Introduction: Telehealth, especially the use of real-time video and phone visits in ambulatory care, is increasingly important in the wake of the COVID-19 pandemic. The current state of internal medicine (IM) interns' telehealth training at the start of residency is unknown. Objective: To characterize the attitudes, training, and preparedness of IM interns regarding the use of telehealth video and phone visits in ambulatory care. Materials and Methods: We conducted a cross-sectional survey of IM interns at four IM residency programs in the United States in 2020. Results: One hundred fifty-six surveys were analyzed (response rate 82%). Seventy-five percent of interns rated training in the use of real-time video and phone visits for ambulatory care as important or very important. The vast majority received no training (74%) or clinical experience (90% no prior video visits, 81% no prior phone visits) during medical school. More interns believed that primary care may be effectively delivered via video visits compared with phone visits (77% vs. 35%). Most interns (69%) missed clinical time during medical school due to the COVID-19 pandemic; 41% felt that the pandemic negatively affected their ambulatory care preparation. Overall, the majority of interns (58%) felt prepared for primary care; only 12% felt prepared to deliver primary care using either video or phone visits. Conclusions: Although IM interns had favorable attitudes toward video and phone visits, few had training or clinical experience; most felt unprepared. Residency programs may need to close training gaps for current interns in conducting telehealth video and phone visits.
Feature Editor: Debjani Mukherjee, PhD Northwestern University Feinberg School of Medicine and Shirley Ryan AbilityLab The term microaggression was coined almost 50 years ago (1970) by Professor Chester Pierce and has reemerged as a topic of scholarly interest, a contested concept, a social media hashtag, and a polarizing issue in our current political climate. A classic article from 2007 by Derald Wing Sue and colleagues defines racial microaggressions as "brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial slights and insults towards people of color."1 Sue and colleagues further define three types of microaggressions. Microassaults are a "verbal or nonverbal attached meant to hurt the intended victim through name-calling, avoidant behavior, or purposeful discriminatory actions." Microinsults are "communications that convey rudeness and insensitivity and demean a person's racial heritage or identity." Microinvalidations are "communications that exclude, negate or nullify the psychological thoughts, feelings, or experiential reality of a person of color" (p. 274). The term was first applied to race and racism, however, the term also applies to other marginalized groups including women, people with disabilities, sexual and gender minorities, and religious minorities, among others.2 There are critiques of the concept, including the observation that the research on microaggressions is "underdeveloped," lacks scientific rigor, and may be "embedded in politics."3 Yet, there is agreement that insults, snubs, and slights undermine relationships and practices and affect health care. How does the experience of microaggressions impact the practice of medicine? How have your experiences or those of your colleagues underscored the complexities of this concept? Illustrative examples, particularly from PM&R, are welcome. What are the ethical implications? Do you have suggestions for decreasing microaggressions, on the individual, group, institutional or societal level? Maryann Katherine Overland, MD University of Washington School of Medicine A man comes to an appointment with his primary care provider. In the exam room, he is greeted by Dr. Morales, a Latina intern, who is not his usual doctor. The patient says, "You aren't a real doctor. You're too young. I want someone who can speak English." When Dr. Morales leaves the exam room to staff the encounter with her attending, she shares what the patient said. Her attending, an older white man, says, "As a woman of color in medicine, you're going to have to get used to that." Microaggressions are commonplace in medicine. Although they might be innocuous in intention, they can be harmful in impact. Microaggressions undermine physician–patient relationships, resulting in a lack of trust and lower quality care.1 Microaggressions take several forms in medicine: they can be perpetrated by physicians against patients, by attendings against trainees, between colleagues, among interprofessional teams, and by patients against physicians. Microaggressions by physicians and other healthcare providers against patients are harmful to a patient's health and can lead to worse health outcomes. However, microaggressions by patients against physicians also put a patient's healthcare quality at risk. Although patients occupy a marginalized group relative to physicians due to the inherent hierarchy of medicine, female physicians, physicians of color, international medical graduates, and LGBTQ physicians are often victims of contrapower microaggressions. Contrapower harassment occurs when a person with traditionally less