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Case 1: "I want to see your pretty face"

Case 1: When I was a 3rd year medical student, I was seeing a patient alongside my attending. After introducing myself, the patient asked me to pull down my mask to see my “pretty face.” I politely declined and said “we are trying to protect everyone by keeping our masks on.” He repeated the request adding that he wanted to see if I were an attractive woman. I again politely declined. After he asked me a third time, I did not answer.

Discussion Questions:

What is the impact of the power dynamic between the involved parties?
How do historical notions of gender norms impact the situation?
What are some things the medical student could do in this situation?
What are some things the attending could do in this situation?

Link to the discussion: https://tinyurl.com/AAPMR1

Please wait to read the attending's and student's and students reaction and then answer question #5 with the group.

Attending's reaction:

My attending said nothing and just looked at me. After an awkward silence that lasted 1 minute, my attending asked me to leave the room as I was too distracting. After the patient left, she asked me not to make another scene when seeing patients or she would contact my school about my misbehavior.

Student's Reaction:

I was shocked and upset. More so because I felt as if my attending should have stepped in to defend my position, not scold me. As a female medical student, I have experienced uncomfortable comments from my patients that my male peers have not experienced, but in this situation, I felt as though my superior should have taken a moment to support me, not leave me feeling helpless.

Discussion Continued:

5. What would justice look like in this situation?

Link to the discussion: https://tinyurl.com/AAPMR1

Case 2: “Go back to Africa”

Case 2:

When I was working on the wards intern year, a patient told me, “go back to Africa.”

Resident’s reaction

As a biracial woman, I have had my share of experiences with racism in the past. However, this was the first time that I had ever had a patient show such overt racism. It was so disheartening to be acknowledged in such a way. It is also difficult being in the position of caretaker with someone who obviously doesn’t want to be part of their care team. At the time, I quickly excused myself from the patient room and informed my attending of the encounter.

Discussion Questions:

1. How would you respond if:

you experienced a comment like this?
you witnessed this exchange?
you heard a resident, colleague or superior make a comment like this?

2. What is the role of institutions in intervening and supporting individuals who have an experience like this?

Link to discussion: https://tinyurl.com/AAPMR2

Institutional Response:

My attending (and the rest of the team) had my back and were extremely supportive. My attending made sure to debrief the event with me and asked how they could best support me. I notified my Program Director, who was also amazing. The case was escalated to our GME as well as the executive leadership board of the hospital. We are in the process of establishing a reporting tool for patient situations involving racism/sexism/ableism/etc in order to flag patients who may cause emotional harm to those in marginalized groups. While this is not a perfect system, it could aid in avoiding traumas associated with such patients.

Additional Key Points:

Institutional support
Micro- and macro-aggressions
Intersectionality

Case 3:“I need my norco”

Case 3: An established patient with a history of chronic low back pain and lumbar decompression presents to PM&R pain clinic requesting refills stating “I need my norco”. He claims to have forgotten his medications on a cruise 10 days ago, and borrowed some norco from a friend to bridge the appointment gap. Upon review of his PMP, we saw that he filled a 7 day script of Norco from a new PCP in Florida.

Discussion Questions:

What violations did the patient commit?
How would you initiate a discussion to address these violations?
Is this grounds to fire the patient? Why or why not? If not, what steps would you take?
Reflecting back to case 1 and 2 about sexism and racism, were those behavior grounds for firing the patient, why or why not?

Link to discussion: https://tinyurl.com/AAPMR3

Additional Key Points:

Knowing your boundaries and communicating boundaries
Patient education and clear expectations
Develop strategies for behavior management

Case 4:“Poor knowledge base”

Case 4: I once completed a rotation in which I felt I had developed a strong and positive working relationship with my attending. There were no signs of any doubt on my performance. However, my written evaluation demonstrated otherwise. Amongst things that were blatantly untrue, my feedback included: “Poor knowledge base with inadequate physiatric recommendations to primary team.” I was applying to fellowship at the time and was panicked by who would see this.

Discussion questions:

What would you do in this situation?
What is the impact of the power dynamic between the resident and the attending?

Link to discussion: https://tinyurl.com/4AAPMR

Please wait to read the resident's reaction and then answer questions #3-5 with the group.

Resident reaction: I was hurt, upset, confused, and astounded. At the Clinical Competency Committee meeting, there were attendings who defended me. I later spoke to the attending who provided the feedback; she told me she was doing me a favor. I spoke to my PD who recommended letting it go and making a note that someone may perceive me this way and to try to avoid it. None of this felt satisfactory. Since then there have been other residents who have received similar treatment.

3. How could an attending prevent a resident from feeling blindsided in written feedback?

4. Strategies in seeking formative feedback during the rotation?

5. How could program/departmental leadership maintain accountability in attending feedback?

Additional Key Points:

Proactive in requesting feedback
Trainee protection for speaking up
Attendings should provide formative feedback before written evaluations
Role of attending support and mentors

Case 5: "Can you get us some coffee"

Case 5: While on a pain medicine rotation, I was sent to fetch coffee for all the OR staff, physicians, and administrators (approximately 10-15 people) while pain procedures were being performed and patients needed to be seen. This happened on 2 separate occasions by the same attending who did pay for the coffees. I am resident who is interested in pain management and sports and spine.

Discussion Questions:

What could a resident do if asked to perform non-medical work?
What is the impact of the power dynamic between the involved parties?

Link to discussion: https://tinyurl.com/AAPMR5

Resident's reaction: At first I was astounded, and then I became frustrated. After the second coffee run, I was seething. I chose not to express my feelings because I didn’t want to develop a reputation as a difficult resident and I didn’t want to impact other residents rotating on this service. However, I also didn’t want other residents to have the same experience. A month after my rotation, I told my program director about the experience who made a request to the rotation director not to have residents perform menial tasks.

Additional Key Points:

Don’t
This impacts med students and residents
Trainees are in a lose-lose situation.