How to answer “Can doctors refuse to treat abusive patients?” in a medical school interview

A strong answer to "can doctors refuse to treat abusive patients" separates the kinds of abuse and weighs the patient's need for care against the safety of the staff. It sets out the conditions under which refusal would and wouldn't be justified, with a reason for each condition.

What the interviewer is assessing

• Ethical reasoning
• Professionalism and integrity

Abuse of health care workers is common, and new physicians have to decide how to respond to it while still caring for the person causing it. The interviewer listens for whether you can tell abuse caused by illness apart from deliberate abuse, and whether you consider the nurses and clerks who face most of it. They also want to hear that you know the duty to treat is strongest in an emergency. Professionalism shows in how you hold both obligations at once.

In a panel interview, the question is often a follow-up to one about teamwork or a hard day on a ward. In a multiple mini interview (MMI), it appears as a scenario, sometimes with an actor playing the patient or a nurse asking you to intervene.

How to structure your answer

1. Define the problem precisely, separating abuse that comes from delirium, dementia, intoxication, psychosis, pain or fear from abuse that is deliberate and repeated.
2. Name the stakeholders: the patient, the nurses and clerks who face most of the abuse, the physician, the other patients in the waiting room, and the hospital.
3. Give the strongest case on each side, including that a patient in an emergency may die without care and that staff who are hit or threatened leave the profession.
4. Describe the options between treating and refusing, such as a written behavior agreement, security at the bedside, a different clinician, or a transfer once the patient is stable.
5. Take a position with the conditions you'd attach, and say whether those conditions change in an emergency or where no other care exists.
6. Say what would change your mind, and close with what your position means for the patient who was abusive.

The rules differ by place. Regulators in both Canada and the US allow a physician to end a relationship with a patient outside an emergency, provided the patient gets notice and a route to other care. Hospitals set their own policies on violence toward staff. Know the rules of the regulator where you're interviewing, since they differ between provinces, states and countries.

Draw on a job or volunteer role where a customer or patient was abusive, because the panel will ask what you did. With three minutes, define the cases in the first minute and spend the rest on your conditions.

Common mistakes

• Answering that physicians must always treat everyone ignores the staff, and the panel will ask what you'd tell a nurse who was punched.
• Answering that physicians can refuse anyone who's rude treats a frightened patient with dementia the same as a person who made a threat.
• Leaving nurses and clerks out of the answer misses that most abuse happens to them rather than to the physician who decides.
• Skipping the emergency case leaves out the one situation where the duty to treat is strongest.
• Stating a rule as if it applied everywhere invites a follow-up that shows you don't know the rules where you're sitting.

Follow-up questions to prepare for

• What would you do if a patient was abusive to a nurse while you were in the room?
• Does a patient's illness excuse their behavior, and where does the excuse end?
• Should hospitals have zero-tolerance policies, and what happens to the patient who's removed?
• How would you handle a patient who was racist toward a colleague?
• Would your answer change in a rural hospital with no other physician available?