SGEM#423: Where is the Love? Microaggression in the Emergency Department

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Reference: Punches et al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023

Date: December 14, 2023

Guest Skeptic: Dr. Chris Bond is an emergency medicine physician and assistant Professor at the University of Calgary. He is also an avid FOAM supporter/producer through various online outlets including TheSGEM.

Case: A 57-year-old Chinese woman presents to the emergency department (ED) with chest pain. She speaks some English, but it is her second language. It is a very busy day, and you proceed to ask her questions in rapid succession. You roll your eyes when you must repeat yourself and ask in a louder and louder voice in order to get a response.

Background: Patient experiences of care are associated with health outcomes and may impact perspectives of ED care and the patient recovery process.(1-5) Perceptions of discrimination in healthcare are linked to delays in seeking medical treatment, nonadherence to clinician recommendations, and mistrust of clinicians and the healthcare system.(6-7) We looked at deaf and hard-of-hearing patients in the ED on SGEM#383.

Microaggressions are discriminatory behaviors that may be subtle or unintentional but may disempower affected individuals leading to differential care and worse healthcare outcomes.(7-10) Discrimination, implicit bias and microaggressions are common in healthcare encounters involving persons from marginalized groups.(11-17)

Microaggressions and discrimination towards patients have been studied in other healthcare settings, but there has been little research on this topic that specifically investigates EDs.(10-11) The ED is a unique part of the healthcare system due to its inherent chaotic environment, time constraints and lack of prior patient-staff interaction.

Clinical Question: How can patient perceptions of microaggressions that occur during an ED visit inform potential interventions and prevent future occurrences?

Reference: Punches el al. Patient Perceptions of Microaggressions and Discrimination Towards Patients During Emergency Department Care. AEM Dec 2023.

As this is a qualitative study, we will use a modified PICO question (PIC):

Population: Adult, English speaking patients visiting one of two urban emergency departments in a Midwest US city.
Interest: Exploring patient experiences of discrimination during their ED visit.
Context: Improving patient care and reducing microaggressions from ED staff

This is an SGEMHOP episode, and it is our pleasure to introduce Dr. Lauren Southerland. She is an Associate Professor in the Department of Emergency Medicine at The Ohio State University. Her research interests include clinical process improvement in the ED and implementation science, and she focuses on the care of vulnerable populations, most often older adults or others lacking capacity or capabilities.

This study used a mixed methods sequential explanatory approach whereby the researchers collected quantitative data on experiences of discrimination using the DMS tool, followed by qualitative data through a semi-structured interview.

Dr. Lauren Southerland

As many of us have over the past four years, we were looking at our emergency care and interested in whether our practice was contributing to disparities. Additionally, many of us in medicine have witnessed or experienced microaggressions, and we wondered if our ED care was contributing to patients feeling discriminated against. So, we looked at the available research and found that no one really had a good answer for our question, and the obvious solution to us was to ask patients about their experiences.

The sequential, mixed methods design came about because we didn’t want to do interviews during the ED visit, as that could make patients feel uncomfortable or like they were reporting on their healthcare workers. But we also know that once someone leaves the ED to go home it is often hard to get them to answer the phone or call back for an interview. So, we added in the quick discrimination in medical settings scale so that we could obtain some information about our current care in case we couldn’t get many interviews. It also allowed us to compare the quantitative and the qualitative evidence, which led us to some interesting conclusions. That is also why we have 48 people completing the quantitative portion but only obtained 30 final interviews. We had some expected loss to follow up.

Another process that worked well was that we did not randomize people to participation. We did not want an average sample of views. We used purposive sampling, were we specifically looked for a people of different ages, genders, race and ethnicities to provide a breadth of viewpoints.

What struck me the most is that I learned more about my own research biases. I went into this study on biases and microaggressions with some preconceived biases. I thought we would hear a lot of stories of gender and racial discrimination. And some of that occurs in the ED, definitely. But the many of our participants felt like they were judged by their appearance, by their age, and by their socioeconomic status. For example, some participants felt that their concerns were dismissed for being too young or too old. And as a geriatrics researcher, I should have expected ageism to show up!