power in a relationship harasses someone with traditionally greater power [ie, a male student harassing his female professor]. Status incongruence - the mixed power differential between an often anxious, sick, stressed patient and a physician from a marginalized group - can lead to encounters that undermine or demean the physician. Although most harassment of medical trainees comes from attending physicians and nurses, many medical trainees report harassment from patients, which can affect career decisions.2 Several years ago, I was attending on the inpatient medicine service at the Veterans Administration (VA) hospital where I work as a primary care physician. We were at the bedside of a man who was discharging home later that day. The senior resident was reviewing his medications. She asked the patient to teach back about the importance of completing his antibiotics as prescribed. The patient replied, "You're so pretty, I'll do anything you ask of me." After a shocked moment I replied, "Sir, we are here to focus on your health and your doctor is trying to keep you safe." He apologized and we finished the counseling. Later the resident shared that nobody had ever stood up for her before, in spite of frequent witnessed and unwitnessed inappropriate patient behavior throughout medical school and residency. She asked me to teach her the words I had used so she could do it herself the next time it happened. I realized that I had never been taught to address these behaviors - in fact, I was explicitly told during medical school that it was the doctor's job to "take it on the chin" when patients harassed or demeaned us. It wasn't until I was supervising trainees that the potential toxicity of microaggressions by patients became explicitly apparent to me. Over the ensuing years, individual female residents would approach me, whispering their own stories of inappropriate patient behaviors, and ask for coaching on how to respond. Residents of color and LGBTQ residents were experiencing it as well. The pervasive feelings were of shame, embarrassment, and anger; these residents were suffering from a death by a thousand tiny cuts. Over time, I witnessed marginalized residents avoiding contact with repeat offenders, which had the potential to negatively affect patient care. In his essay on microaggressions and epistemic injustice, M. Tschaepe wrote, "microaggressions undermine the credibility of knowers, and their capacity for becoming knowers. Marginalization and depersonalization from microaggressions places persons who are targets of microaggressions in a position in which their autonomy is called into question and diminished."3 The experience of being devalued diminishes an individual's ability to fully participate in complex cognitive tasks. Repetitive mistreatment during training leads to negative emotional and physical repercussions, decreased work performance, and ethical distress. Microaggressions committed against people early in their journey of professional identity formation has the potential to have a larger negative impact than when it occurs later in a physician's career. "It is important to emphasize that microaggressions are not about having hurt feelings. Rather, it is about the negative effect that being repeatedly insulted, invalidated, alienated, and dismissed have at both a micro [biological] and macro [social] level."4 Education to address microaggressions that empowers trainees to prepare for, assess, respond to, and reflect on the microaggression can mitigate the negative impact. In the University of Washington Internal Medicine residency program and our affiliated VA hospital, we have initiated a multipronged education initiative to address and mitigate the impact of microaggressions on trainees. This includes faculty development and resident training. We teach a three-step approach to addressing microaggressions before, during, and after an event. We encourage attending physicians and senior residents to introduce the idea of responding to microaggressions and other mistreatment before the events occur. This conversation happens early in the professional relationship and includes open-ended questions about how individuals on a team prefer to respond to patient microaggressions. Some trainees prefer to address microaggressions themselves, whereas others prefer a response from more senior members of the team. During this conversation, the team can reflect on situations in which a direct response might not be the best one. We create space for trainees to share their own experiences of microaggressions in medicine if they wish to do so. Although every team will have its own dynamics and strategies for responding to microaggressions, we recommend making explicit plans on how to respond. Step 2: Address the comment - name the behavior as inappropriate Step 3: Refocus the conversation on the patient's health Step 4: Share your perspective Step 5: Remind the patient of roles Step 6: Temporarily remove learners from the environment In our experience, we rarely have to move past step 2 to refocus the visit on the patient's health care and protect the trainee's well-being. However, we find that practicing this approach in a role-playing or other nonthreatening