Patient Biases Take Toll on Physicians

By Will Boggs MD

October 30, 2019

NEW YORK (Reuters Health) - Physicians and physician trainees experience several types of patient bias and often face significant barriers to responding effectively, according to focus-group findings.

"While we did not ask about the prevalence of these encounters in this study, it was clear that everyone had a story of either directly experiencing or witnessing these encounters," Dr. Alicia Fernandez of the University of California, San Francisco, told Reuters Health by email. "Physicians were very upset and hurt when patients discounted their training and expertise because of their ethnic or racial background or their gender."

More than half of physicians report having been demeaned by a patient in the past five years, but little is known about physicians' perspectives on these encounters and their effects.

Dr. Fernandez and colleagues conducted focus groups with convenience samples of 11 internal-medicine hospitalist physicians, 26 internal-medicine residents and 13 medical students to evaluate the range and importance of encounters with biased patients and the barriers and facilitators to effective responses.

Demeaning behaviors by patients included explicit refusal of care, explicit or socially biased remarks, questioning the clinician's role, nonverbal disrespect, ethnic jokes or stereotypes, assertive inquiry into participant's ethnic background and contextually inappropriate compliments or flirtatious remarks.

Focus-group participants reported both negative and positive effects of these encounters, the team reports in JAMA Internal Medicine, online October 28. Many described emotions of anger, confusion and fear that were distracting and painful, while others reported a growth in self-efficacy from learning to respond to such encounters.

Commonly reported responses to encounters with patient biases included setting limits, avoiding confrontation by ignoring the behavior, reassigning the patient to another clinical team or switching physicians within teams, and explaining the detrimental clinical consequences of the behavior because it usually created a delay in care.

The authors describe several barriers and facilitators to addressing demeaning behavior and remarks.

Barriers included clinical priorities that precluded an immediate response, lack of skills or uncertainty over how to respond appropriately, lack of support from colleagues or the institution, lack of knowledge of institutional policies, the fear of being perceived as unprofessional, perceived ineffectiveness of responding, and an excessively high emotional burden associated with responding.

On the other hand, facilitators included support from colleagues or the institution, a sense of professional responsibility to others, individual ethics, role models, and recognition that the biased behavior is egregious.

"These types of incidents take many forms and can lead physicians to feel isolated and cynical, which is not good for patient care or for physician well-being," Dr. Fernandez said. "Professional obligations to patients do not require silence about patient bias. With the support of institutional policies, it is possible to maintain a therapeutic relationship while also requesting to be treated with respect."

"Institutions such as hospitals and health plan need to create policies about how to deal with the more egregious forms of bias, such as when patients refuse care from a physician because of her race," she said. "But policies alone are not sufficient. For physicians to come forward when these encounters happen, the institutional culture needs to value their experience and endorse diversity and inclusion as community values."

Dr. Lisa A. Cooper of Johns Hopkins University School of Medicine, in Baltimore, Maryland, who co-authored a linked editorial, told Reuters Health by email, "The main message I hope physicians and healthcare leaders will take away is that it is important that they should embody the change they desire to see in biased patients. They can do this by learning to recognize their own biases and stereotyping behaviors and considering what a better response might be, by taking the time to get to know all their patients (not just people who are like them) as individuals, by imagining themselves as a member of a stereotyped group, and by gaining exposure to people from diverse backgrounds."

"I think the role of society is to become more aware of the existence and negative impact of these biases and to commit to becoming a part of the solution to these problems," she said. "This is one of the reasons I recommend bystander anti-discrimination training for all health professionals, staff, and trainees. I think that kind of training for our society holds promise for addressing biased treatment of persons from racial and ethnic minority groups, immigrants, and sexual and religious minorities."

Dr. Jessica Greene of Baruch College, City University of New York, recently reported that physician names can affect some patients' selection of physicians. She told Reuters Health by email that the new "findings underscore the importance of physicians standing up for colleagues who are treated unfairly by patients. To do so effectively requires training and guidance."

"Medical schools and continuing education need to develop trainings on how to respond to demeaning patient behavior, and hospitals should develop policies for handling these difficult situations," said Dr. Greene, who was not involved in the new work.


JAMA Intern Med 2019.