Image by Getty Images
Image by Getty Images

How to handle biased patients

Hospitalists have developed strategies for these problematic encounters.

As a black woman, ACP Resident/Fellow Member Lachelle Dawn Weeks, MD, has plenty of experience encountering bias from patients.

“I've certainly entered a patient's room with my white coat on, with a stethoscope, did a complete physical exam, offered the plan for the day, and then had the patient ask me to replenish their towels or clean their commode,” she said.

Dr. Weeks, a fellow in hematology and oncology at Dana Farber Cancer Institute in Boston, said she is not alone. “I don't know of any black physicians, or even female physicians, who will tell you that they've never been on the receiving end of at least biased remarks from patients,” she said. “They're so commonplace that we will brush them off when they occur. You can't respond to it every day.”

But some comments can hit a physician so hard they provoke a response, and not always an ideal one. In a 2013 Annals of Internal Medicine essay titled “The Racist Patient,” Sachin H. Jain, MD, FACP, recalled a moment during residency when a patient, unhappy that the hospital pharmacy did not stock his brand of insulin, yelled, “Why don't you go back to India!”

“On pure instinct, I responded, ‘Why don't you leave our [expletive] hospital?’ To underscore my point, I repeated myself,” Dr. Jain wrote. “I exited the room in a cold sweat.”

These types of encounters are not rare. In a 2017 survey of 823 U.S. physicians (33% based in the hospital) conducted by WebMD and Medscape, 59% of respondents reported that a patient had made an offensive remark about their personal characteristics in the past five years. The most common characteristics were younger age (28%), ethnicity/national origin (22%), gender (20%), and race (19%), along with accent, political views, religion, and body weight. Less frequently, incidents went beyond comments, with 31% of respondents reporting they had received a request from a patient to see a different clinician due to their personal characteristics.

There are little data on whether patient-bias incidents have increased in recent years, said Alicia Fernández, professor of medicine at the University of California, San Francisco and a general internist at Zuckerberg San Francisco General Hospital. But what's important, she said, is that more physicians feel like they are being targeted.

“We do have an increasingly diverse workforce, and we are in a much more polarized society now, perhaps, than we were, say, 10 years ago,” said Dr. Fernández, who has researched patient bias and during residency had a patient refuse care from her because she is Latina. “And when those two things meet, I think that what happens is that more of these sorts of problems surface.”

Despite the emotional toll, some experts believe that doctors have an ethical obligation to treat patients exhibiting bias. More hospitals are trying to get in front of this issue by creating policies and procedures to protect their clinicians, as well as teaching them strategies to handle these incidents when they arise.

An ethical issue

The ACP Ethics Manual, seventh edition, says that “By history, tradition, and professional oath, physicians have a moral obligation to provide care for ill persons. . . . A physician may not discriminate against a class or category of patients.”

This includes difficult patients, even if their behavior is morally reprehensible or hurtful, said Daniel P. Sulmasy, MD, PhD, MACP, acting director of the Kennedy Institute of Ethics and Andre Hellegers Professor of Biomedical Ethics at Georgetown University in Washington, D.C.

“I have many times in my experience even been spit at by patients, cursed at. I remember once having had a patient who . . . as we were leaving the room, came out in the hallway and said, ‘Thanks for the effing good news, a******,’” he said. “So what am I supposed to do, not care for the patient?”

Matthew DeCamp, MD, PhD, FACP, agreed. “In fact, the guiding principle, even in response to difficult comments, should be to focus on the well-being of the patient,” he said.

On the other hand, there are points when it becomes necessary to take reasonable steps to protect health care professionals from threatening or violent behavior, Dr. Sulmasy said. “But short of the point of a threat of physical harm, my view is it's hard to say when we would restrict the patient's access to care on the basis of their reprehensible behavior,” he said.

In some cases, an individual physician may believe that he or she cannot provide the best care due to a patient's comments or beliefs, said Dr. DeCamp, an associate professor of bioethics and humanities and general internal medicine at the University of Colorado Anschutz Medical Campus in Aurora. But physicians should be very critical of the notion that they cannot provide good care due to what a patient says or believes, he said. Plus, arranging for care from another physician in the hospital setting can be tricky, Dr. DeCamp added.

