Katz Sydney, Ramsdell Amanda K
Division of General Internal Medicine, Weill Cornell Medical College, New York, NY, USA.
Weill Cornell Medicine, New York-Presbyterian Hospital, Department of Medicine, Division of General Internal Medicine, Section of Hospital Medicine, New York, NY, USA.
J Gen Intern Med. 2025 Jun 25. doi: 10.1007/s11606-025-09656-7.
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.
违反医嘱出院（AMA）是一种常见的临床情况，在这种情况下，患者与医疗服务提供者之间的权力差异、指责以及不一致的优先事项可能会结合在一起，导致产生一种充满污名的高风险临床遭遇，并伴有不良健康后果。对违反医嘱出院患者的污名化可能以多种方式表现出来，包括与医院工作人员的负面互动、疼痛和戒断管理不当、病历中的污名化记录、被评判或歧视的感觉以及出院时的不达标护理。尽管违反医嘱出院通常被认为是患者个人的决策，但更大的社会力量导致患者有先前的经历和相互冲突的优先事项，促使他们过早出院。与社会资源分配不均相关的风险因素，如社会经济地位、保险状况和住房状况，与违反医嘱出院有关，并且有可能既导致不良健康后果，又使污名化持续存在。结构胜任力（SC）是一种教育框架，它将症状、健康和疾病视为更大的结构性社会力量的下游效应。我们认为，结构胜任力是一种强大的工具，可以重新构建违反医嘱出院的情况，将责任从患者身上转移开，并重新设想更公平、以患者为中心的过早出院的最佳做法。
