Social EM & Population Health: Respect: A Driver of Empathy and Equity

Shanna S. Strauss, MSc MS4; Megan Healy, MD FAAEM; and Sara Urquhart, MA RN

In 1967, Arethra Franklin created “Respect,” a song that not only stayed at the top of the charts for months, but also became a civil rights anthem (Brown, 2018). Respect was central to creating equality in the 1960s and it is just as important today as we strive to create health equity for our patients. This important end cannot be achieved without fair work environments for clinicians.

In many ways, we have seen how public admiration doesn’t translate to workplace respect. On one hand physicians are admired as health care heroes by the public, on the other hand some are also being retaliated against for speaking out about lack of PPE during a pandemic (Carville et al., 2020). Physicians are not immune to the experiences of dehumanization, devaluation, and exploitation in the workplace. These are commonly experienced as unfair employment contracts, punitive policies, and incentives that drive us away from the bedside and our patients. Is there a connection between the systems eroding the physician-patient relationship and our patients’ health outcomes? • Hostile work environments contribute to burnout and high physician attrition rates (Nunez-

Smith et al., 2009). • Physician attrition affects patient care. Not only does it limit clinical research but it also sequesters funds for hiring that could be invested in employee satisfaction and patient outcomes (Meurer et al., 2013). • Burnout is not only expensive for physicians and employers; it is also contributing to the significant rise in physician suicide. “Burnout has widespread consequences, including poor quality of care, increased medical errors, patient and provider dissatisfaction, and attrition from medical practice, exacerbating the shortage and maldistribution of

EPs” (Stehman et al., 2019). • As physicians become more burned out, their self-reported empathy levels decline (Wolfshohl et al., 2019).

In the pioneering article “Reframing Clinician Distress,” (Dean et al., 2019) the authors argued that moral injury lies at the heart of physician burnout. Moral injury “describes the challenge of simultaneously knowing what care patients need but being unable to provide it due to constraints that are beyond our control.” Medicine at large is ill equipped to address the main social determinants of our patients’ health outcomes, especially those drivers that impact the most marginalized patients. Many of our patients experience the direct effects of criminalized poverty (Yungman, 2019) and institutionalized classism (Scambler, 2019). These social factors are foundational to the health inequities contributing to our patients presenting illness. To compound the problem, most medical centers do not have robust systems in place to address issues like homelessness, food insecurity, and violence. At minimum, emergency physicians need to be empowered to speak out about issues that impact patient safety. Work environments that lack transparency, threaten physician autonomy, or place profit above patient care are unsafe. In challenging work environments like these, physicians face substantial barriers to providing equitable care. We must also recognize that our patients experience independent hardships when they seek treatment in the emergency department. Just as

we AAEM members scrutinize the systems and cultures that threaten our ability to practice good medicine, we must also turn a critical eye to the systems and culture that disempower our patients. Part of the answer to addressing these inequities lies in the same core value: respect. Often patient mistreatment is institutionalized and disproportionately affects patients based on their socioeconomic status, their racial categorization, sexual identity, mental health conditions, and/or addiction. We

Physicians are

not immune to the experiences of dehumanization, devaluation, and exploitation in the workplace.”

must look beyond individual patient encounters to the systems, policies and incentives that propagate injustice. Stigma is one byproduct of medical culture we must closely examine. It is particularly challenging to prevent the stigmatization of people who experience social factors with chronic and less visible stressors. For example, when a patient is obese because they are underemployed and living in a food desert they cannot afford or access unprocessed foods. Too often, this obese patient is stigmatized by their weight, as their weight becomes an easy means of judging their value. The patient becomes the object of blame, rather than the system that failed them. Research has shown negative provider attitudes impact quality of care and outcomes for obese patients (Phelan et al., 2015). Likewise, when we see patients who are unemployed presenting with mental health crises, how often are we attributing their unemployment to their mental health instead of their crisis as a result of unfair employment practices? This will be increasingly important to recognize as we continue to address the downstream impact of the pandemic. “Unemployment has been linked with a number of psychological disorders, particularly anxiety, depression, and substance abuse; dangerous behaviors including suicide and violence toward family members or others also correlate with unemployment. These associations hold true not only in surveys of those already unemployed but also in studies that follow one or several individuals with no psychological difficulties into a period of unemployment.” (LexisNexis, 2009 There are similar impacts on psychological health in the underemployed (LaMontagne, 2017). 46% of Americans are experiencing underemployment (PayScale, 2018). At the end of 2020 the United States unemployment rate was at 6.7 percent (Bureau of Labor Statistics, U.S. Department of Labor, 2020). These two statistics highlight that unemployment doesn’t quite capture all of the stressors our patients face. We do not need to live our patients’ experiences to be able to express empathy. We as physicians inherently understand the importance of respect and feel the repercussions when it is lacking. When we are able to find solidarity with our patients, it connects us to our common humanity. Simple actions rooted in respect move us closer to empathy and equity in healthcare. When we recognize where we are attributing blame or reinforcing the stigmatization of our patients because of their social factors, we are taking steps towards ending healthcare disparities. When we advocate for our own fair workplace environments, we are taking steps towards increasing our agency. Our ability to advocate for patients is central to addressing health care disparities. By uplifting our patients’ voices and valuing their lived experiences as important contributors to their health, we strengthen our platform for creating better health outcomes. There is hope in respect. Through solidarity and respect, we increase our power to implement solutions. 

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