Bias and Burnout: Evil Twins

Carol Peckham


January 12, 2016

In This Article

Do Physicians Have Bias Toward Some Patients?

In this year's Medscape survey, physicians were asked whether they believed that they had biases toward specific types or groups of patients. Overall, 40% of physicians admitted that they did. Within the top 10 of those who expressed some degree of bias were physicians who had the most direct contact with patients: emergency medicine physicians (62%), orthopedists (50%), and psychiatrists (48%), followed by family physicians and ob/gyns (47%). Two of the specialties least likely to report bias were those also least likely to be directly involved with patients: pathologists (10%) and radiologists (22%), Cardiologists were also in the bottom three and reported a percentage of bias equivalent to that reported by radiologists.

One limitation to this survey is the issue of implicit bias—also called "unconscious" or "nonconscious" bias, which can unwittingly perpetuate disparities and affect treatment.[16] Whether identified as a low- or high-prejudiced individual, studies indicate that all persons automatically respond to cultural stereotypes. In one study, those who were low-prejudiced tended to repress stereotypical thoughts and replace them with those that reflected equality.[17] Implicit bias plays a strong role both in physician behavior and in patient responses. One physician who responded to this survey commented, "[W]hile my subconscious attitudes and perceptions may be affected, I check these at the door and do my best to be empathic no matter what."

Patient Characteristics That Trigger Bias

When physicians who admitted biases were given a list of patient characteristics that might be a potential trigger, the two that garnered the largest responses were emotional problems (62% of men and women) and weight (52% of all physicians). Other characteristics that were major bias triggers for physicians were intelligence (44%), language differences (32%), and insurance coverage (23%). Less than 20% of physicians chose other characteristics (Figure 5). When asked to add other triggers verbally, physicians most frequently cited drug-seeking and abuse. Also mentioned very frequently were malingering, entitled, and noncompliant patients. Of interest, patients with chronic pain also evoked bias in many physicians.

Figure 5. Patient Characteristics That Trigger Bias

Responses were similar between men and women, although some differences were observed for weight (48% of women vs 56% of men), insurance coverage (19% of women vs 26% of men), and income level (8% of women and 17% of men). Of interest, very few male or female physicians admitted to gender bias (8% and 7%, respectively).

Does Bias Affect Treatment?

Only a small percentage of all physicians who admitted bias reported that it actually affected their care of patients. As one would expect, specialists who rarely see patients did not believe that this bias affected their treatment of patients (pathology at 1% and radiology at 2%). Nevertheless, percentages were also low among oncologists, cardiologists, and critical care (all 4%). The highest percentages of those who report that their bias affects treatment are emergency medicine physicians (14%) and plastic surgeons (12%). Other physicians who were over 10% were orthopedists, family physicians, psychiatrists, and rheumatologists (all 11%).

It should be stressed that the effect of bias on treatment can be negative, positive, or both. The Medscape survey asked physicians two questions on the effects of their biases: whether they resulted in positive treatment (eg, extra time, friendlier manner), or whether they negatively affected treatment (eg, spending less time or being less friendly). Responders could answer "yes" to both questions. One quarter of those whose biases affect treatment believed that they overcompensated and gave patients special treatment, whereas 29% admitted that their biases had a negative effect on treatment. Twenty-four percent believed that their biases have both positive and negative effects, and another 22% suggested that neither choice was applicable.

The Effect of Bias on Patient Care

For every specific patient characteristic included in the survey, slightly more physicians reported that biases resulted in positive treatment (more time, more friendly) compared with negative treatment (less time, less friendly). It is useful, however, to look at some of these characteristics separately.

The emotional or difficult patient. Sixty-two percent of both women and men who had biases picked emotional problems in their patients as the factor mostly likely to trigger bias. Among the small group of physicians who said biases affected treatment, more of them believed the effect was positive (78%) than negative (72%). This still meant that nearly three quarters of these physicians were less friendly and/or gave these troublesome patients less time.

The emotional patient can fall under the umbrella of "difficult," a term used to refer to those with whom a physician may have trouble forming a normal therapeutic relationship.[18] Reports describe difficult patients as having depressive or anxiety disorders or severe and multiple somatic symptoms.[19,20] Indeed, although not listed an as option in the Medscape survey, many physicians who responded verbally to the question on bias triggers, frequently sited chronic pain, which is often included in the criteria for difficult patients. Perhaps the best description of such patients was written by Dr Tom O'Dowd in the British Medical Journal in 1988[21]: "There are patients in every practice who give the doctor and staff a feeling of 'heart sink'...They evoke an overwhelming mixture of exasperation, defeat, and sometimes plain dislike that causes the heart to sink."

Weight. Weight came in second as a bias trigger, with more than one half of physicians (52%) who expressed bias citing it. More men (56%) than women (48%) reported this bias. Among the small group who said their bias affected treatment, 63% said the effect of this bias was positive, but an equally large percentage (61%) conceded that the effect was negative. Weight is often cited in studies as a concerning physician bias and has specifically been observed to elicit negative attitudes, including lack of emotional rapport with obese patients.[22,23]

In the Medscape survey, explicit weight bias was strongest among proceduralists (Figure 6), suggesting that the physical difficulties of dealing with an overweight or obese patient may play a strong role in triggering bias. Nevertheless, one should not underestimate the implicit psychological and emotional bias against overweight patients, regardless of the physical difficulties of dealing with obesity and overweight.[23] Weight bias toward patients is observed starting with physician training.[24] One study found that thinner physicians were more likely to have both implicit and explicit bias against heavier patients than physicians who were heavier. However, in the study, anti-fat bias was significant even among the most obese physicians.[25]

Figure 6. Weight Bias, by Specialty

Race. Although only a small percentage of physicians admitted bias related to a patient's race (13%), implicit bias toward these patients should not be underestimated, particularly in the unconscious effects of stereotyping on treatment. Studies suggest that black and Hispanic patients in emergency departments receive less pain relievers than white patients.[16] Implicit bias in favor of white persons also affects patient response. In one study, black patients tended to react less positively to physicians with relatively low explicit but relatively high implicit bias than to physicians who were either (1) low in both explicit and implicit bias, or (2) high in both explicit and implicit bias.[26]

Gender. An even smaller percentage of physicians admitted to gender bias (8%). Dermatologists at 20% had the highest percentage of gender bias; all other physician group percentages were 12% or under. As in race, however, implicit bias should not be underestimated and is known to result in disparate treatment of women vs men, particularly undertreatment.[16] An important example was a major study published in the New England Journal of Medicine, which found that the degree of underuse of arthroplasty for severe arthritis in women was three times greater than that in men.[27]


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