Secondly, the patients were overall very understanding of the pressures of the ED and attributed many of the comments to people being overworked or overstressed, which was a kind way to say that we get a lot more leeway from our patients than I would have expected.

Finally, the quantitative data did not always match up to their qualitative data. Sometimes on the discriminations in medical settings survey patients endorsed discrimination on this ED visit, but when interviewed they were recalling past visits or healthcare experiences. We interpreted that as meaning that these past experiences color your perceptions of future healthcare experiences. Many patients endorsed avoiding or not wanting to go back to an ED where they had a bad experience.

Authors’ Conclusions: “Patients attributed microaggressions to many factors beyond race and gender, including age, socioeconomic status, and environmental pressures in the ED. Of those who endorsed moderate to significant discrimination via survey response during their recent ED visit, most described historical experiences of discrimination during their interview. Previous experiences of discrimination may have lasting effects on patient perceptions of current healthcare. System and clinician investment in patient rapport and satisfaction is important to prevent negative expectations for future encounters and counteract those already in place.”.

CASP Checklist for Qualitative Research

Was there a clear statement of the aims of the research? Yes
Is a qualitative methodology appropriate? Yes
Was the research design appropriate to address the aims of the research? Yes
Was the recruitment strategy appropriate to the aims of the research? Yes
Was the data collected in a way that addressed the research issue? Yes
Has the relationship between researcher and participants been adequately considered? Unsure
Have ethical issues been taken into consideration? Yes
Was the data analysis sufficiently rigorous? Yes
Is there a clear statement of findings? Yes
How valuable is the research? Valuable in that it is emergency department specific as opposed to other similar research.

Results: They approached 94 potential participants of whom 52 consented to participate and 48 of 52 (92%) completed the DMS scale. 30 participants (57.7%) who completed a follow-up interview. Of those completing the DMS scale, 26 (49%) reported some/moderate or significant discrimination during this ED visit. Their data was broken up into quantitative and qualitative data.

Key Result: There were five main themes from this study on micro aggression that included – clinician behaviour, emotional response, perceived reasons for discrimination, environmental pressures in the ED, and hesitancy to complain.

Quantitative Data: DMS scores ranged from 0-15 with a median of 3. It’s a 5-point Likert scale which includes seven questions including:

Being treated with less courtesy than other people were
Being treated with less respect than other people were
You received poorer service than others
A doctor or nurse acted as if they thought you were not smart
A doctor or nurse acted as if they were afraid of you
A doctor or nurse acted as if they were better than you
You felt like a doctor or nurse was not listening to what you were saying

There were 33% of participants who had a DMS score of 0. Another 39% of participants experienced some or moderate discrimination (DMS 3-9) while 14% of participants experienced significant discrimination (DMS 10+)

Interestingly, 20% of participants reported that their health care team member acted as if they were afraid of the person, which would be really damaging to a doctor/patient relationship. Also, participants gave poor marks for listening, as over half reported that the doctor or nurse was not listening to what they were saying.

Qualitative Data: There were five main themes that emerged from the qualitative data.

1. Clinician Behaviors (Communication and Empathy): Patients described the staff’s positive and negative behaviors such as communication, body language and thoroughness of care. Positive behaviors could include items such as frequent communication, reassurance, privacy, and validation of concerns. Negative behaviors could include rudeness, unprofessionalism, dismissiveness and microaggressions.

Participants commented on good behaviors, such as the doctor or nursing sitting down with them and focusing on their story. Or bad behaviors, such as a healthcare team member assuming someone was opioid seeking instead of asking how they manage their pain at home.

2. Emotional Response to Healthcare Team Actions: Participants described positive interactions with clinicians which reassured confidence in the ED visit and willingness to return for future healthcare. Negative interactions in which patients felt disturbed, shocked or vulnerable were often related to previous healthcare visits and made patients question whether they should leave the ED prior to completion of their care.

