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Improving Equity at Premature Discharge: Reframing Discharge Against Medical Advice Using the Structural Competency

Sydney Katz1,2, Amanda K Ramsdell3

  • 1Division of General Internal Medicine, Weill Cornell Medical College, New York, NY, USA. sek9028@med.cornell.edu.

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Summary
This summary is machine-generated.

Discharge against medical advice (AMA) is often stigmatizing due to patient-provider conflicts and societal factors. Structural competency can reframe AMA discharges, promoting patient-centered care and reducing blame.

Keywords:
AMAagainst medical advice dischargehealth equitypremature dischargestructural competency

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Area of Science:

  • Medical Sociology
  • Health Equity
  • Patient-Provider Communication

Background:

  • Discharge against medical advice (AMA) presents a complex clinical challenge, often marked by power imbalances, blame, and conflicting priorities between patients and healthcare providers.
  • Patients leaving AMA face significant stigma, including negative staff interactions, inadequate symptom management, discriminatory documentation, and substandard discharge care.
  • AMA discharge is frequently viewed as individual patient choice, overlooking the influence of broader societal factors, prior experiences, and competing patient priorities.

Discussion:

  • Socioeconomic status, insurance, and housing status are key social determinants linked to AMA discharge, exacerbating poor health outcomes and perpetuating stigma.
  • Structural competency (SC) offers a framework to understand health and illness as outcomes of societal structures, shifting focus from individual blame.
  • Applying SC to AMA discharge can reframe the scenario, mitigating patient blame and fostering more equitable, patient-centered care practices.

Key Insights:

  • AMA discharge is a high-risk encounter influenced by systemic inequities and patient-provider dynamics.
  • Stigma associated with AMA discharge negatively impacts patient care and health outcomes.
  • Structural competency provides a novel approach to address systemic drivers of AMA and promote equitable care.

Outlook:

  • Integrating structural competency into medical education can equip providers to better manage AMA discharges.
  • Reimagining AMA discharge protocols through a structural lens can lead to improved patient experiences and outcomes.
  • Further research is needed to develop and evaluate SC-based interventions for reducing AMA rates and associated stigma.