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

Discharge against medical advice (AMA) is a common clinical scenario in which power differentials, blame, and discordant priorities between the patient and provider may coalesce to produce a stigma-laden high-risk clinical encounter associated with poor health outcomes. Stigma against patients who leave AMA can manifest in many ways, including negative interactions with hospital staff, inadequate management of pain and withdrawal, stigmatizing documentation in the medical record, perceptions of being judged or discriminated against, and substandard care at discharge. Though AMA discharge is typically conceptualized by individual patient decision-making, larger societal forces cause patients to have prior experiences and competing priorities which drive them to leave the hospital prematurely. Risk factors related to the inequitable distribution of social resources, such as socioeconomic status, insurance status, and housing status, are associated with AMA discharge, and have potential to both drive poor health outcomes and perpetuate stigma. Structural competency (SC) is an educational framework that looks at symptoms, health, and illness as the downstream effects of larger structural societal forces. We believe that SC is a powerful tool to reframe AMA discharge to move blame away from the patient and re-imagine best practices for a more equitable and patient-centered premature discharge.