgrounds, races, genders, sexual orientations, and ages. About half of patients reported “some/moderate” or “significant” discrimination during the ED visit.
Thirty of the patients completed a follow-up interview. Those patients discussed being a patient in the ED in general and, specifically, any instances of discrimination during medical visits (either during the ED visit in question or previously). If patients recounted any discrimination, researchers asked the patient why they felt it had occurred. “There was a wide range of physical and social factors that patients perceived they were being judged on,” reports Punches.
Patients believed they had been treated disrespectfully for all kinds of reasons — their age, health literacy, physical appearance, disabilities, chronic conditions, gender identity, and socioeconomic status, or combinations of these factors. One patient talked about being treated poorly because of education level, race, and income level; another patient described “slight judgmental looks” that were attributed to being non-binary.
The research team identified behaviors that patients considered to be helpful in communication, as well as those that were considered unhelpful. Communicating frequently, reassuring the patient, giving the patient privacy, conveying respect, and validating the patient’s concerns were viewed by patients as helpful, positive behaviors for clinicians in the ED. Patients also described strong emotional reactions to negative clinician behaviors, such as communicating in a dismissive manner. Some patients reported that rude treatment by clinicians led them to consider leaving the ED before their care was completed. Some patients had observed negative clinician behaviors that, in their view, instigated a threatening response from another patient in the ED.
Patients with moderate or high scores on the DMS scale often reflected on previous healthcare experiences rather than just their current ED visit. One patient talked about going to an ED years ago in severe pain and a nurse making a comment that implied that the patient was a drug-seeker. “This suggests that previous healthcare experiences can have a lasting impact on patients’ perceptions of future care. ED care teams should take a moment to think about how they communicate with patients,” says Punches.
One patient had been transferred from a local ED to another hospital and was told by an ED provider, “We are transferring you because we can’t care for people like you here.” “This statement can be interpreted in many different ways, and it hurt the patient’s feelings,” says Lauren Southerland, MD, director of clinical research for emergency medicine at The Ohio State University Wexner Medical Center. Southerland suggests that, instead, ED providers explain the need for transfer by saying, “I am concerned about your health issues and want you to have access to specialists and tests that you may need. So, I would like to transfer you to the larger hospital.”
One patient cautioned ED staff against assuming that someone is homeless or does not take care of their health just because of their appearance or clothing. “They may have just come from working out in the yard or after a shift as a line cook,” says Southerland. Southerland says a better approach, if ED providers are concerned, is to ask the patient about the concern directly. By wording questions carefully, ED providers can convey that the issue is something that is routinely considered for all ED patients. “This can reduce a sense of being judged,” says Southerland. For instance, an emergency physician (EP) might say, “Many people in our area have difficulty accessing safe housing. This is important for me as a doctor to know, as this can greatly impact my patients’ health and the plans we make together for their care. Are you experiencing any unstable housing, unsafe housing, or lack of housing?”
Some patients were unsure whether an ED provider was judgmental or simply having a bad day. One surmised that fatigue probably made a healthcare provider less sympathetic. Another suggested that healthcare providers were probably testy with patients because of the high levels of stress in their job. “This suggests that we need to do more to support our ED clinical teams and reduce burnout,” says Southerland.
There is no question that an unhappy patient is much more likely to sue than one who is happy, regardless of the outcome or actual liability, according to David Ledrick, MD, associate residency director and clinical clerkship director in the department of emergency medicine at Mercy St. Vincent Medical Center in Toledo, OH. “A patient who is truly unhappy will usually be able to find a plaintiff attorney willing to throw the dice on a case, regardless of its merit,” says Ledrick.
Even if a malpractice lawsuit ultimately is decided in the EP’s favor, the process entails a significant amount of anxiety, work, and cost. “It’s important to remember that a patient’s perception is their own reality. The situational awareness of a patient in the ED is focused on their own issues,” says Ledrick.
Even if the patient’s problem is relatively minor, it was enough of a concern to get them to the ED. The EP may have spent the past 45 minutes on a difficult intubation of a 7-year-old with meningitis. “But all the patient has seen is an empty nurses’ station, an unanswered call light, and a bunch of ER personnel, including the physician who does not seem to really be paying attention to them,” says Ledrick. That does not mean that an unhappy patient with pharyngitis deserves the same amount of attention as the child with meningitis. “It does mean that you can be conscious of the fact that they’ve just spent hours waiting on you to spend five minutes with them. It means that you have the cultural awareness not to be insulting and have the interpersonal skills to understand that they are frustrated,” says Ledrick.
Ideally, the ED medical director and attending physicians lead by example, setting high expectations for the rest of the staff. “If the attending is seen to be consistently attentive to patient concerns and comfort, the staff is more likely to do so,” says Ledrick.
Inevitably, any ED will have some dissatisfied patients. Not everybody’s expectations can be met. “My experience, however, is that most patients will forgive you if they see you’re making a genuine effort to take care of them,” says Ledrick.
- Punches BE, Osuji E, Bischof JJ, et al. Patient perceptions of microaggressions and discrimination toward patients during emergency department care. Acad Emerg Med 2023; Jun 19. doi: 10.1111/acem.14767. [Online ahead of print].
Is a patient unhappy with the way they were treated in the ED? Some patients might assume they received poor care because of their race, gender, or age, or because of their appearance, income, or health literacy level.
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