setting is vital to empowering trainees to respond in what is a stressful situation. Debriefing is an important step in addressing microaggressions by patients. Make time to reflect on these uncomfortable patient encounters after they occur. We encourage faculty to ask trainees how the situation felt for them. The individual or team can reflect on what went well and what could have gone better in the future. This reflection can mitigate the moral distress and negative impact of microaggressions. Patient–physician relationships are nuanced and complex, even more when an individual in the dyad is from an historically marginalized group. Although addressing every microaggression from patients to physician trainees might not be appropriate, ignoring, suppressing, laughing off, or otherwise minimizing microaggressions is also inappropriate. Respecting our patients means holding them to high standards of behavior. Training, mentoring, and empowering a diverse medical workforce is vital in ensuring the health of our diverse population. Our approach is one possible method to mitigate the impact of microaggressions against trainees. I encourage all training programs to consider what is best for their trainees and patients. University of Washington School of Medicine Jennifer M. Zumsteg, MD, Edwin G. Lindo, JD "No, where are you really from?" "Courtney, I never see you as a Black girl." "You're not really Asian." "I'm sorry, I asked for the doctor" (Black female attending wearing her white coat) "Hi Alfredo, good to see you." (The person's name is actually Edwin) "How old are you?" These quotes are statements made to individuals from marginalized groups. But how can these words, which some suggest to be only missteps of the tongue, be a problem? Shouldn't individuals from marginalized groups build a thicker skin and not be so sensitive to words? That would prevent so much trouble, wouldn't it? We would like to be clear on microaggressions: They are affirmative acts, done subconsciously, that, when compounded over time, cause significant harm to the recipients. Although the word contains the prefix, "micro," the effects of the acts are far from micro — they contribute to the totality of the systemic oppression of marginalized communities. Starting from this premise, we can explore the nuances of microaggressions in the practice of medicine. Biases are the beliefs and attitudes we hold, implicitly and explicitly, of others. Biases can be negative or positive. Biases are formed from the early stages of our lives, shaped by biased education, media, and the influence of biased family and friends. These nascent biases are normalized throughout our upbringing and solidified as we enter adulthood and our careers. For example, Dr. Samuel Cartwright, a prominent antebellum physician used medical science as his tool to perpetuate vile stereotypes and racist ideologies of melanated people of African descent.1 He coined the term "drapetomania" — described as a psychological disease of enslaved Africans fleeing captivity, because only a diseased person would run away from slavery. Cartwright also hypothesized and coined the African-only disease of "Rascality:" The disease, as it was characterized at the time, carries many symptoms, but most notable is the symptom of "insensitivity of the nerves." Cartwright suggested that enslaved Africans can be plagued with a mental disease that makes their skin lose its sensitivity and thus people of African descent could have a higher threshold of pain. But this is just absurd quackery from the mid 1850's, right? No. It's bigoted racialized medicine intended to stigmatize and dehumanize. Sadly, the residue of these thoughts linger today and such history still affects our practice. The bias of these beliefs change how providers care for their patients, such as evaluation and treatment of pain. A 2016 study compared 91 individuals without medical training meeting the a priori criteria [white, English speaking U.S. citizens], and 418 medical students meeting the same criteria. In this study both groups were asked whether any of a list of 15 false biological differences were true or untrue. Examples of the false differences included: "Black people have thicker skin," "Black people's nerve-endings are less sensitive than White people's nerve-endings," and "Whites, on average, have larger brains than Blacks." Among the nonmedically trained, 73% believed at least one of the false biological differences, with 50% of the medical students also believing at least one.2 Study subjects who endorsed more false beliefs rated black patients as experiencing less pain compared to white patients and were less accurate in their pain treatment recommendations for black patients compared to white patients.2 From Samuel Cartwright in 1851 to medical students in 2016, the legacy of racialized medicine lingers with real consequence. Racialized theories of the past are now biases of the present. This is true not just for pain thresholds and treatment, it is true for sociopolitical biases we carry of others, such as of intelligence, demeanor, gender roles, and cultures. These biases are difficult to break, even when we explicitly and openly denounce them. People can have public values