How Best to Care for Biased Patients

I want to kill all the Jews,” shouted the man accused of killing 11 people and wounding seven others in the Tree of Life synagogue in Pittsburgh on October 27, 2018, as he arrived in the emergency room of Allegheny General Hospital in need of treatment after being shot by police. Among the team that treated him were several physicians and nurses who were Jewish, and the president of the Hospital, Jeffrey K. Cohen, MD, a congregant of the synagogue, stopped by the man’s room after treatment to check in on him. “We’re here to take care of sick people,” Dr. Cohen said, as reported in The Washington Post. “We’re not here to judge you.”

This pledge to care for all patients, regardless of bias and circumstance, underwrites the code of conduct and belief that healthcare workers commit to in a profession devoted to caring for people in need. And yet, what do physicians and healthcare workers do when a patient treats them with hostility or resistance because of bias—most often based on race/ethnicity, sex, or religion?

“There is a rising prevalence of explicit acts of xenophobia in the country,” said Howard W. Francis, MD, MBA, professor and chief of the division of head and neck surgery and communication sciences at Duke University Medical Center in Durham, N.C. “We need to be prepared to quickly and effectively address this issue when it arises. To do otherwise will compromise our efforts to build inclusive, diverse, and effective teams.”

A recent poll shows that 70% of African American and 69% of Asian American physicians report they are more likely to hear biased comments from patients, and 41% of women were far more likely to experience bias based on their sex. More men than women are likely to experience bias based on their religion. Although no hard data are available to show whether the incidence of patients expressing biased beliefs toward physicians has increased in recent years or whether the reporting of such incidences has increased, what is known is that the challenge of caring for patients who are biased is emerging as a critical issue among healthcare workers who need to balance their oath of caring for all patients with the need for respect from patients that is required for good medical care.

“In medicine, we have this deep and honorable value in taking care of all people no matter what their beliefs are, where they are from, what they say, or even what they do,” said Margaret L. Plews-Ogan, MD, associate professor of clinical internal medicine in the department of medicine at the University of Virginia Health System in Charlottesville, Va. “Unfortunately, however, that can also translate into not directly confronting patients when they exhibit disrespectful and, in some cases, racist and sexist behavior because we’re held back by the belief that we should care for them no matter what.”

“The solution cannot be isolated to the potential victim of racism but must represent a unified front by administration, senior physicians, and nursing that reflects the values of inclusion and mutual respect of the organization.” —Howard W. Francis, MD, MBA

“So we need to figure out a way to carry out both of those values, how to create an environment of respect where everyone is treated with respect and also one in which we care for people who have very different beliefs from us,” she said.

Physicians in Training: A More Diverse Profession

Although the opening scenario may be extreme, shared to dramatize just how challenging it may be to care for a racist patient, a far more common scenario in daily clinical practice is the patient who questions the credentials of a physician, often one in training and often based on race/ethnicity or gender, or asks to be treated by a physician who looks more like them.

“Things that happen commonly are that a medical student, resident, or fellow as part of a training team, a person usually with a darker skin tone, will be singled out by a patient and asked where they are from and where they received their training,” said Kimberly N. Vinson, MD, assistant professor of otolaryngology and assistant dean for diversity affairs at Vanderbilt University Medical School in Nashville. “It all kind of boils down to [the fact] that, [for some patients], unless their doctor looks like them, the patient thinks the doctor is not educated or equipped enough to take good care of them.”

Dana Thompson, MD, MS, chief of pediatric otolaryngology and professor of otolaryngology–head and neck surgery at Northwestern University’s Feinberg School of Medicine in Chicago, who, after more than 30 years of practicing medicine, said she could write a book about her experiences of racial and gender bias as a black female surgeon, said that she sees three trends in patients who are uncomfortable with being treated by a physician whose appearance differs from theirs: those who are surprised or intrigued by the difference and express curiosity about the physician’s background, those who have implicit bias without overt anger but say insulting things like, “I am not used to seeing a black doctor,” and those with explicit bias who show mean-spirited behaviors and beliefs that may be fueled by intrinsic racism.

