By Solveig Dittmann, RN, BA, BSN, CPHRM
Coverys is committed to addressing social injustices to help effect positive change and create a more diverse and inclusive society. Healthcare organizations benefit tremendously from a diverse workforce. While we typically think of implicit bias in healthcare as something that impacts patients, sometimes implicit bias is displayed by patients toward healthcare providers. This article offers strategies for supporting healthcare providers who are the target of bias.
Healthcare practitioners have access to numerous educational programs to enhance cultural sensitivity and reduce bias toward patients who are members of racial, cultural, or religious minorities. But little educational material exists on how practitioners should react when patients exhibit bias toward them. A Medscape survey of more than 800 U.S. physicians concluded that in the past five years, 59% had heard an offensive remark about a personal characteristic from a patient or family member, and 47% had a patient request another doctor because of bias against the physician’s ethnicity, age, gender, or religion. Racist, sexist, and bigoted comments, while infrequent, are painful and degrading and can leave lasting emotional scars.1
Discriminatory acts against physicians who are members of cultural or ethnic minorities can compound the stress inherent in practicing medicine and even accelerate “burnout.”2 Here are some examples from recent literature:
- An elderly patient congratulated a female African American resident for “making it through medical school” and then said, “now don’t waste your affirmative action.”2
- A fair-skinned African American nurse who entered a patient’s room for the first time was told, “Thank goodness, you are the first white nurse I’ve seen here.”3
- A Harvard-educated chief neurology resident at Massachusetts General Hospital and Brigham and Women’s Hospital, who is Muslim and wears a headscarf, had a patient demand to know what foreign medical school she had attended.4
Employees of healthcare institutions have the right to a workplace free from discrimination based on race, color, religion, sex, and national origin, according to Title VII of the 1964 Civil Rights Act. Organizations that base assignments on race or require an employee to relinquish patient care assignments because of a patient’s race-based, biased request may be exposed to allegations of racial discrimination. Some healthcare workers have successfully sued organizations for implementing these actions.6
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On the other hand, patients may refuse to be treated by a particular physician or healthcare worker. The New England Journal of Medicine article “Dealing with Racist Patients” notes that in cases where patients request provider reassignment based on ethnicity or race, the reasoning behind the request may be important to consider.7 Some studies have suggested that religious and cultural similarities between patients and practitioners may enhance patient satisfaction, comprehension, and trust.7 Nevertheless, ignoring the impact of these care refusals on the practitioner is not justified in any case.
Although guidelines for managing patient prejudice are few and far between, a 2016 article in Academic Medicine recommends a simple, four-step approach for physicians confronted with racism from a patient:
1. Assess the condition of the patient.
2. Focus the encounter on the shared goals of treatment.
3. Depersonalize the event whenever possible.
4. Foster a community of support within the organization.8
Implementation of this approach requires further discussion of each step. During an emergency, the patient should be treated by the available provider or providers. Once the situation has stabilized, the patient’s request for a different provider can be addressed. A situation “debrief” should provide an avenue to discuss the comments, their possible source, and the feelings they provoked. What motivated the patient’s comment or request? Did the targeted practitioner experience stress that was distracting or had a negative impact on their ability to provide care? Was there anything the coworkers or other practitioners present could have done to reduce the stress for the targeted practitioner during the emergency?
In order to “focus the encounter on the shared goals of treatment” in the face of discrimination or bigotry during non-emergent encounters, the practitioner should try to understand that all persons have biases that may become more evident when they are under duress from significant illness. It may be appropriate to politely tell the patient that the comment was offensive, then continue with a comment such as, “I’m sorry you feel that way. I hope it won’t get in the way of my taking care of you.”3 In both this situation and in emergencies, the patient’s comment or comments should be reported to a supervisor or administrator so they are aware of the bias and can prepare to respond if the patient decides to escalate their concern.
In order to depersonalize the event, it helps to realize that you are probably not going to change the patient’s mind during a time when they are worrying about their health. There may also be situations in which the request for a different practitioner is based upon experience, not overt bigotry. Consider the case of a Vietnam War veteran with post-traumatic stress disorder who does not want to receive care from a Vietnamese practitioner who reminds him of his previous “enemy.” In some situations, it may be appropriate to reassign the patient’s care. However, emotional reactions to discrimination for any reason are not easily prevented, and organizations should provide an avenue to discuss these feelings and gain support from colleagues and leaders. Encourage targeted practitioners and staff members to report via your facility’s occurrence reporting system. Track and trend these incidents, and discuss them in patient safety and/or quality improvement meetings.
In order to deal effectively with patient bias, educate practitioners and staff on the steps above and on how to respond to the many types of situations that may arise. Role-playing with observation and discussion of various approaches’ effectiveness may be a way to ensure practitioners are prepared to respond consistently and professionally when faced with discrimination or personal attacks by patients.
Healthcare organizations are required to have policies that protect employees from discrimination by colleagues and supervisors. But when patients discriminate against practitioners, there is often little recourse. Open discussions, in the context of policies that support minority clinicians who are victims of derogatory remarks or actions, will bring these issues to the forefront and provide support to reduce stress and possible subsequent burnout. Physician Lachelle Dawn Weeks notes that we must move toward making our organizations “safe and affirming environments for health care providers to discuss how cultural and religious differences affect how we are perceived and treated by those whose lives we have sworn to save.”2
1. Tedeschi B. 6 in 10 doctors report abusive remarks from patients, and many get little help coping with the wounds. STAT. October 18, 2017. https://www.statnews.com/2017/10/18/patient-prejudice-wounds-doctors/. Accessed October 22, 2019.
2. Weeks L D. When the patient is racist, how should the doctor respond? STAT. June 12, 2017. https://statnews.com/2017/06/12/racism-bias-patients-doctors/. Accessed October 22, 2019.
3. Combating bias in the nursing workplace. https://minoritynurse.com/combating-bias-in-the-nursing-workplace/. Published March 30, 2013. Accessed October 22, 2019.
4. Saadi A. Opinion: American-Muslim Doctor Reflects on Bigotry At Some Top Hospitals, And Beyond. CommonHealth. https://www.wbur.org/commonhealth/2016/01/08/hospital-bigotry-opinion. Published January 8, 2016. Accessed October 22, 2019.
5. How do I deal with a racist patient? AAFP Fresh Perspectives Blog. https://www.aafp.org/news/blogs/ freshperspectives/entry/20170821fp-race.html. Published August 21, 2017. Accessed October 22, 2019.
6. Paul-Emile K. Patients’ racial preferences and the medical culture of accommodation. UCLA Law Rev. 2012; 462-504.
7. Paul-Emile K., Smith AK., Lo B, Fernandez A. Dealing with racist patients. NEJM. 2016; 374;8. February 25, 2016; 708-711.
8. Whitgob E., Blankenburg R., Bogetz A. The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees. Academic Medicine. 2016;91;11;S64-S69.