that are betrayed by their implicit biases, and implicit biases are often better at predicting discriminatory behavior than people's conscious values and intentions.3 Our biases manifest in our work, including education, patient care, and advocacy, and contribute to disparities in rehabilitation with negative impacts on the patients and communities we serve. Microaggressions are pervasive, harmful, and preventable. They are the manifestations of our deepest biases, exposing themselves to the world through our positions of privilege and power. Marginalized communities can face microaggressions on a daily basis. Marginalization may occur based on ability, age, body size, citizenship status, gender identity, race and ethnicity, religion, sexual orientation, and other group categorizations and their intersections. Microaggressions are sometimes committed by those in power including attendings, more senior trainees, and the leadership in our organizations. The majority of medical students and residents experience harassment or discrimination during training. A meta-analysis by Fnais et al4 reported attending physicians as the main source of mistreatment (34.4%), with other sources including patients, patient families, nurses, and peers. There is also strong evidence that microaggressions lead to elevated levels of depression and trauma among marginalized communities.5 For example, in a study of undergraduate students, depression and suicidal ideation were linked to racial microaggressions.6 Associated impacts described by our physiatrists in training include interference with communication in the physician–patient relationship, loss of ability to use common areas such as eating and break facilities for their intended purpose, threats and distractions within the learning environment, loss of leadership opportunities with feedback that they were too emotional or too assertive, questioning of self and authority, and feelings of burnout and exhaustion. It is important to distinguish between intent and impact: Intent is the understanding of what the actor meant by the behavior; the impact of the behavior is the effect the microaggression has on the recipient. The key is focusing on the impact we make on our trainees and others, not defending our intent. For example, as presented in the introduction to this journal section, microinvalidations are "communications that exclude, negate or nullify the psychological thoughts, feelings, or experiential reality of a person of color." When we commit a microaggression, responses such as "I was just joking" invalidate the impact on the recipient and fail to move forward our training culture. As another example, in our "postracial" environment, colleagues may suggest they are "color blind." This framework is not only untrue but is a microaggression because the impact of the message communicates, "You are outside the group I identify with; I don't see your race or culture as important enough to respect or consider." Owning and understanding our bias, including microaggressions, and changing our words and behaviors are powerful actions that, over time, can shift our culture. Interventions at the individual, group, institution, and societal levels are needed. Examples include learning more about our own bias through training such as implicit association evaluation (eg, https://implicit.harvard.edu/implicit/) and workshops, and defining appropriate policies and procedures within organizations [eg, behavioral expectations, adopting gender-neutral language]. Many resources are available, including strategies for reducing implicit bias and improving the conditions of decision making (https://equity.ucla.edu/wp-content/uploads/2016/11/Science-of-Equality-Vol.-1-Perception-Institute-2014.pdf). In our national discussions about cultivating a diverse PM&R workforce for the future, wellness, and positively affecting patient outcomes and health equity, essential next steps are to intervene on our bias and the acts that stem from them. Maurice G. Sholas, MD, PhD, FAAPMR Sholas Medical Consulting, LLC The challenge of writing a commentary about microaggressions and their impact on the PM&R workplace is that one must decide which audience is key. I could "preach to the choir"—those affected by microaggressions who are gaslighted by being told over and over that they are imagining things. Or, I could help turn on a light inside those who may be complicit in witnessing or perpetuating microaggressions in the hopes of changing behavior. The former is important as it builds resilience, which is crucial for pioneers into previously exclusive spaces. The latter is critical to decreasing the overwhelming isolation and hostility that is precipitated in affected persons made to feel "otherized" by the very culture of medicine they seek to join. Physiatrists of color must be seen and believed when they relate their experiences and how these occurrences contributed to their burnout and further isolation. It is easy for our profession and policy practices to appreciate and regulate more overt forms of conflict that cause blatant discrimination. However, microaggressions, which are more pervasive, are just as damaging and more challenging to acknowledge, combat, and