Patient perceptions of microaggressions and discrimination toward patients during emergency department care

Abstract

Background:

Disparities in emergency department (ED) care based on race and ethnicity have been demonstrated. Patient perceptions of emergency care can have broad impacts, including poor health outcomes. Our objective was to measure and explore patient experiences of microaggressions and discrimination during ED care.

Methods:

This mixed-methods study of adult patients from two urban academic EDs integrates quantitative discrimination measures and semistructured interviews of discrimination experiences during ED care. Participants completed demographic questionnaires and the Discrimination in Medical Settings (DMS) scale and were invited for a follow-up interview. Transcripts of recorded interviews were analyzed leveraging conventional content analysis with line-by-line coding for thematic descriptions.

Results:

The cohort included 52 participants, with 30 completing the interview. Nearly half the participants were Black (n = 24, 46.1%) and half were male (n = 26, 50%). “No” or “rare” experiences of discrimination during the ED visit were reported by 22/48 (46%), some/moderate discrimination by 19/48 (39%), and significant discrimination in 7/48 (15%). Five main themes were found: (1) clinician behaviors—communication and empathy, (2) emotional response to health care team actions, (3) perceived reasons for discrimination, (4) environmental pressures in the ED, and (5) patients are hesitant to complain. We found an emergent concept where persons with moderate/high DMS scores, in discussing instances of discrimination, frequently reflected on previous health care experiences rather than on their current ED visit.

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 health care. System and clinician investment in patient rapport and satisfaction is important to prevent negative expectations for future encounters and counteract those already in place.

INTRODUCTION

Patient experience of care has been associated with important health outcomes and may impact the recovery process and perspectives on the quality of emergency department (ED) care.^1–5 Perceptions of discrimination in health care have been linked directly to delays in seeking medical treatment, nonadherence to clinician recommendations, and subsequent mistrust of clinicians and health care systems.^6,7 Microaggressions, discriminatory behaviors that may be subtle and unintentional, may disempower the individual affected leading to differential care and worse health care outcomes.^7–10 Prior studies have identified discrimination, implicit bias, and microaggressions as common in health care encounters involving persons from marginalized groups.^11–17 Categories of perceived discrimination can vary widely and include social factors, race/ethnicity, education, socioeconomic status, abilities, and gender identity.^{11,12,18–20}

While microaggressions and overt discrimination toward patients have been studied in other health care settings, there has been little research on microaggressions or perceptions of discrimination in EDs.¹⁰ The ED is a high-risk setting for microaggressions toward patients. Physician decision making in the ED is challenged by a busy environment and a focus on short-term outcomes. Patients and clinicians meet for the first time over an acute medical problem and do not benefit from preestablished relationships. Additionally, the patient may interact with many different health care team members (e.g., paramedics, nurses, respiratory therapists), resulting in multiple interactions, potentially abrupt encounters, and increased risk of a negative interaction. Finally, both staff and patients may perceive a power differential in which patients lack the ability to interrupt or disarm microaggressions or attenuate their effects during the ED visit.¹¹

To date, there is little evidence characterizing patient-level discrimination or experiences of microaggressions in the ED or their distribution across social and demographic factors. One recent study of patient satisfaction after the ED visit found that Black patients were more likely to feel that they were treated with less respect or receive lower quality care due to their race, but other factors such as gender were not considered.²¹ While this finding is important, quantitative data can lack nuance. We theorized that microaggressions against patients occur during the ED visit and that an exploration of patients’ perceptions of discrimination could inform interventions to prevent future occurrences. We evaluated this hypothesis using a sequential, explanatory mixed-methods study combining both a quantitative survey and a qualitative semistructured interview that allowed ED patients to share their stories in an open and nonjudgmental manner.

