Keywords

Case Scenario

A 6-year-old male is brought by his mother and father into the pediatric emergency department for evaluation. The chief complaint as reported to the triage nurse is “dehydration .” Upon entering the exam room, the female attending physician observes that the child is sitting on the exam bed playing games on a tablet. The physician introduces herself and reaches to shake hands with the parents. The father immediately stands up and shakes the physician’s hand but then positions himself in front of the mother, such that the physician cannot extend her hand toward the mother. The physician then sits at the foot of the bed, next to the patient. The father remains standing and provides very curt, abrupt answers to the physician’s questions about the medical history. He avoids eye contact, appears agitated, and interrupts the mother when she attempts to provide additional details. Eventually, the father explodes, “I am done talking to you. I need a male physician to take care of my son.”

Review of Symptoms

The patient had loose, watery, non-bloody stools for the last 2 days. He had a normal appetite until this evening at dinner, when he had onset of nausea and vomiting. He had three episodes of non-bloody, non-bilious emesis. He has been afebrile over the course of the illness. The remainder of the history is difficult to obtain, as the father refuses to answer additional questions.

Past Medical History

The patient has a history of asthma but has never been hospitalized. He had tympanostomy tubes placed bilaterally at age 2.

Social History

He is in the first grade, where multiple children have had “the stomach flu.” The father refuses to provide any additional information pertinent to the social history, demanding, “Why does all this matter?”

Family History

The father refuses to provide additional history.

Physical Exam

Vital Signs

Temperature 37.6 °C, Pulse 98, RR 19, BP 98/57, O2 Sat 98% on room air.

General

Healthy-appearing young male child, who is resting comfortably, engaged in a game on his tablet, appears well hydrated.

The remainder of the physical exam cannot be obtained.

What Was Said?

Prior to the physician being able to examine the patient, the father demands that his child be treated by “a male doctor.” The female attending physician replies calmly, “It seems as if you are upset, sir. Please tell me your concern about having a female physician.” The father angrily replies, “I don’t need this!” He grabs his wife and child and attempts to leave the emergency department.

What Was Done?

Before the family exits, the male charge nurse talks with the father and promises to find a male physician to care for his son. The family returns to the examination room and a male attending physician evaluates the patient, diagnoses him with an acute gastroenteritis, and discharges him to home with a prescription for Zofran.

Questions for Discussion

  1. 1.

    Why did the patient’s father demand a male physician ?

Attitudes/Assumptions: The Father

  1. (a)

    Male physicians are smarter and more competent healthcare providers.

  2. (b)

    Males are the authoritarian figures in his family, and his son should see this leadership modeled in his environment.

  1. 2.

    Why did the charge nurse and second physician acquiesce to the father’s demands without discussing expectations with him or providing verbal support to the original female physician?

Attitudes/Assumptions: Charge Nurse and Second (Male) Physician

  1. (a)

    Pleasing the patient/customer is the highest priority.

  2. (b)

    This experience, although an annoyance, will not have any lasting effect on the female physician.

  1. 3.

    How could the female physician have improved the interaction with the patient’s father?

Attitudes/Assumptions: Female Attending Physician

  1. (a)

    If I am polite enough to the father, he will see that I am trying to help his son, and he will become more reasonable.

  2. (b)

    If I openly acknowledge his concern about having a female physician, we can then start a dialogue about his concerns; this improved communication will improve the patient encounter.

Cross-Cultural Tools and Skills

  1. (a)

    Ask questions to elicit patient/parental preferences. From the beginning of this patient encounter, the father displayed nonverbal cues that indicated his disapproval. The female physician used tactics, such as sitting on the patient stretcher, which she assumed would be viewed as conciliatory. Rather than speculate about patient preferences, one should inquire in a respectful and direct manner.

  1. 4.

    Are there additional steps the female physician could have taken to help prevent similar situations in the future?

Attitudes/Assumptions: Female Attending Physician

  1. (a)

    These patient encounters will “come up from time to time” and “that’s just the way it goes.”

  2. (b)

    There are no helpful resources for situations like these, so “I just have to deal with it.”

Gaps in Provider Knowledge

  1. (a)

    Lack of knowledge of specific strategies to address bias in others

  2. (b)

    Inability to recognize institutional cultural challenges

Pearls and Pitfalls

Pearl

The mature physician recognizes the nonverbal cues that indicate a patient or family member may be experiencing displeasure. One should define his or her personal and professional boundaries in order to manage surrounding conflict without being manipulated by it [1].

Pearl

During an encounter with a difficult patient or family member, it is important for the physician to remain calm, be empathetic to their needs, and try to engage them in conversation to determine a mutually agreeable solution to the problem [1].

Pitfall

One will likely not change the cultural beliefs and practices of a patient/family member in a single encounter. It is important to manage your own expectations as well as the patient’s.

Pearl

Team dynamics play a critical role in the healthcare setting. Rather than dismissing the opinions or value of a team member, as noted in this case by the nurse manager and male physician, providers should have open communication and define shared goals such that each team member is supported.

Pearl

While there are many studies that explore physician gender bias toward their patients, the literature is less robust with respect to the gender bias of patients toward their providers. Some studies suggest that communication between patients and doctors of the same gender is more satisfactory. However, female physicians have been noted to engage in more patient-centered communication , and their decision-making styles have been described as more participatory [2, 3]. These strengths of women providers should be acknowledged and leveraged in the healthcare setting to optimize patient care.

Case Outcome

The patient was discharged to home with the prescription for Zofran. The female attending physician was notified by emergency department leadership that the father filed a complaint about her to the hospital patient representative and submitted a negative patient satisfaction survey. The physician spoke with her direct supervisor, who recommended she seek additional support and resources offered by the Office of Equity and Inclusion .