eradicate. They appear in three forms: microassault, microinsult, and microinvalidation.1 An occurrence I experienced in clinic illustrates these concepts. I introduced myself to a new patient who was an 8-year-old boy. He was cognitively typical, so I engaged him and extended my hand to shake his and welcome him to clinic. He withdrew and stated forcefully that he did not shake hands with doctors who have black skin. That microassault was then compounded by the microinsult of his parent minimizing the act by insisting that they were simply not accustomed to seeing nonwhite providers. It is difficult to describe the feeling of hopelessness that accompanies knowing that none of my accomplishments left me "qualified," in the mind of this patient, to even be allowed basic human contact. Following that visit, I did not seek support from my direct supervisor, clinic officials, or human resources for fear of microinvalidating responses explaining how this situation was actually not as bad as I reported it and my professional duty required me to be unaffected by it. I ultimately found support from an online community of black and brown medical professionals. Unpacking issues around microaggressions is nuanced and complicated. When talking about the embedded racism in microaggressions, it is critical to note that negative intent is not required. An additional truth about microaggressions is that those unaffected by them are not in a position of authority on whether they exist or what constitutes circumstances derogatory to persons of color. Ironically, it is challenging for individuals with gender, race, sexuality, religion, socioeconomic status, or lineage privilege to be empathetic to those marginalized by that privilege. The roadblock to empathy is a lack of lived experiences for them and those in their peer group blunting the ability to connect and self-identify. Finally, there are real barriers to cross-racial conversations about microaggressions against African American or other physiatrists of color due to disbelief, denial, or dismissal of genuine experiences. As a result, productive conversations require work and preparation. These are new norms for those accustomed to setting the industry standards and cultural mores. However, it is a worthwhile endeavor as it is essential for true professionalism and moral behavior. As a field, we must do better in rooting out overt and covert behaviors that negatively affect and systematically undermine select members of our community. Some seek to dismiss this need as "political correctness" run amok. However, there are profound and objective reasons to change a culture permeated with microaggressions. Physicians of color do not want to work in environments that erode their humanity and degrade their self-worth. Thus there is an impact on recruitment of high-quality staff. In addition, microaggressions actively prevent inclusion of physicians and practitioners of color in our healthcare community, which leads to poor retention of diverse talent. A lack of physicians and practitioners of color in medicine, especially as thought and clinical leaders, contributes to poorer patient outcomes, subpar care quality, and magnification of healthcare disparities.2 The Oakland Men's Health Disparities Study provides rich evidence demonstrating that black men having a doctor of their same race improves communication and trust resulting in better clinical outcomes.3 Microaggressions make the workplace hostile to physiatrists of color. And, as these skilled physicians exit these toxic environments, patient care suffers and the financial bottom line is negatively affected. McKinsey and Company did a sentinel analysis of 366 public companies across multiple industries. In the U.S. market, there is a linear relationship between racial and ethnic diversity and better financial performance.4 In addition to the business community taking note, the clinical ethics community has started exploring the effect of micro and macro aggressions in health care experienced by providers as racist acts.2 It is critical that we as a field appreciate that microaggressions are real and impactful. Crusading against them is not antiwhite and requires the efforts of the entire physiatry community. Cheung et al5 have published a widely cited protocol for responding to an act of microaggressions via taking A.C.T.I.O.N. This system focuses on asking about the intentions of the microaggressor, carefully listening to their response, telling others what was experienced was problematic, demonstrating the impact of the microaggression, everyone owning their thoughts and feelings around the impact, and requesting an appropriate next step. That approach should not be limited to the person directly affected by the microaggression, but all who witness it. For white bystanders to assist and intervene requires each of them to recognize the microaggression in real time. There lies the heavy lifting and a major barrier to success. As a colleague, I ask my peers to get involved in making our profession a better place for all of us. I present one of my life experiences as an example. On my first day as a pediatric PM&R fellow in Chicago, while wearing a tie and white lab coat in the cafeteria, I