“In high-acuity settings, there may or may not be other options for care or other physicians who can provide the kind of care expertise that an individual physician has in the inpatient setting,” said Dr. DeCamp. “In some cases, it could actually be unethical to engage in physician reassignment.” For instance, if the patient declines care from the only cardiologist on the floor, assigning another physician could compromise care, he said.

Dr. Weeks added that there may come a point at which it becomes harmful or unsafe for the physician-patient relationship to continue. “I do not think that a physician who is repeatedly on the receiving end of racist or bigoted comments necessarily needs to martyr themselves and continue to be in that position,” she said.

Physicians subject to behaviors from patient refusal of care to explicit racist, sexist, or homophobic remarks to belittling compliments or jokes reported an emotional toll that included exhaustion, self-doubt, and cynicism, according to a qualitative study of 50 hospitalist attendings, internal medicine residents, and medical students conducted by Dr. Fernández and colleagues. Those who had been bystanders to such behaviors reported moral distress and uncertainty about how to respond, according to results published in 2019 by JAMA Internal Medicine.

Even if patients don't engage in obviously biased behaviors, repeated microaggressions can build up over time, potentially leading to decreased physician well-being if they are not addressed, Dr. DeCamp said.

Bias, whether from a patient toward a clinician or vice versa, can drive a wedge between the two parties in a way that could affect patient safety, Dr. Weeks said. “You like to have open avenues of communication between a clinician and a patient, and if there's something that is not allowing that avenue to be clear, then you might misinterpret clinical signals or clues because the patient is behaving in a certain way,” she said. “So it's something that you definitely need to talk about up front.”

Skills training

In a situation where the patient requests another physician, the first step should be for the treating physician to try to manage the situation without reassignment, which should be a last resort, said Dr. DeCamp. “The first response to a comment should be to engage with the patient about what they meant by that comment, or to help understand where that potential comment was coming from,” he said.

Also, Dr. Fernández noted, “There's a difference between an affirming request versus a discriminatory refusal.” For example, it can be reasonable for a woman to request a woman clinician to complete a pelvic exam or for a Spanish-speaking patient to request a Spanish-speaking physician, she said.

To better prepare their clinicians for these situations, hospitals should train them in useful ways to respond that don't threaten the therapeutic alliance but nonetheless put a halt to the conversation, said Dr. Fernández. “And it is important not only to train residents and interns and students, but it's also important to train faculty,” she said.

When facing or witnessing biased patient comments or behavior, “No one quite knows how to respond,” Dr. Fernández said. In her research, useful methods include acknowledging the comment while still in the room, debriefing as a team after the interaction, and placing careful limits on the patient, she said.

“I think saying something like, ‘Actually, we're your medical team. It's not appropriate to speak like that, and we want to take very good care of you. We respect you, and we want you to treat everyone on the team with respect,’ can be incredibly useful,” Dr. Fernández said. “Because while there are patients who say things out of extreme bias and hatred, many patients may underestimate how offensive they're being.”

The response from the care team is especially important to protecting trainees, said Sharonne N. Hayes, MD, professor of cardiovascular medicine and director of diversity and inclusion at Mayo Clinic in Rochester, Minn. “Patients who are biased, they know the pecking order on a health care team. They might be all sweetness and light when the attending physician comes in and does rounds, but they may have done something very egregious to other staff members,” she said. “And we see that very frequently.”

Without training, clinicians, including those with trainees, may respond in highly variable ways, Dr. Weeks said. For example, during her residency, she and a Muslim-American intern were taking care of a patient who would comment that people who practice Islam are terrorists.

“We mentioned it to our attending, who was just kind of like, ‘You know, sometimes people say things that are off-color, and you can't take it all seriously,’ but it bothered both of us,” she said. She later learned that other attendings were more vocal and would support their residents through having a conversation with the patient.

Not every hospitalist attending will feel comfortable explicitly setting boundaries with a patient on behalf of a trainee, but guidance, training, and practice can help, said Dr. Hayes. “This is the perfect thing for a simulation, honestly, because it doesn't naturally come out of your mouth to do this,” she said.

