Racial Discrimination from Patients: Institutional Strategies to Establish Respectful Emergency Department Environments

Social identity-based discrimination from patients against healthcare providers is a prevalent and well-documented phenomenon.1–3 Numerous studies and essays detail clinicians’ experiences of slurs, harassment, and violence from patients based on racial identity.4–8 In this essay, we advance arguments about how emergency departments (ED) should respond to interpersonal racism from patients. We use an anthropological definition of race as a socially constructed way of categorizing humans based on perceived physical traits, such as skin and hair color.9 However, race does not have an inherent biological or genetic basis: there is greater physical and genetic variation within racial groups than between them, and racial categories vary across societies.9 Rather, race is assigned in ways that afford privilege, wealth, and power to some, while disadvantaging others.9,10 In this editorial, we focus on interpersonal racism, defined as the expression of racial discrimination between individuals, including racial jokes, harassment, and singling someone out on the basis of race.10 We recognize that racial discrimination can manifest in more subtle ways, such as microaggressions, or commonplace verbal or behavioral exchanges that convey hostility—often unintentionally—toward marginalized groups.11 Given significant variability in healthcare providers’ recognition and acceptance of microaggressions as discriminatory,12 our advocacy here focuses on unified institutional responses to interpersonal racism. We are interested in increased discussion about protecting the rights and wellbeing of emergency physicians at the same time that we address patients’ medical needs, particularly in our climate of profound political polarization in the United States. Strategies for Dealing with Racist Patients: the Lens from Acute Care Settings Biomedical scholarship predominantly advances the individual physician’s appeasement, negotiation, and accommodation of racist patients, with a focus on prioritizing and moving forward a patient’s medical care.13,14 For example, when a patient declines care from a physician who is a racial minority, hospital staff often seek out another physician to care for the patient.4 When a patient yells racial slurs at physicians or tells them to “go back to their country,” the physician is expected to respond to the patient courteously, if at all, in the interest of maintaining professionalism,6 or to re-orient themselves to patient needs and “depersonalize” their experiences.15 These strategies construe acceptance of racism from patients as necessary to maintain the therapeutic relationship and imply that the targets of such abuse should be willing to incur it as part of the inevitable costs of the job. However, as seen in the response to sexual discrimination and harassment and bullying, both in broader society and in the medical profession specifically, attitudes and behaviors that were once accepted as part of the prevailing culture are increasingly and rightfully being denounced.16,17 Recognition of the detrimental effects of sexual discrimination and bullying, including psychological consequences, hindered career advancement, and the effects of burnout and attrition on the profession as a whole, have led organizations such as the Joint Commission on Accreditation of Healthcare Organizations and the National Academies of Sciences, Engineering and Medicine to call for institutional and systemic responses.18,19 Less emphasis has been placed on institutional responses to interpersonal racism in healthcare settings. Williams and Rohrbaugh suggest conceptualizing racist language as verbal assault to underscore traumatic consequences and to trigger reporting of such encounters to administrators, as is done for physical assaults that occur in hospitals.4 They also suggest team debriefing and de-escalation trainings to help cope with disruptive and discriminatory patients.4 Others have advocated for involvement of ethics committees with disruptive and hateful patients.13 Unique aspects of emergency care settings affect the possibilities for individual and institutional responses to interpersonal racism. Prior evidence suggests that workplace violence is more common in EDs than in other clinical settings, yet emergency physicians may feel ill-equipped and unjustified in responding to racist abuse from patients who are experiencing an acute psychiatric crisis, delirium, intoxication, or are otherwise in distress.20 Unlike longitudinal care settings, the ED leaves little time for clinicians to establish a therapeutic relationship with patients, which may further disincentivize confronting racist patients. Emergency physicians also face pressure to appease racist patients due to the Emergency Medical Treatment and Labor Act (EMTALA), which stipulates that all patients who seek care in the ED must receive a medical screening examination and stabilization of an emergency medical condition, regardless of their social identity, ability to pay, or behavior.21 Additionally, time constraints, acuity, and frequent changes in team composition preclude emergency clinicians’ abilities to acutely or consistently involve ethics committees, debrief in real time, or find another clinician to care for a racist patient. Consider the following scenarios: Scenario A Black emergency medicine resident begins a primary survey during a trauma resuscitation. The patient, who is alert, shouts racial slurs at the resident, including “[N-word] bitch,” and demands another physician. None of the team members present acknowledge the discriminatory behavior and proceed with the rest of the survey.