There was the time a male patient used the N-word, shouting, “Out of my view, I hate you, don’t touch me” at a doctor.
Or the fourth-year medical student who remembers walking by a room and having a patient’s son whistle at the entire all-female care team.
Or the time a patient called a nurse a “(expletive-deleted) faggot” and ordered him out of the room.
Or the Muslim medical student who was wearing a headscarf and had a patient tell her, “You. You are the cause of everything that’s gone wrong in America.”
For a clinical workforce that is becoming more diverse, encounters with biased patients are all too common and range from patients refusing care to explicit racist, sexist or homophobic comments and belittling jokes, according to a study published Monday in JAMA Internal Medicine.
To get a handle on the problem of patient bias, researchers held 13 focus groups made up of 50 hospitalist attending physicians, internal medicine residents and medical students from three campuses affiliated with the University of California, San Francisco, School of Medicine.
Of the 50 participants, 24 (48%) were nonwhite; 26 were women; 22 were men and two were gender nonconforming. The group included eight Latinx, seven Asian, three south Asian, one Middle Eastern and five black participants.
They reported a wide range of experiences with biased patient behavior that they either directly experienced or witnessed ranging from explicit racist, sexist or homophobic remarks to inappropriate compliments, flirtatious remarks and jokes reflecting ethnic stereotypes to outright rejection of care, although that was infrequent.
Those demeaning experiences had a negative effect on participants’ emotional well-being and the clinical care environment and many said they were uncertain about appropriate and effective ways to respond to these encounters, the study found.
Targeted physicians reported an emotional toll that included exhaustion, self-doubt and cynicism. “Being in those situations…it makes the rest of the day painful to get through…and if [it] is happening to you every day, it stacks up,” said a third-year resident who is an Asian woman.
Even doctors not directly targeted reported moral distress and uncertainty about how to respond.
Reactions to demeaning patient behavior varied. Some described withdrawing from their clinical roles, such as visiting a patient less frequently than others. Others said they avoided clinical sites where those encounters were reputedly common, such as a Veterans Administration medical center where one medical student said someone called her “honey” at least once a day.
The encounters also had a negative effect on learning and clinical practice. “[Biased interactions] take away from your ability to focus on learning or training or developing into a better clinician,” said a first-year female resident.
Their reports of uncertainty, confusion and pain when subject to biased patient behavior indicates a need for training and institutional policies to deal with biased patients, the researchers concluded.
Barriers to physicians and students effectively responding to patient behavior included a lack of skills, insufficient support from senior colleagues and the institution along with a perception that complaining about such behavior would not change anything. Participants said they need training on dealing with biased patients and clear institutional policies to guide their responses.
“Addressing biased patient behavior will require a concerted effort from medical schools and hospitals to create policies and trainings conducive to a clinical environment that respects the diversity of patients and physicians alike,” the researchers said.
In an accompanying commentary, the authors wrote that health professionals who experience bias from patients should not have to tolerate it or struggle to decide how to respond without support from their health organization.
“Physicians and healthcare institutions must remain committed to the welfare of patients; however, when anyone, including a patient, exhibits biased and disrespectful behavior, silence is not golden. It is tacit approval. We all have the responsibility to speak and act,” the authors wrote.