METHODS

Study design

This study used a mixed-methods sequential explanatory approach to examine patients’ perceptions of discrimination, clinician behaviors, and microaggressions in the ED. In this design, quantitative data are collected first, and then qualitative data are collected and analyzed to further explain the quantitative data.²² This study was approved by the institutional review board. The study follows the Consolidated Criteria for Reporting Qualitative Research checklist (COREQ).²³

Setting

Patients were approached during their ED visit to one health system that includes a large tertiary care academic hospital (82,000 annual ED visits) and a medium sized community hospital (55,000 annual ED visits). Both hospitals are in an urban setting in a large Midwest city. In 2020, the ED patient population was 51% White, 41% African American/Black, 2% Asian or Pacific Islander, and 6% other races.

Quantitative sampling methods and data collection

A purposive sampling algorithm was created to approach potential participants from a diverse range of ages, races, ethnicity, and gender identity (Supplemental Material A in Data S1). We created a table of different age groups, genders, races, and ethnicities and randomized them to prioritize certain populations for recruitment each day. Recruitment times were deliberately varied between daytime hours and evenings, from May to July 2021.

Exclusion criteria included age <18 years old, non-English speaking, unable to consent due to an acute medical issue or cognitive impairment (determined by the study assistant), hearing impairment severe enough to preclude interviewing over the phone, or psychiatry consultation requested during the enrollment ED visit. Written informed consent was obtained at the time of enrollment, and verbal consent was obtained again at the time of the semistructured interview. A $25 gift card was provided as compensation to patients after the interview completion. Three types of data were collected: baseline characteristics during recruitment in the ED, a discrimination survey, and a semistructured interview that occurred after the ED visit.

Quantitative measures

Baseline demographic characteristics were collected in the ED. Each participant’s experiences of discrimination were quantified using a modified version of the seven-item Discrimination in Medical Settings (DMS) tool with the questions adapted to the ED setting (Supplemental Data B in Data S1).²⁴

Qualitative data collection

All participants were invited to a follow-up interview after the ED visit. Interview guides from prior studies of racism or microaggressions in health care were examined and the pertinence/relevance to the ED population was discussed by the study team.^25,26 Questions were vetted by the study group and an interview guide was created and piloted (guide included as Supplemental Data C in Data S1). The interviews focused on the experience of being a patient in the ED and any instances of discrimination during a medical visit. If a description was needed, discrimination was defined as being treated differently, for example, due to your race, gender, or appearance. The interviews were conducted over the phone by a trained interviewer (EO) within 2 weeks of the ED visit. Interviews were audio recorded and professionally transcribed.

Quantitative analysis

Demographic characteristics were descriptively analyzed. Characteristics of those approached, those who consented to participate, and those who completed all study activities including the interview are presented in Table 1. The DMS survey data were analyzed using 0 = never to 4 = always. Adding the scores for all seven questions resulted in a cumulative score with a range of 0–28. The following ranges for cumulative scores were assigned: none or rare discrimination (0–2), some or moderate experiences of discrimination,^3–9 and significant experiences of discrimination (≥10).

TABLE 1.

Characteristics of study population.

Sample characteristics	Potential participants, N = 91	Consented to participate, n = 52 (57.1%)	Completed interview
			n = 30 (57.7%)	DSM score
DSM score	—	3.5 (±4.1)	4.5 (±4.7)
Age (years)	36.7 (±14.3)	38.3 (±15.2)	40.6 (±14.8)
Race/ethnicity
Asian	8 (8.8)	3 (5.7)	2 (6.6)	4.5 (5.0)
Black/African American	40 (44.0)	24 (46.1)	10 (33.3)	6.1 (5.6)
Hispanic/Latino	10 (10.9)	6 (9.6)	5 (16.7)	5.2 (4.0)
American Indian/Alaska Native	2 (2.2)	2 (1.9)	2 (3.3)	3.5 (0.7)
White, Non-Hispanic	38 (41.8)	19 (36.5)	13 (43.3)	2.9 (4.9)
Gender
Female	43 (47.3)	22 (42.3)	14 (46.6)	4.9 (5.0)
Male	48 (52.8)	26 (50.0)	13 (43.3)	4.1 (4.1)
Non-cis	4 (4.4)	4 (7.7)	3 (10.0)	4.7 (5.0)
LGBTQ+a	Not available	8 (15.4)	6 (20.0)	8.0 (6.3)
Generation
Generation Z (18–24)	25 (27.5)	14 (26.9)	4 (22.8)	8.5 (5.9)
Millennials (25–40)	33 (36.3)	16 (30.8)	12 (30.8)	3.1 (3.4)
Generation X (41–57)	23 (25.3)	14 (26.9)	9 (48.2)	5.1 (4.3)
Baby Boomers (58–75)	10 (11.0)	8 (15.4)	5 (64.6)	3.4 (6.0)

Note: Data are reported as mean (±SD) or n (%).