was mistaken for the new cook and publicly told to step out of line at the register and head to the kitchen. That indignity should have been addressed by all who witnessed it in real time as well as by my supervisor and human resources at a later date and time. But, nothing happened in the moment or in follow-up to support me as a professional managing this situation. When those unfamiliar with this concept are presented with a person in their work diaspora that experiences a microaggression, the simplest and most effective advice was on a t-shirt slogan created by writer Ally Henny through her Blog The Armchair Commentary (https://thearmchaircommentary.com). "It is critical that people lay down their privilege without arguing, interrogating, minimizing or gas lighting." Many times that I have experienced microaggressions, the root cause was a lack of diversity and awareness. As such, remedies that make our work environment more reflective of the patients we serve and the varied communities of our country are effective. Diversity and awareness in the leadership of our profession would also be beneficial. Thus, the Academy of PM&R and our Certification Board should also reflect the diversity of our profession. The presence of voices and perspectives make it easier for experiences detailed in this submission to be recognized by more than just those immediately affected. Issues related to microaggressions should be elevated as they affect patient outcomes and medical practice operations as well as policy formulation. Benevolent and well-intentioned allies are necessary and important, but they are not enough. There is a need to value and empower a diversity of perspectives and create an environment that is affirming and welcoming to people of color. Roberto E. Montenegro, MD, PhD, Georgina D. Campelia, PhD University of Washington School of Medicine Seattle Children's Hospital Talking about race and racism in medicine is difficult and uncomfortable and remains an incendiary topic. A critical first step to having a productive conversation is understanding the historical and sociopolitical origins of race and racism in the United States. In brief, race is not a biological trait nor does it have any genetic basis. Race is also a poor proxy for ancestry since there is as much or more genetic variation within racialized groups as there is between racialized groups. Race, instead, is an artifact of European colonization created to serve as a sociopolitical classification system that assigns groups and individuals to categories that are hierarchical and ranked based on arbitrary traits such as skin color.1 On this basis, race has been used to justify social inequity and oppression as "natural," such as in the global economy of the slave trade. This structuring of inequity was reinforced by European biological, religious, philosophical, and political academic doctrines. These doctrines were quickly adopted as academic and scientific "truths," simultaneously reinforced by and reinforcing a racialized hegemony of power and thought. They became embedded within the pedagogy of our founding universities and have since perpetuated a deeply rooted system of hierarchy and superiority.1 Unlike race, racism is very real. Racism is a "system of power that restructures an inequitable distribution of resources, opportunities, and benefits and assigns value based on the social interpretation of how one looks"– i.e. skin color.2 Implicit bias, a form of interpersonal racism,2 can be conceptualized as a "habit" that can negatively impact the practice of medicine.3 Microaggressions represent a specific form of implicit bias and are powerful in that they tend to be difficult to identify for both the person committing the microaggressions and the recipient of the microaggression. Physicians, for example, are often influenced by implicit racial stereotypes, which cause them to favor white patients both in attitude and clinical decisions.4 For those who commit microaggressions, they may seem like misunderstandings of intent. This can take the form of "an innocent question" that was meant to express genuine interest in the other person, or a "simple mistake" seated in unconscious biased assumptions, or a statement meant as a "compliment" or "constructive feedback." The harmful and unjust impact of these statements and their detrimental sequelae are often ignored, challenged, or dismissed. Most white providers,a for example, are not routinely asked, "Where are you really from?" or "Did you train in the United States?" They are typically not complimented with "you speak English really well" or "you are very articulate." White providers may not be as frequently asked to "smile more," "soften their tone," or to "not sound so authoritative" because others perceive them as being "angry" or "intimidating and unsafe to approach."b And because whiteness, masculinity, and the role of a physician are attributed disproportionate value in our culture, it is not surprising that white male providers are rarely asked "can I please see the doctor n
