Use of a simulated patient case and structured debrief to explore trainee responses to a “non-compliant patient”

Abstract

Background: Labeling a patient “non-compliant” is a form of dehumanization that can deprive the patient of positive human qualities and/or agency in the mind of a physician. The term “non-compliant” is frequently used in medical record documentation and has been shown to compromise care, particularly for marginalized communities. There is limited literature on the impact of the label on medical trainees. We aimed to explore how internal medicine residents and fellows (trainees) perceive the term “non-compliant patient” and its impact on their practice after interacting with a simulated refugee patient who has not followed a physician’s recommendations. Methods: Kolb’s experiential learning cycle guided the design of the educational session which was part of a required communication skills curriculum for trainees. A scenario was created to simulate a refugee patient who had not adhered to their treatment plan and could potentially be labeled as “non-compliant.” Trainees participated in the 3-h session consisting of a remote simulated patient encounter immediately followed by a virtual structured debrief session that was recorded and transcribed. Thematic analysis of debrief transcripts was conducted starting with the use of provisional codes from the literature on the doctor-patient relationship and de/humanization. Results: In group debrief sessions, trainees reflected upon the standardized patient case and chose to also discuss similar cases they had experienced in clinical practice. Trainees indicated that the term “non-compliant patient” served as a biasing function and described how this bias negatively impacted the doctor-patient relationship. Trainees described how marginalized communities might be more susceptible to the negative connotation associated with the term “non-compliant patient.” For some trainees, the term triggered further investigation of underlying barriers to care and exploration of the social determinants of health. Conclusions: The use of the phrase “non-compliant patient,” though common in medical practice, may lead to patient dehumanization among trainees. A simulated refugee patient encounter followed by a facilitated group debrief allowed participants to verbalize and reflect on the meaning and possible impact of the label.