^aLGBTQ+ status was only available for persons who consented to the study.

Qualitative analysis

During the first phase of qualitative analysis, conventional content analysis was used to analyze the data, first reviewing the transcripts independently and then together as a group. Four of the authors read through the transcripts, coding important statements while exploring patients’ perceptions of clinician behaviors and microaggressions. Next, the team grouped these important statements, developing the first level of coding and removing redundancies. Transcripts were then sequentially examined line by line using the developed code book, allowing additional codes to develop. We considered data saturation achieved when no additional themes were found.²⁷ The analysis team examined the categories of data and grouped them into meaningful themes and subthemes (Figure 1). We chose representative quotes from the transcripts to highlight the themes within the results (Table 2). Credibility and confirmability were assured through triangulation of four investigators in the analysis and ensuring inclusion criteria of participants were upheld. Disagreements were resolved through group discussion and consensus. Integration of the quantitative data occurred by examining participant transcripts with a DMS score of 3 or greater and assessing the perceptions of discrimination during the ED visit.

FIGURE 1.

Enrollment and follow-up flow diagram for sample. DMS, Discrimination in Medical Settings.

TABLE 2.

Summary of thematic analysis and illustrative quotes.

Themes	Quotations
Clinician behaviors
	“Whenever I would tell them something, it was like they didn’t care what I thought.” (Millennial, White, female) “It was just a bad day for [them] … a it was probably hard. They probably had it up to their wit’s end and kind of lost it a little bit for a moment. And we all went on about our way. And eventually, I walked out healthy several […] days later.” (Baby Boomer, Black, female)	“[They] had the best communication. They told me everything before anything was done. It was with manners and no tones of attitude. Like they’re happy to be at work kind of thing … They explained everything. […] It made me feel safe. I wasn’t afraid of them accidentally grabbing the wrong thing in a quick and hurry […]. Really friendly staff.” (Millennial, White, nonbinary)
Patient response to health care team actions
Positive Interactions	“It was from my nursing staff to the X-ray technologist and the CT technologist and the medical students that were there … addressed me seemingly sympathetically and at times empathetically. […] All the language […] was more encouraging than discouraging … It made me feel protected … I felt like my concerns were appropriately questioned but then acted on appropriately … which made me feel like they were not just there to either give me what I wanted but to actually investigate what the problem was.” (Millennial, White, male)	“So that doctor that I had the negative interaction with, he kind of shrugged. That’s probably why I felt like he kind of shrugged off. And I said I was in pain. And the female doctor that I had the good interaction with, when she came in to tell me about what was going on with me, she actually sat down looked me in my eye, and her tone just felt like she cared more.” (Gen Z, Black, female) “The way they talked to me was like they were listening. They were concerned about what was going on. They were trying to help me get better.” (Gen X, Black, male)
Negative Interactions	“It was something I observed, […], an [ED staff member] was being very excessively rude to another patient. It was very disturbing for me … It appeared the patient … was asking too many questions, and maybe [they] didn’t have the amount of time to stay with that patient, tried to express that they had to keep going but did it very rudely, very rudely, to the point the patient came out in the hallway threatening … It was bad. I was shocked … not professional.” (Baby Boomer, Black, female)	One participant recalled an experience from years prior stated: “When I’m giving my symptoms and it has to deal with anything with pain, I remember one of the nurses was like, ‘So we don’t automatically just give narcotics.’ And I said, ‘… I said nothing about narcotics. And … I can’t even take narcotics. I can only take Tylenol and ibuprofen.’ … And that made me want to leave right then and right there … I’m sitting here shaking right now because it still makes me so mad … I ended up being severely sick. … That [made] me feel—I’m sorry. I got tears right inside my eyes. It made me feel like they didn’t care.” (Gen X, Hispanic, female)