For institutions, Dr. Thompson emphasized the need for cultural training and full support for trainees who may find themselves in a situation with a biased or racist patient. “Supporting trainees when it happens is necessary, and having immediate debriefing and a show of support to the trainees is essential,” she said. “How we show support or do not show support models the behavior and response moving forward.”

Both Drs. Vinson and Francis also emphasize the importance of faculty and staff support of these physicians in training. “Everyone should be aware that certain members of our specialties do deal with these things and [should] be supportive when their colleagues are in these situations,” said Dr. Vinson.

Dr. Francis was even more pointed. “The solution cannot be isolated to the potential victim of racism but must represent a unified front by administration, senior physicians, and nursing that reflects the values of inclusion and mutual respect of the organization,” he said.

Addressing the Problem

All sources underscored the importance of addressing this problem and not “sweeping it under the rug,” as Dr. Francis phrased it. Although physicians may have ignored biased comments in the past, the younger generation, who are more diverse and less tolerant of biased behaviors, seems to be leading the drive to more directly and systematically address how to deal with a patient who exhibits biased beliefs and behaviors.

According to Dr. Vinson, medical students are driving the awareness of the issue and conversations about it at Vanderbilt University. “I think there is a generational difference in how people respond to these things,” she said. “The younger generation has lived a life in which they haven’t seen blatant racism, so I think it is eye opening to them that someone would make a racist comment or demand to be treated by a physician of a different race.”

To help medical students and other physicians in training, Vanderbilt recently held a medical center-wide forum in which the administration discussed ways to deal with harassment from a patient. One way is for physicians in training to stand up for themselves and be honest about their credentials, said Dr. Vinson. Another avenue they are exploring is making the code of conduct physicians are expected to follow as visible as the code physicians have for patients. Fundamental to this code is mutual respect.

At the University of Virginia Health System, the administration has taken an even more systematic approach by developing a protocol, BEGIN (Breath, Empathy, Goals/values, Inquire, eNgage), that it hopes other institutions may be able to adopt. The protocol is built on a framework informed by the best available evidence on good interpersonal communication and focused on achieving a successful outcome.

“We’re trying to help people to have compassionate interactions with patients, where they can achieve the respectful outcome for everyone,” said Dr. Plews-Ogan. “A lot of our focus is to try to state clearly our values, without breaking the relationship, but trying to figure out ways to repair or strengthen the relationship.”

“This is the best outcome of all,” she said.

All medical faculty and staff are trained in using BEGIN in workshops designed to simulate a patient/physician encounter. Workshop attendees engage in role playing, using the acronym to become more comfortable with and proficient in creating the kind of interaction with the patient that will, hopefully, result in a better relationship, one in which both physician and patient stretch beyond themselves to understand better the differences that undergird racist behavior and beliefs.

To date, 10 workshops have been conducted over the past two months. Dr. Plews-Ogan said that the faculty and staff are still learning a lot about what makes an interaction more effective. “We have some promising data from a pilot study to suggest that people [who have undergone the training] do feel more comfortable when they are stepping into a situation that is a very tough circumstance to step into,” she said.

Dr. Thompson also emphasized the importance of compassion and engaging patients in understanding the their fears, being aware that fear is usually the foundation of bias. “I generally ask what their concerns are and try to understand if [their biased statement] is a statement of fear at a time when the patient feels vulnerable,” she said. “I often will engage in a conversation, allowing them an opportunity to see another physician and also letting them know I care and I am qualified.”

Some humor also may help, she said, particularly in patients who are curious and show implicit bias. For some patients with explicit bias, however, she said the best recourse may be to get them a physician they are more comfortable with if they still show mean-spirited beliefs or behaviors after the physician has tried to understand their fears. “I am also human, and persistent mean-spirited and racist comments feel like attacks and can disrupt the bond of the patient–physician relationship that is necessary for patient-centric health care,” she said.

According to Dr. Thompson, in a specialty such as otolaryngology, in which minority physicians are underrepresented, it is easier to find a replacement for a patient who prefers a white doctor and, perhaps, a white, male doctor. “Any underrepresented minority physicians in otolaryngology really stick out to non-minority patients,” she said. However, she added, “When a patient questions my ability based on gender or race, I find speaking to my credentials, skill, and experience with confidence helps.”

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Mary Beth Nierengarten is a freelance medical writer based in Minnesota.