A resident discusses dialysis with her elderly patient, who later says, "You look too young and pretty to be a doctor!"Microaggressions are "subtle, stunning, often automatic, and non-verbal exchanges which are 'putdowns.'"1(p272) Commonplace in medicine, these interactions can degrade one's health over time. Because of their subtle nature, they can be difficult to classify.1 Discrimination in medicine is multidirectional, and all perspectives are a crucial part of the conversation. Here, we focus on microaggressions that occur from patient to medical trainee to provide targeted teaching tools to mitigate the impact of microaggressions.Historically, medical training has promoted a culture of silence and submission—suggesting that, somehow, experiencing inappropriate behavior is a rite of passage.2 Problematic patient behavior contributes to physician burnout, poor work performance, and avoidance of specific patients.3,4 Medical education in the United States has not adequately addressed this problem. While many residents experience inappropriate behavior from patients, they lack specific strategies to respond.5 The hidden curriculum in medicine around problematic patient behavior should become explicit to build trainee resilience. Studies from other health disciplines suggest that training on how to respond to inappropriate patient behavior reduces its negative impact.6 Protecting our residents from the harm caused by inappropriate behavior is vital to ensuring the health of the workforce and, ultimately, our patients.Embedded in the patient-physician relationship is a complex power dynamic. We must acknowledge the privilege of the physician in understanding patients' biopsychosocial contexts to reflect on difficult encounters and improve clinical care. Psychiatrist James Groves elucidated the importance of this:The physician aims to get to know the patient better, forming a relationship built on mutual respect. The following tools may allow for reflection in order to build patient rapport, promote patient-centered care, and attend to resident well-being. While there is no one-size-fits-all approach to microaggressions, we offer an approach to the complex nuances of experiencing a microaggression that integrates a 3-pronged approach to address transgressions before, during, and after the clinical encounter.An Asian American resident anticipates his next patient interview at the VA, wondering what comment he will receive this time. In his previous interview, his patient asked, "Are you planning on returning to China after your training?"It is crucial to prepare faculty and residents for discriminatory events before they happen. Setting expectations provides residents and supervisors with appropriate in-the-moment responses and prepares them for meaningful reflection and debriefing. It is the attending physician's role and responsibility to create a positive learning climate.During orientation to clinical rotations, we learn about the values of team members, discuss how the team would prefer to address inappropriate patient behaviors, and prime residents with the skills to respond. Attending physicians make an explicit pledge to protect their learners as much as possible and invite open dialogue if their learners feel that supervisors are contributing to a negative clinical learning environment. Anecdotally, across multiple hospitals at our institution, this first step of reflection is well received by residents, who are grateful for the safe space created for discussion.Start the conversation about problematic patient behavior in an open-ended manner (table 1). Ask residents how they might respond and how they would like their supervisors to respond—if at all. Microaggressions can occur in the discrepancy between a patient's intentions and a target's perception; therefore, it may not always be appropriate to address a microaggression with a patient. If residents determine that they would appreciate a response, it could happen in the moment, after the encounter, with the patient alone, or with everyone present.Formal curricula may include implicit bias training, communication skills, and role-playing. These have been shown to empower residents to respond in the moment.5 Training structures can target a training level. Curricula for residents might involve practicing how to respond to problematic patient behavior directed at interns and students. As this occurs across all levels of training, it is crucial to address the roles within the existing hierarchy of medicine.An African American resident is discussing a care plan with her patient on the wards with the rest of the medical team in the room. The patient later asks, "Can you step out so I can just talk with my doctors?"Residents may lack the tools to respond in a way that avoids negative repercussions.8 Our approach (table 2) prioritizes patient care by first assessing the patient's clinical and mental stability before naming inappropriate behavior gracefully, clarifying roles, and (re)establishing respect. As in other stressful situations, practice the steps in a no-risk situation so you are prepared to respond in real-life situations. In our experience, we rarely have to progress past step 2 to redirect the conversation and demonstrate an environment of respect.When used in a stepwise fashion, patient care is prioritized while respecting learner well-being. Clarifying roles is a significant