Perceived reasons for discrimination
	“… but they were saying, ‘Oh, for your age, you shouldn’t be having these issues.’ But I said, ‘It is genetically in my line. I’m type 1 diabetic. I’ve had coronavirus, which we now know could be vascular,’ and so I was very concerned. […] That kind of really pissed me off. I rolled my eyes once when the student had said that to me … So it was very frustrating for me and personally having to go through that.” (Gen Z, American Indian/Alaska Native, nonbinary)	“I looked probably rather disheveled because I had been sick, I hadn’t shaved my face in probably three or four days, and with having the fever for about a day and a half, I’m sure my hair was oily and all, so I probably looked really rough and came off as somebody of a low socioeconomic class.” (Gen X, White, nonbinary)
	“There were quite a few of them that did not want to use my preferred name, which actually kind of hurt a little bit … I don’t know if they were just having a bad day. I don’t know if it was religious beliefs or what the reason may be. I get doctors and nurses are busy with a lot of patients … I was afraid for some reason of being rejected … I’m always afraid to speak up at first about my true identity because I don’t know what kind of situation I could possibly be in … at [that ER] I don’t know if they were trying to hide it and failed or just didn’t care if I noticed, but some of them seemed like they had slight—some of them had slight judgmental looks.” (Millennial, White, nonbinary)	“Because I am an older female. I am overweight … I think because of being in that demographic, you’re not likely to make the fuss that somebody else may … I’ve witnessed it, yes, in our own family … My ex-husband was biracial, so I have seen them treated differently. I have seen people, where I’ve been in a waiting room, treated differently because of their race, whether it be African American, whether it be Indian, sometimes not always the most respectful, and language barriers, cultural barriers.” (Gen X, Hispanic, female)
	“People have different situations and different things that’s going on when they have to come into the ER and might look a certain way, maybe unclean or unkempt. It doesn’t mean that they’re always like that.” (Millennial, Black, female) “A lot of times they feel like their education lets them know everything. Also, because my income, they automatically think that I don’t know and they underestimate me because of my race” (Gen X, Hispanic, female).	“I don’t need [them] talking to me like that … If you was sitting out in that waiting room, and just analyze, analyze how they talk to Black people, how they talk to foreigners, how they talk to White people, then you’ll see it for yourself.” (Baby Boomer, Black, male)
Environmental pressures in the ED
	“I was in so much pain … It was just I felt like there were some things I was saying that she wasn’t listening to, and so I guess immediately felt a little bit hurt but momentarily … Well, I’m in health care, and knowing how things work, I came in at the end of a long shift for, I think, a lot of people that were on that night, and I think that there is some level of exhaustion that goes into it where I was probably that person’s, who knows, maybe 20th patient. And I think fatigue can have an effect on your sympathy to some degree.” (Millennial, White, male)	“The other hospital, I would say the people were a little more short. They were a little more testy with patients. They just didn’t seem—I’d hate to say it—happy in their job because the job is stressful.” (Gen X, Hispanic, female)
Patients are hesitant to complain
	“Why I probably have never spoken up until this point is because this is … what you’re doing can affect, I feel like, the future, and my complaint would’ve just sat in a filing cabinet and been sitting there for months and maybe years to be filed, and nothing would’ve probably happened, and it would’ve just been passed over.” (Millennial, Black, female)	“I don’t know [if I would file a complaint], man, honestly. Because it seems like a lot of times, when people do stuff like that, they seem to get away with it. And appropriate action ain’t always taken, so I’m not confident in that at all, actually.” (Gen X, White, male)

RESULTS

Of the 94 potential participants approached, three did not meet inclusion criteria. Over half of those approached (n = 52, 56%) consented to participate, and 48 (92%) of those completed the DMS scale. Thirty (57.7%) participants completed a follow-up interview. Of those completing the DMS scale, 49% (n = 26) reported some/moderate or significant discrimination during this ED visit.

