No, You Can't See a Different Doctor: We Need Zero Tolerance of Patient Bias

Cleveland Francis, Jr., MD


December 08, 2022

It was 1970. I was in my second year of medical school. I had been up half the night preparing for a history and physical on a patient with aortic stenosis. When I arrived at the bedside, he refused to talk to me or allow me to examine him. He requested a "white doctor" instead. I can remember the hurt and embarrassment as if it were yesterday.

Coming from the Deep South, I was very familiar with racial bias, but I did not expect it at that level and in that environment. From that point on, I was anxious at each patient encounter, concerned that this might happen again. And it did several times during my residency and fellowship.

The Occupational Safety and Health Administration (OSHA) defines workplace violence as "…any act or threat of physical violence, harassment, intimidation, or other threatening disruptive behavior that occurs at the work site. It ranges from threats and verbal abuse to physical assaults."

There is considerable media focus on incidents of physical violence against healthcare workers, but when patients, their families, or visitors openly display bias and request a different doctor, nurse, or technician for nonmedical reasons, the impact is profound. This is extremely hurtful to a professional who has worked long and hard to acquire skills and expertise. And, while speech may not constitute violence in the strictest sense of the word, there is growing evidence that it can be physically harmful through its effect on the nervous system, even if no physical contact is involved.

Incidents of bias occur regularly and are clearly on the rise. In most cases the request for a different healthcare worker is granted to honor the rights of the patient. The healthcare worker is left alone and emotionally wounded; the healthcare institutions are complicit.

This bias is mostly racial but can also be based on religion, sexual orientation, age, disability, body size, accent, or gender.

An entire issue of the AMA Journal of Ethics was devoted to this topic. From recognizing that there are limits to what clinicians should be expected to tolerate when patients' preferences express unjust bias, the issue also explored where those limits should be placed, why, and who is obliged to enforce them.

The newly adopted Mass General Patient Code of Conduct is evidence that healthcare systems are beginning to recognize this problem and that such behavior will not be tolerated.

But having a zero-tolerance policy is not enough. We must have procedures in place to discourage and mitigate the impact of patient bias.

A clear definition of what constitutes a bias incident is essential. All team members must be made aware of the procedures for reporting such incidents and the chain of command for escalation. Reporting should be encouraged, and resources must be made available to impacted team members. Surveillance, monitoring, and review are also essential as is clarification on when patient preferences should be honored.

The Mayo Clinic 5 Step Plan is an excellent example of a protocol to deal with patient bias against healthcare workers and is based on a thoughtful analysis of what constitutes an unreasonable request for a different clinician. I'm pleased to report that my healthcare system (Inova Health) is developing a similar protocol.

The healthcare setting should be a bias-free zone for both patients and healthcare workers. I have been a strong advocate of patients' rights and worked hard to guard against bias and eliminate disparities in care, but healthcare workers have rights as well.

We should expect to be treated with respect.

The views expressed by the author are those of the author alone and do not represent the views of the Inova Health System.

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About Dr Cleve Francis
Cleveland Francis, Jr., MD, Diversity, Equity and Inclusion Advisor; Inova Heart and Vascular Institute (IHVI), Falls Church, Virginia; Former president and founder, Mount Vernon Cardiology Associates; Chair, IHVI Committee on Equity, Healthcare Disparities, Education and Outreach; Member, Inova Inclusion Counsel

Dr Francis is also a songwriter and performer. He is a former recording artist on the Capitol Nashville Country Music Label (1992-1995), and his music has been featured at the National Museum of African American History and Culture in Washington, DC.

Connect with him:
Twitter: @muzicdoc2
Facebook: Cleve Francis
Instagram: @muzidoc


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