Photo courtesy of Dr Padela graphic from Getty Images
Photo courtesy of Dr. Padela; graphic from Getty Images
Q&A | March 1, 2023 | FREE
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Muslim physicians report significant discrimination

Diversity, equity, and inclusion programs should address religious identity, too, a researcher says.

Discrimination against Muslim physicians in the U.S. has increased in the past decade, a recent study found.

Researchers at the Medical College of Wisconsin and the Initiative on Islam and Medicine compared two national surveys of Muslim physicians, 255 participants in 2013 and 264 in 2021, and found that the more recent sample more frequently reported facing religious discrimination in their career (24% vs. 53%), experiencing job turnover (7% vs. 32%), and having patients refuse their care (9% vs. 33%). The results were published Jan. 4 by the Journal of General Internal Medicine.

While diversity, equity, and inclusion (DEI) programs are becoming more common in U.S. health care systems, religious discrimination continues to be overlooked, said study lead Aasim I. Padela, MD, MSc.

Dr. Padela, a professor of emergency medicine, bioethics, and the medical humanities at the Medical College of Wisconsin in Milwaukee, recently talked to ACP Hospitalist about the study's findings.

Q: Why did you do this study?

A: We thought that comparing surveys from Muslim physicians in 2013 and 2021 would give us a good opportunity to assess whether trends in society—basically, anti-Muslim bias and discrimination—are spilling over into the health care environment. We also did another qualitative study of interviews. These were the goals: See what's happening in terms of time trends, but then also dig deeper into the psychological and professional effects on Muslim physicians and get some real qualitative data that allows us to set up intervention work to better accommodate clinician religious identity in health care.

Q: Did anything about your results surprise you?

A: There's been a rise over the last five to seven years in diversity, equity, and inclusion programming within hospitals, and attention to health equity has really been foregrounded in many institutions. We knew that in society there are large rates of anti-Muslim bias and discrimination, and that Muslims are still a targeted minority, but we thought that the health care system itself and these DEI programs would have some buffering effect and that the 2021 respondents might be a bit more protected. Yes, we expected things to be perhaps somewhat worse [than in 2013], but not to the extent that we found, not on almost every measure of discrimination.

Q: What are some of the potential reasons for the increase that you saw?

A: One reason is societal trends. There's no doubt that the Muslim community has been in the crosshairs for a long time, and there's been more anti-immigrant, antiforeigner sentiment in the United States that's put those who are not White Americans more in the crosshairs. Another thing we mentioned in the paper is that it could be that people who are born in the United States, such as myself, are more sensitized and less tolerant [than older immigrant physicians were], and so therefore they report more discrimination. When someone asks you, “Do you feel discriminated against because of your identity? Have you left a job because of it?”, if you've encountered these things, then you voice them. An immigrant population might not have done so.

Q: What did you make of the finding that although many respondents reported discrimination, more than 70% said their workplace accommodated their religious identity?

A: People interpreted that term “accommodated” very differently. For some people, accommodation means that they can come to work and take time for prayer. For others, it's that their workplace lists a Muslim holiday on the calendar. But a more underlying psychological phenomenon, which I think is much more important to ponder, is that physicians often discount their own experiences of being discriminated against. For example, if there is a Muslim holiday on the calendar, but Muslims can't take that day off, there's a problem there, but a physician might think, “Well, at least it's on the calendar.” There was this huge cognitive dissonance where they disconnected the notion of accommodation from actual inclusive action by the hospital system; from structural policy and pragmatic accommodations.

Q: What would a workplace that is not just accommodating but supportive look like?

A: We developed a policy report that looked at three domains of religious identity that can help drive health equity. One is the domain of observances, where there are policies and support for wearing the hijab, for example. Similarly, we should accommodate the fact that people have different religious holidays and days of significance, and you can take that day off without fear of retribution. You can just tell your supervisor, “I'm taking the day off,” and we will figure out how to cover your clinical schedule.

Another domain is that of practices. For example, for Ramadan fasting, we can flex your time so that you can break your fast, or we can recognize that it might be arduous in the middle of summer to not eat or drink for 15 hours and we're not going to put you on a seven-hour overnight shift. … With these types of policies in place, physicians wouldn't feel singled out, because the hospital is saying, “No, we can accommodate this. This is part and parcel of you being who you are, and we are a work environment that is allowing that to be lived out.”

The other domain was focused more generally on faith. There might be a faith community liaison, for example, that helps both patients and providers first assess what their religious needs are and then help the health care system create programs with strategic allocation of resources and time to support them. If you really want to be living out diversity, inclusion, and equity, this dimension of identity, the religious dimension, cannot afford to be ignored.

Q: Why is religious identity sometimes overlooked in medicine's DEI initiatives?

A: The logical explanation is that the post-enlightenment division between religion and science also happens in medicine. The expectation of physicians, perhaps through the “hidden” curriculum, is to do things in your private space in your own time, and your religious practices are not supposed to be part of your profession. … Whenever religion is thought about in medicine it's in conflict modality, as opposed to the idea that there's any synthesis or integration possible that could make you a better doctor. … Religion is always seen as an opposing force, as opposed to adding a positive force from the physician's side.

Q: How can that be remedied?

A: I think it starts with medical education, really in training. When you come into medical school and the expectations are that now you're in a white coat and everyone's the same, it sets up a conflicted personality. For example, we learn bioethics in medicine, usually in the first two years. Do we talk about religious traditions in bioethics, or wisdom of religious traditions? No, not really. It's all about principles and secular-based ways of managing conflict. Do we have courses on caring for communities that have a religious orientation, meaning when you go out and do community engagement, do you spend time thinking about a faith-based practice of healing? We don't talk about how religious traditions can animate your thinking about virtue and character in the profession of medicine or ethics. We don't think about people's prayer as a modality for them to understand their illnesses. Our model of education and training doesn't accommodate broader worldviews, and therefore it is expected and understood that people who are religiously animated in medicine struggle. Looking at the Muslim population is a good way to evaluate this question, because they're not the dominant religious group, and there are societal issues with what that religious identity means, and it seems like they're struggling even more.

Q: How can health care organizations and individual physicians work toward solutions?

A: When we talk about diversity, equity, and inclusion, we should say, “OK, what are the features of our hospital work staff that they bring in with them?” Based on those features, we can then say, “OK, here's how we can accommodate the dyad, providers and patients.” That could also be a quality health equity marker in our health care system. They're not just patient-driven markers, they're also provider-driven markers, and then religion and spirituality are embedded within those dashboards in both places. If you're aware of something and you start measuring it, that can lead to change.

Lastly, medical education is a way for us to recognize that science and religion both address fundamental questions about the human being: who we are, what is happening to us and why, and where we're going. … We have to see both religion and medicine as explanatory mechanisms. Therefore, when you have a conflict with the patient, don't think of it as a conflict but consider that perhaps there is a way, humbly, to bring those different explanatory mechanisms together and negotiate a good path towards health and wellness for that patient and for the physician. You don't have to divorce your own moral being in that encounter.