Quantitative data

DMS scores ranged from 0 to 15, with a median of 3. A third of the participants (33%, n = 15) had a DMS score of 0. Some or moderate discrimination (score 3–9) was experienced by 39% (n = 19), and 14% (n = 7) reported significant discrimination (score 10+; Figure 1). The individual DMS score elements found that 41% (n = 19) reported experiencing less courtesy than others, 43% (n = 20) reported experiencing less respect than others, 39% (n = 18) reported experiencing poorer services than others, and 41% (n = 19) reported their health care clinicians acting as if they were better than them. Additionally, 20% (n = 9) reported their health care clinicians acting as if they were afraid of them, and over half (54%, n = 25) reported that they felt like a doctor or nurse was not listening to what they were saying. Participants could select a range of reasons why they felt they were treated this way, and more than one reason could be chosen (Table 1). Age, race, gender, ethnicity, and socioeconomic status were some of the more common reasons. Every participant that reported gender as a mode of discrimination was a woman.

Qualitative results

Participants discussed their perceptions of ED clinical staff treating them differently and corresponding behavioral actions to stressors, sometimes viewing these microaggressions as related to the ED environment. The qualitative analysis resulted in four main themes: (1) clinician behaviors—communication and empathy, (2) emotional response to health care team actions, (3) perceived reasons for discrimination, (4) environmental pressures in the ED, and (5) patients are hesitant to complain. An emergent concept was recognized during the integration of quantitative and qualitative data. For participants with a DMS score of 3 or greater, 15/17 (88.2%) attributed these feelings of discrimination/microaggressions to previous health care encounters and did not describe occurrences during the ED encounter at which they were recruited.

Theme 1: Clinician behaviors—Communication and empathy

ED patients described the staff’s positive and negative behaviors, communication, body language, and thoroughness of clinical care. Positive behaviors included frequent communication, reassurance, privacy, respect, and validation of concerns. Empathy and eye contact were also mentioned. Negative behaviors included rudeness, unprofessionalism, dismissive communication, and microaggressions toward individual patients.

Theme 2: Emotional response to health care team actions

Participants also described their emotional responses and thought processes related to health care team behaviors. Positive interactions with clinicians reassured confidence in the emergency care visit and willingness to return for future health care. In contrast, the respondents describe vivid reactions to previous negative clinician behaviors including saying that they were “disturbed” and “shocked” and “felt vulnerable” and that they questioned whether to leave the ED before the completion of their care. Participants detailed beliefs that clinician behavior sometimes instigated a violent and threatening response from other patients.

Theme 3: Perceived reasons for discrimination

In this theme, respondents discuss their perceptions of being treated differently by previous ED clinicians. Presumed reasons for differential treatment varied by age, gender identity, race, physical appearance, health literacy, chronic conditions, and disabilities. A participant with a complex medical condition described another hospital’s ED encounter, “[they were] trying to transfer me … I kind of had the sense that they really didn’t want to deal with me” (millennial, White, female). The ways in which the participants were treated differently varied and were primarily captured by the theme “clinician behaviors.” However, the perceptions of discrimination and microaggressions aligned to their individual differences.

Theme 4: Environmental pressures in the ED

In this theme, participants described the setting and general atmosphere during their ED encounters. This theme often provided context to the clinician behaviors described in the interview. Participants often noted long wait times and busy staff when describing negative ED experiences. One participant in describing their previous experience noted the clinician’s behaviors and how they felt hurt. However, they perceived this was due to the ED’s environmental demands.

Theme 5: Patients are hesitant to complain

While some participants did consider filing a complaint or had previously filed a discrimination complaint, many had concerns about filing a complaint. This included not wanting to identify staff members, not feeling that the complaint would be acted on, or feeling that their medical care would suffer if they brought up their concerns.

