Abstract
The country as a whole has been on high alert since early 2020. That year began with the SARS-CoV-2 pandemic, then moved through the largest single day drop of the Dow Jones industrial average, the murders of Breonna Taylor and George Floyd and subsequent Black Lives Matter protests, murder hornets, the election of Joe Biden, alleged voter fraud, and then culminated on January 6, 2021, with the assault on the United States Capital Building. Societal issues including racism, discrimination, and distrust of leaders have been themes in the news and social media. It should come as no surprise that we may be called upon to provide treatment to patients with whom we have significantly different belief systems, which could result in conflict. The emotional rawness that pervades much of society lays emotions bare for many. Our ethical responsibilities as healthcare providers compel us to think about these complex relationships intentionally, and with compassion. In an interactive workshop conducted at the 42nd Forum for Behavioral Science in Family Medicine, participants were led through scenarios in which conflict could enter the exam room, discussion of the potential consequences, and consideration of ways to respond ethically in those situations. The discussions were couched in the codes of ethics of the American Psychological Association, the National Association of Social Workers, and the American Medical Association. The interactive session was designed to encourage participants to (1) consider potentialities of patient-provider conflict, (2) consider ethical, compassionate responses, and (3) be mindful of social media.
Conceptual background
It is becoming increasingly difficult to avoid political and social-cultural issues from entering the exam room with so much tension and politicized health-related concerns. The past three years have brought significant tension, divisiveness, tribalism, isolation, and sorrow in the midst of a pandemic. Workplace shifts in effort across multiple roles for family medicine faculty has led to exhaustion, depersonalization, and burnout, especially for women. 1 Although some stress has been tempered by increased practice opportunities and managerial support during COVID, there are concerns about how primary care teams will manage as the crisis endures. 2
Dr. Bryant Adibe, Rush University Medical Center’s Chief Wellness Officer and Vice President of the Rush University System for Health stated that “[f]rom widespread economic hardship as a result of the COVID-19 pandemic, to important conversations regarding social justice and equity…it is not enough for us to acknowledge that these larger societal issues are just happening out there.” 3 These societal forces shape the culture of organizations, the delivery of healthcare, and the beliefs and attitudes of patients. Drs. Hersh and Goldenberg 4 in examining the impact a primary care physician’s party affiliation has on perception of concern and recommended treatment plan found that the political views of a physician can have an impact on the delivery of care. This is even with the American Medical Association’s (AMA) call for physicians to refrain from initiating political conversations during clinical encounters and edict that political views are not to interfere with the delivery of care. 5
It has been suggested that family medicine is uniquely poised to help heal the divide, 6 given that family physicians are on the front lines practicing in communities that reflect the geographic distribution of America’s population more than any other medical specialty. 7 Romano and Grumbach argue that the work of primary care is to appreciate the complexity of patient’s stories and to partner with patients, families, and communities to improve health. They propose in fulfilling family physician’s “duty to health divisions” and to “build bridges between diverse communities” there needs to be a commitment to address bias, model inclusivity, attend to the social determinants of health, and advocate for health (pg. 5).
Curriculum overview
The curriculum presented at the Behavioral Forum was designed to provide behavioral and family medicine providers an opportunity to examine bias, ethical responsibilities, and ways to negotiate political differences through case-based learning. During this engaging and interactive ethics workshop, participants explored the intersection of political and social issues, personal beliefs and opinions, and the clinical environment. The session began with a brief overview of the topic, a description of the relevant guidance from various codes of ethics8-11 (including potential conflicts between codes of ethics), and a brief pretest to assess participants previous conflictual relationships with patients around these issues, current social media habits, and familiarity with ethical guidelines.
Participants were randomly grouped into two breakout rooms. Each breakout room was provided a scenario that involves a potentially contentious relationship between a patient and a provider (attending physician, resident, medical student, psychologist, social worker, nurse, receptionist). While in the breakout rooms, participants critically analyzed the elements of their assigned scenarios, looking for the potential of conflict or confrontation, ethical missteps, and opportunities to find common ground and build relationships. Discussion also included ethical responsibilities to patients, coworkers, society, and ourselves, particularly when political differences seem irreconcilable.
The primary limitations of the session were that it could create discomfort with the content and that some of the ethical dilemmas presented may have no easily discernable resolution. Each presenter visited a breakout room to ensure the safety of all participants and to encourage participants to explore topics more deeply. The scenarios presented were drawn from or reflective of current or recent socio-political events.