step of this process. Sometimes residents appreciate when their attendings speak up,9 while others may appreciate addressing the situation on their own. When a patient behaves inappropriately (assuming the patient is clinically stable), the care of the team can be directed toward the target of the problematic behavior. Business as usual is not an acceptable response.After returning to the team room, a resident states, "I just don't know how to get patients to take me seriously! It makes me feel inadequate when they call me 'sweetie' or 'honey.' I don't want to go back to the patient's room."Debriefing is crucial after a patient behaves inappropriately. As suggested in table 3, start by inquiring how the situation felt to the residents. They might think about what felt empowering or disempowering, discover defense mechanisms, or reflect on their response. Faculty can highlight the importance of depersonalizing the event to redirect the team's energy toward the goal of "do no harm."5 Residents should provide feedback on what could have gone better. Sometimes supervisors do not recognize the problematic behavior or know how to respond, which leads to silence. By reflecting on these situations, negative consequences may be mitigated.In addition to debriefing, wrap-up sessions after rotations can improve morale and camaraderie. During these sessions, teams can review their patient cases from a biopsychosocial view. This fosters a healing discourse and long-term insight, potentially reducing the likelihood of lasting moral distress.The patient-physician relationship is nuanced and may require intense reflection in order to promote patient care. Reflection is crucial in preventing burnout. Silence is not an option in the face of problematic patient behavior. We can address discriminatory patient behavior while preserving relationships and promoting outstanding care. Preparing, having a framework to respond in the moment, and reflecting represent significant steps to improve both resident and patient well-being. This 3-step approach can empower everyone to speak up to protect the learning and working environment for residents and encourage a diverse medical workforce that can improve care for future diverse populations.
This article was migrated. The article was not marked as recommended. Introduction: We performed a pilot study to improve self-efficacy with giving and receiving feedback among primary care Internal Medicine residents in the ambulatory setting. Methods: We trained Internal Medicine residents to give and receive feedback, scheduled observation sessions, and protected time for feedback and reflection on the process. This pilot took place over four month-long ambulatory blocks over a two-year period at the University of Washington's primary care continuity clinic sites. Twenty-eight residents participated each year. We developed a survey question to measure self-efficacy with feedback and compared means using the Wilcoxin Signed-Rank test. We also collected qualitative data that was analyzed using Grounded Theory. Results: The residents demonstrated a statistically significant and meaningful increase in their self-efficacy with giving feedback to peers. Conclusion: Peer-to-peer feedback is a low-cost, high-yield way to increase feedback and feedback-seeking behavior without undermining resident autonomy. This educational intervention could be easily translated across clinical settings and specialties. Based on the initial success of the program, the University of Washington internal medicine residency program will provide expanded opportunities for structured, longitudinal peer observation and feedback.
Abstract Background There is a significant gap in understanding which strategies effectively enhance vaccination rates for recommended adult vaccines in primary care settings. This review aimed to identify interventions in outpatient clinics that increase vaccination rates for commonly recommended adult vaccines and describe the change in vaccination rate associated with each intervention aimed at increasing vaccination rates in adults. Methods Systematic searches identified randomized, controlled trials aiming to increase the rate of vaccination in adults in outpatient clinics. Following PRISMA guidelines, PubMed, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Two reviewers independently extracted relevant data and assessed risk of bias. Meta-analysis was not done due to heterogeneity of data. Results Forty-four RCTs met inclusion criteria. Clinician reminders to order vaccine increased vaccination 4%–32%. Electronic health record (EHR) prompts to patients or physicians increased vaccination 1%–16%. Bundled interventions increased vaccination 4%–42%, with more intensive interventions associated with higher increases. RCT of interventions involving face-to-face contact with patients increased vaccinations 6%–17%. Group outpatient visits increased vaccination 13%–17%, home visits 6%–17%, and physician or nurse recommendation 15%. Conclusions Clinics may increase vaccination rates by reminding doctors to order vaccine, promoting face-to-face conversations about vaccination, and instituting bundled clinic process improvements. EHR prompts may be less effective.