DISCUSSION

Microaggressions and perceptions of discrimination may have lasting effects on patient perceptions of care and outcomes.^28,29 The majority of ED patients in this study reported experiences with ED discrimination and microaggressions when surveyed during their emergency care encounter. However, when participants with high DMS scores were later interviewed qualitatively and in greater detail, they attributed their perceptions reported during the original ED interview more generally to other prior health care encounters, sometimes not even involving the ED. If patients expect negative health care interactions based on past experiences, it follows that emergency clinicians must proactively intervene to prevent any misperceptions. Urgent intervention is critical, not only to remedy the short- and long-term consequences for the patient but also to prevent long-term effects for future health care encounters.

Patients’ preferences for care and responses to health care clinician behaviors can vary across demographic groups.³⁰ We found that participants described concerns of discrimination for a plethora of reasons including race, gender, age, and physical appearance. However, participants reporting discrimination were most commonly racial minorities. Our findings are consistent with tenets of Minority Stress Theory including experiences of discrimination, expectations of stigma, and internalized stigma and implications for negative mental health outcomes.^31,32 Studies in other settings have found associations between experiences of discrimination, lower levels of trust in medical professionals, and a greater likelihood of nonadherence to physician recommendations.^28,29

Strategies for more intensive intervention to remedy the issues highlighted by this study will presumably involve modifications to clinician behavior and care delivery systems. Design of these interventions and monitoring of their effectiveness will necessarily depend on greater understanding and improved measurement. For example, it is unclear whether to focus separately on individual biases (e.g., racism, homophobia) or whether a cross-cutting and broadly applied intervention, aimed at increasing nonjudgmental empathy and inclusiveness, might be more effective. Conversely, it could be that staff animosity perceived by patients is indeed a result of the staff member’s “bad day” in which case individual wellness interventions and system improvements might be more impactful. Our findings suggest great variability in the perceived reasons for microaggressions and discrimination. Categories of discrimination could range as widely as the number of characteristics about which patients are mindful.

A conceptual model by Graham et al.³³ describes patient perceived needs for an emergency care visit. These include adequate communication, emotional support, competent clinical care, and environmental and waiting needs. Combining these perceived needs with our findings that reflect aspects of the Minority Stress Theory highlight the critical need for culturally competent communication and emotional support within the ED setting. This framework may guide future intervention development with further characterization of the phenomenon. Ultimately, full characterization of this problem is urgent and will likely require a large body of rigorous mixed-methods research to address heterogeneity, differences in perception, and root causes. This might require purposive sampling of patient-clinician dyads involving patients who perceived discrimination.

LIMITATIONS

Our results should be considered in context with several limitations. Our quantitative data may not be broadly generalizable to other settings due to small sample size, limited number of EDs, and sampling process. Further, although qualitative data are intended to provide rich understanding as was gained in this instance, it may not extrapolate to the entire patient population. Secondly, while the DMS has been validated and is in use,³⁴ it has not previously been adapted to the ED setting and we did not conduct additional validation. Another limitation is the timing of the study. Several participants attributed their previous mistreatment to the ED environment and overworked staff, leading to less empathy from clinicians. Our interviews were done with patients seen in the ED in the summer of 2021, when nationally there was a lull in hospitalizations of COVID patients, but EDs were still understaffed and often over capacity with patients.³⁵ Staff burnout rates, which are associated with low empathy, were very high in 2021.³⁶ It may be that repeating this study at another time point would have different results. Finally, there may be unknown influences and power dynamics as a result of the research team’s background, training, and study perspectives including physician leadership of the study an academic medical center setting.

CONCLUSIONS

In conclusion, our mixed-method study found that many patients report discrimination in health care and past experiences can influence current ED encounters. Also, patients perceive discrimination due to many reasons, beyond race and gender. Emergency medicine culture, individual biases, and the ED setting could all be targets of future interventions to reduce patient experiences of discrimination and microaggressions. Due to the potential lasting adverse effects on patients in their current and future health care encounters, there is an urgent need for interventions that address patients’ perception of their care.