Anyone who has worked in the ED has witnessed an upset patient leave the ED rather than continue their care. Patients who had prior negative interactions with healthcare professionals did not want to return to that ED and some mentioned trying to avoid emergency care because of fear of being mistreated or looked down on for asking for help with their health. One example was a Muslim women who was getting an EKG done in a triage bay and so was feeling very exposed. While the test was being done, another male healthcare team member walked right in without asking, ignoring her, and talked over her head to the techs doing the EKG. She felt both exposed and ignored as if her opinion or comfort didn’t matter. ED visits since then she has tried to never describe pain as “chest pain” so that she doesn’t have to get an EKG again.

3. Perceived Reasons for Discrimination: In this area, participants discuss their perceptions of being treated differently by previous ED clinicians. Reasons for differential treatment varied by age, gender identity, race, physical appearance, health literacy, chronic conditions and disabilities.

This wasn’t part of our purposive sampling criteria, but we had several patients with recognizable physical disabilities such as a lower extremity amputation. The persons with physical disabilities endorsed feeling like they were dismissed or treated differently. One quote from a white nonbinary person summed up the physical appearance sentiments well. If I may paraphrase, they said, “I looked probably rather disheveled because I had been sick, I hadn’t shaved my face in 3-4 days and I had a fever so I’m sure my hair was oily. I probably looked really rough and came off as somebody of a low socioeconomic class.” People endorsed having to rush to the ED from work or in the night and not being able to make themselves presentable, and how they felt judged for that.

4. Environmental Pressures in the ED: Participants described the setting and general atmosphere of their ED encounter which often provided context to the clinician behaviors described in the interview. They often noted long wait times and busy staff when describing negative ED experiences and sometimes perceived poor care was due to ED environmental demands.

Some of the negative experiences were during waiting room waits. And there is an clear element of judgement in triage as we try to use algorithms to justify who goes first and who next, but when you get to 40 people waiting sometimes it comes down to the squeaky well or who looks “more sick”. So, I was not surprised to hear stories from the waiting room. But many participants noted the busy ED setting as a contributor to people being rude or not listening.

5. Patients are Hesitant to Complain: Some participants considered filing a complaint or had previously filed a discrimination complaint, while others had concerns about filing a complaint. Concerns about filing a complaint included not wanting to identify staff members, not feeling that the complaint would be acted on or feeling their medical care would suffer if they brought up their concerns.

One man said (and I’m paraphrasing again) “why would I file a complaint? Whoever I am complaining too works with the person I am reporting and has no reason to believe me over them. Its not going to do any good.”

Listen to the SGEM podcast to hear Lauren answer our five nerdy questions.

1. External Validity: Your patients were recruited from two large urban EDs in the United States. How do you think your results reflect smaller centers and other parts of the US and the world?

2. Past Experiences: You often mention that patient’s perceptions of discrimination were based on past encounters and not the current ED visit. How did the authors interpret this issue?

3. Data Collection and Sample Size: Can you walk us through an example of how the data was collected and do you think the sample collected was adequately reflective of the greater population?

4. Non-English: One of the inclusion criteria was the ability to speak conversational English. How do you address this significant limitation for discussing discrimination in non-English speaking populations?

5. Next Step: Where is the research headed in this space of microaggression and do you plan to be part of the research?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: Patients perceive discrimination in the ED for many reasons. We should address our ED culture and individual biases to help reduce patient perceptions of discrimination and improve ED care.

Dr. Chris Bond

Case Resolution: Rather than asking the patient questions quickly and in a loud voice, you slow down, speak in a normal tone of voice, and enunciate clearly. This helps collect a clearer history, but you are still having a bit of difficulty, so you find a Chinese speaking translator service to collect the history more accurately and explain things to the patient.

Clinical Application: Being aware of environmental pressures and your own biases will allow you to provide better care for your patients with fewer microaggressions and discrimination.

Keener Kontest: Last weeks’ winner was Guilherme Resener. He knew approximately 20% of Americans live in rural areas.

Listen to the podcast to hear the question for this episode. If you think you know the answer, send and email to TheSGEM@gmail.com . The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on patient perceptions of microaggressions and discrimination in the ED? Tweet your comments using #SGEMHOP. What questions do you have for Lauren and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.

REMEMBER TO BE SKEPTICAL OF ANYTHING YOU LEARN, EVEN IF YOU HEARD IT ON THE SKEPTICS’ GUIDE TO EMERGENCY MEDICINE.

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