Session description
The scenarios that were developed by the presenting team were developed from a combination of current news events and actual, deidentified patients amalgamated from a number of different clinical settings. Any similarities between either of the scenarios presented and any actual persons, living or dead, is purely coincidental. Yellow Team Scenario You are a respected behavioral health provider and faculty member at a family medicine residency in an ambulatory medical clinic. In addition to your faculty responsibilities, you maintain an active patient panel consisting largely of adult patients from the surrounding community. You are well-liked by most of your patients and are considered to be an excellent and empathetic therapist. You are active in your children’s schools as the president of the parent-teacher association. The leadership of your children’s school system has been struggling with many of the issues related to the pandemic, including mask and vaccine mandates, social distancing, and remote versus in-person learning. In your role as president of the PTA, your school’s principal has requested that you speak in the upcoming public meeting of the board of education about the necessity of children to be both safe and in a face-to-face learning environment. Specifically, she wants you to mention that students learn and develop better when they are around their peers and that there is no reason to think that students cannot wear masks consistently or that there is any reason why they shouldn’t. You agree to do this and put together a presentation with data to back your positions. When you arrive at the meeting, you realize that two of the community members present are actually your patients. One of them has a history of advocating radical conspiracy theories and does not believe that the pandemic is even real. He wants things to return to normal, with no masks allowed and no social distancing. The other one has a history of anxiety that has been exacerbated by the pandemic. She does not want students to be in the schools at all, advocates for universal mandatory masking and vaccines, and rarely leaves her house. You look at the agenda and realize that you present in five minutes. Blue Team Scenario The identified patient is a 71-year-old white female who is the patient of an African American PGY3. They have a good relationship. The patient has a history of back pain and anxiety, both of which are poorly controlled. She is a Medicare beneficiary. The patient’s 52-y-o son lives with her. He has had 6 strokes in the preceding two years and is in a wheelchair. He is not yet on disability and has no health insurance. Their combined income is less than $800 per month. Social work has been working with the dyad to address multiple socio-economic issues, including transportation, access to food, home health, and affording medications. However, the most significant of the nonmedical issues is their living situation. They live in a dilapidated mobile home. The roof leaks, the freezer does not work, and there are holes in the floor. To make the toilet flush, the identified patient has to fill the tank with buckets of water that she draws from the tap. In order to make the heating and air conditioning work, she has to go outside and do something to the external unit. The clinic where this family receives care is a multi-disciplinary, team-based system. Social work has found a two-bedroom, two bath, handicap-accessible, first floor apartment at an apartment complex that is very close to the clinic where they are patients. A member of the social work department calls patient to let her know the good news. The patient replies forcefully, “I don’t want to live by black people!” and begins to talk despairingly about the Black Lives Matter movement. Within a few sentences, her conversation shifts to support for the people who rioted in Washington, DC on January 6th. Your patient goes on further to describe your clinic’s efforts at providing care for her and her son as nothing but a plot to make them live with “those people” so that the clinic can control them. She talks about how she’s heard about it on Facebook. You have a teenaged daughter who is a self-described social justice warrior. You are aware that she has been vocal on Facebook, Twitter, and TikTok about her support for many social justice causes, including BLM. In your team meeting about this patient, the PGY3 who has been her physician commented that she has seen people who appear to be this patient and her son on Facebook.
As prompts, the participants were asked to consider the following questions during their breakout room discussions: 1. What ethical issues do you see in the scenario presented? 2. For what reasons might it be difficult for you to be a healthcare provider for these patients? 3. From the perspective of your discipline, what are your obligations? 4. As a parent, what are your obligations? 5. What do you owe this patient? 6. What do you owe your employer? 7. What do you owe society? 8. What do you owe yourself? 9. What can you do to maintain the trust of these patients? 10. Can you think developmentally about these patients in a way that could help you understand why they think the way that they do, even though you may disagree with them?
Presenters facilitated dialogue within the breakout rooms around the topics and served as moderators to ensure that people’s different opinions were represented and respected.
The participants remained in their respective breakout rooms for approximately 30 minutes, after which the presenters closed the rooms and brought all of the participants back together for further discussion.
Curriculum goals and objectives
The stated goals for this interactive workshop were: 1. Upon completion of this session, participants will be able to think about the ways that they may be placing themselves at risk of a conflictual relationship with patients by virtue of their own use of social media and ways to mitigate those risks. 2. Upon completion of this session, participants will understand ways that various codes of ethics address conflict with patients. 3. Upon completion of this session, participants will have the skills to critically analyze ethical issues stemming from a patient-provider relationship and will have new understanding of the ways that socio-political discord can negatively affect patient care.
Additionally, presenters hoped that discussion of challenging topics in a safe environment would provide attendees with the opportunities to explore some of their own hidden biases and stereotypes, thus becoming more empathetic teachers and compassionate, understanding healthcare providers.
Performance to date
The presenters have only facilitated this workshop one time, and it was a virtual presentation; however, plans are afoot to facilitate similar, face-to-face sessions at future conferences.
Conclusion
The workshop has the potential in being utilized in a variety of settings where the intent is to create critical consciousness and reflection on ethical responsibility. It is appropriate for learners from multiple disciplines and at any developmental stage who are learning and practicing within primary care. There is particular opportunity for learners to be challenged in reflecting on one’s own bias and attitudes, while also becoming more cognizant of how ethical codes are applied to scenarios that are reflective of our time and culture.
Given today’s pervasive and ubiquitous news and social media landscape, it is perhaps inevitable that healthcare professionals may encounter challenging interpersonal situations during the scope of patient care. Intentional personal development of the skills necessary to respond to patients and coworkers in ways that do not inhibit continued care is an important aspect of professional development. This workshop, and others like it, may be an effective way for providers to equip themselves in a way that ensures the best care of and respect for their patients, while simultaneously allowing themselves to stay true to their own character and beliefs.
Footnotes
Acknowledgments
Dr. McKinney would like to acknowledge and thank Drs. Joseph Gibes and Fred Martin, whose session titled “Ethics Rouncs on the Inpatient Service: Fostering Idealism” at the 2018 Spring Meeting of the Society of Teachers of Family Medicine was the catalyst for this workshop.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
