Understanding Microaggressions in Emergency Care

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,