Mayo uses the SAFER acronym to help physicians remember how to set limits and take action: Step up, Address the inappropriate behavior, Focus on our values, Explain expectations and boundaries to the patient, and Report. Dr. Hayes also recommended that hospitalists who practice in a learning environment explicitly tell learners that they can come talk about such situations, even if they feel uncomfortable.

She said, “How I do it is, ‘When you're on my team, you're going to be treated with respect, whether it's by nursing staff or by the patients. So you let me know if you need any help in that regard. I'd like to hear, because I stick up for my team.’”

Hospitalists can also benefit from talking with peers after experiencing bias. “Physicians who don't talk about it, even to each other, miss the opportunity to bring these comments and circumstances more to the surface to allow them to be managed,” Dr. DeCamp said. “Managing the situation by internalizing it and not talking about it with colleagues may not be the best approach.”

What the law says

When out with physician friends one day, Kimani Paul-Emile, JD, PhD, professor of law at Fordham University in New York City, said she heard something unusual.

“One of them said, ‘Today I had a patient who rejected me because he said, ‘No Asian doctors.’ My friend was put off by it, but he said . . . it was just part of the job, and it happens to physicians of color,” she recalled. “I said, ‘This wouldn't be tolerated in any other profession. It would violate a whole host of workplace discrimination laws.’”

While physicians have an ethical duty to treat patients, they also have employment rights. Under Title VII of the Civil Rights Act of 1964, physicians have the right to a workplace free from certain types of discrimination, including on the basis of sex, race, religion, and ethnicity, Dr. Paul-Emile said.

“So if a patient or a number of patients continue to discriminate against a particular provider, the obligation is the institution's,” she said. “How they respond is what's important because if they don't respond or respond poorly, then they could be liable for creating a hostile work environment.”

Nurses in nursing homes and hospitals have sued for this kind of discrimination, Dr. Paul-Emile reported. In one case, a black nurse in 2013 sued a Michigan hospital after a supervisor agreed to a man's request that no African-American nurses care for his newborn (he allegedly showed the supervisor his swastika tattoo as well). The lawsuit was settled but was followed by similar allegations of discrimination by black nurses.

Dr. Paul-Emile hasn't uncovered any such cases by physicians in her research. “What I found was that physicians weren't being forced to accommodate these patients; they were deciding amongst themselves whether and under what circumstances to accommodate,” she said.

Dr. Paul-Emile said all hospitals should have policies in place to address biased patient behavior. “And more and more are because they're seeing more and more of it,” she said.

The ways hospitals manage biased patient comments and requests for physician reassignment vary. In the WebMD/Medscape survey, only 15% of physicians said their institution provides formal training on how to handle patients' biases toward them and their colleagues.

Mayo Clinic was an early adopter of a patient bias and misconduct policy, which went into effect in 2017. The policy outlines when patient or visitor behavior becomes harassment and gives the care team the ultimate decision-making power on requests for physician reassignment, said Dr. Hayes.

Mayo also developed a reporting structure for this type of behavior in 2017, although it's still grossly underreported for a variety of reasons, she said. “If it hasn't been acted upon, people feel like, ‘OK, I guess this is maybe part of what I have to put up with to work here,’” Dr. Hayes said. “We [also] go into health care for compassion and to care for people, so most of us will put up with a lot from patients. We shouldn't have to.”

Dr. Hayes recalled giving a talk in 2018 to about 50 chief medical officers and chief nursing officers about patient bias and misconduct. “I said, ‘How many of you have seen an uptick in this over the past couple of years?’ Every hand went up,” she said. “Because of the national discourse that has got people just saying what they want and need . . . I think people are feeling emboldened to ask for things that they knew were ‘politically incorrect’ previously.”

At the same talk, Dr. Hayes asked how many hospitals had a policy to address patient bias and misconduct. Other than Mayo, only two did, and at that point, none of the hospitals had had the policy in place for more than a year. Now, though, more and more institutions are developing such policies, she said. “There are dozens of hospitals and hospital systems that have reached out to us or who are actively working on them . . . so it's very top of mind,” Dr. Hayes said.