Patients aren’t the only ones who suffer from racial or gender biases; a retrospective survey study found that internal medicine residents frequently experience biased behavior from patients, particularly if they are non-white or female — and the vast majority of these incidents are never reported, researchers found.
The topic of diversity, equity, and inclusion in health care has gained prevalence in recent years, with the American Medical Association (AMA) calling racism a threat to public health as the number of hate groups and hate crimes continues to grow across the U.S. Due to this volatile environment, Alicia Fernandez, MD, of the Department of Medicine in the University of California, San Francisco, and colleagues argued that physicians may be experiencing an increased rate of biased patient behavior, ranging from offensive remarks to outright refusal of care, an issue that poses several clinical and ethical challenges and “can exact a heavy psychological toll on physicians,” they explained in JAMA Network Open.
In order to inform the creation of institutional policies to address these toxic patient encounters, Fernandez and colleagues surveyed 232 internal medicine residents from three health care institutions to assess the frequency of various types of biased patient behaviors and identify how residents typically respond to these behaviors.
The study authors found that “biased patient behavior ranging from belittling comments to refusal of care was experienced or witnessed by nearly all residents. Forty-five percent of Black/Latinx residents experienced epithets or refusal of care, and most women (87%) experienced sexual harassment; however, most residents (84%) did not report these encounters to their institutional leadership.”
“Given this environment, it is not surprising that women and [under-represented minority] URM physicians experience greater levels of burnout, which could lead to them leaving medicine altogether,” wrote Rhonda G. Acholonu, MD, and Suzette O. Oyeku, MD, MPH, of the Department of Pediatrics at The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, New York, in an invited commentary accompanying the study.
A necessary step to addressing workplace inequities for physicians, Acholonu and Oyeku argued, is “recognizing some women and individuals from URM groups feel obliged to be the advocates and ambassadors for [diversity, equity, and inclusion] DEI initiatives and may end up doing an excessive amount of service activities. This is known as the minority tax—the disproportionate responsibility usually placed on individuals from URM groups—which can lead to exhaustion. This is further compounded by the fact that this work is frequently uncompensated and undervalued and, until recently, was not considered in academic promotion and tenure decisions. This is counterbalanced by what is known as the majority subsidy, the perceived addition of time and opportunity that those in the majority have to devote to career advancement.”
For their study, Fernandez and colleagues administered an electronic survey to second- and third-year internal medicine residents at three academic medical centers — University of California, San Francisco; University of California, Los Angeles; and Duke University, Durham, North Carolina. First-year residents were excluded due to their limited interactions with patients at the time of recruitment. Data were collected from August 21-November 25, 2019.
The study authors sent the survey to 331 residents, of whom 232 (70%) responded (116 [50%] women; 116 of 247 [47%] White [participants were allowed to select >1 race/ethnicity]; 23 [10%] identified as lesbian, gay, bisexual, transgender, or queer). Participants were asked to indicate how frequently they experienced belittling or demeaning stereotypes, role questioning, explicit epithets or rejection of care, and sexual harassment, as well as how frequently patients targeted their own social identities and how frequently they witnessed biased patient behavior targeting the social identities of their fellow residents. Respondents were also asked how they responded to these patient behaviors, their prior experience with training on how to respond to these behaviors, and the degree to which they believed training and institutional policies for guiding responses are necessary.
“Nearly all residents (228 of 232 [98%]) reported experiencing or witnessing biased behavior at least once in the past year,” Fernandez and colleagues reported. “The frequency of specific biased patient behaviors varied. A total of 14% of residents (32 of 231) experienced belittling comments at least once a week, 11% (25 of 230) experienced questioning of credentials or abilities, and 17% (38 of 230) experienced assumption of nonphysician status occurring at least once a week. Behaviors reported by one-third of participants as occurring at least once per month included belittling comments (87 of 230 [38%]), assertive inquiries into racial/ethnic origins (75 of 231 [33%]), generalizations about social identity (70 of 231 [30%]), and credential or ability questioning (77 of 230 [34%]). In contrast, epithets, refusal of care, and requests to change physicians were less common yet were experienced at least 1 to 3 times per year by 40% of residents (91 of 230), 30% of residents (69 of 230), and 27% of residents (61 of 229), respectively. Sexual harassment was also common and experienced at least 1 time per year by 60% of participants (138 of 230).”
Women, Black or Latinx, and Asian residents reported higher frequencies of biased behaviors, the study authors found. “Forty-five percent of Black or Latinx residents (17 of 38) encountered instances of explicit epithets or rejection of care,” they wrote. “All 70 Asian residents reported experiencing inquiries into their ethnic origins. Most women residents (110 of 115 [96%]) experienced role questioning behaviors, and 87% (100 of 115) experienced sexual harassment.”
The need to prioritize clinical care (34%) and a sense of futility in responding (25%) were cited as the most significant impediments to responding to biased behaviors. What’s more, 85% of residents never reported these incidents to their institution, and 89% identified training and policies as “necessary or very necessary.”
Due to this lack of reporting, Fernandez and colleagues noted that institutions and residency program directors might not even know how prevalent these incidents are in their facilities.
“At the institutional level, low use of a formal structure to address and report incidents may indicate either a lack of formal reporting processes, a lack of knowledge of existing processes, or a reluctance to engage in these processes for fear of negative repercussions,” they wrote. “This finding should be explored further and clear reporting mechanisms instituted, while recognizing that reporting systems succeed only when institutional culture encourages reporting without fear of retaliation.”
“Leaders of academic medical centers must recognize the microaggressions and subtle indignities that affect their workforce’s daily lives, which are currently magnified by their personal lived experiences,” Acholonu and Oyeku wrote. “Further work is needed to better understand effective strategies that incorporate leadership accountability and the use of resources and data to meaningfully change the workplace environment. Persistent and deliberate actions will collectively move us further along the path to understanding and transformation of the workplace environment for women and individuals from URM groups, with the ultimate goal of achieving equity and inclusion in health care.”
Study limitations included the potential for recall bias in survey responses, the relatively small sample size, and a potential lack of generalizability, as the study authors surveyed residents in three urban areas in two geographic locations and thus the results may not reflect the experience of residents in other parts of the country.
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The vast majority of residents (98%) have either witnessed or experienced biased behavior from patients at least once in the last year, with women, Black or Latinx, and Asian residents reporting the highest frequency of biased behavior, according to results from a retrospective survey study.
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Over 80% of residents surveyed said they never report incidents of racial, ethnic, or gender bias to their institution.
John McKenna, Associate Editor, BreakingMED™
The Greenwall Foundation funded this study and supported efforts of study authors de Bourmont and Fernandez. Co-author Burra was funded by the PROF-PATH Program, University of California, San Francisco Latinx Center of Excellence (HRSA D34HP31878). Co-author Nouri was funded in part by a National Research Service Award fellowship training grant (T32HP19025). Co-author Mohottige was funded by training grant T32-DK007731-22 from the National Institutes of Health, National Institute of Diabetes and Digestive Kidney Diseases. Fernandez was funded by grant K24DK102057 from the National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases.
Co-author Mohottige serves as a member of a cohort of Duke Department of Medicine faculty and trainees who have been trained to offer informal support in response to incidents of bias, harassment, or other unprofessional behaviors and has lectured in grand rounds format regarding the above program (which addresses discrimination, bias, and micro-aggressions and macro-aggressions at Duke University, University of North Carolina–Chapel Hill, and the University of Washington).
No other disclosures were reported.
Cat ID: 925
Topic ID: 915,925,254,438,504,728,791,508,556,730,187,188,118,935,190,127,130,191,138,192,146,195,158,241,925,240,159
