Oct. 18, 2017 -- A majority of health care professionals -- including doctors, nurses, and physician assistants -- say patients have made offensive comments to them based on their age, gender, ethnic background, race, weight, or other personal traits. And nearly half have had a patient request a different doctor because of characteristics like these, finds a new WebMD/Medscape survey done in collaboration with STAT.
The survey, Patient Prejudice: When Credentials Aren’t Enough, includes nearly 1,200 doctors and other health care professionals and more than 1,000 patients.
Most of the bias documented in the survey toward health care professionals over the past 5 years was based on visible features. The most common areas include age, gender, ethnicity, race, and weight.
- Women (41%) were far more likely to experience bias about their gender, compared with their male counterparts (6%).
- Women were also more likely to hear comments about their age (36%, vs. 23% of men), and their weight (15%, vs. 9% of men).
- Doctors under the age of 34 -- both men and women -- were more likely to hear negative comments about their age (54%).
- African-American (70%) and Asian doctors (69%) were more likely to hear biased comments from patients.
- Male doctors most often report hearing biased remarks about their ethnicity (24%) and age (23%). Men are also more likely to hear remarks about religious bias (15%) than women doctors were (8%).
Experts say that bias in hospitals and clinics isn't isolated or unique.
"Health care isn't different than other domains of life and service where these types of experiences are unfortunately part of our everyday lives," says Sachin Jain, MD, a practicing physician and an adjunct professor of medicine at Stanford University in California.
Yet when it happens in a medical setting, the consequences can be more serious.
Jain was finishing up his residency at a Boston hospital in 2012 when he encountered a patient who was upset that the hospital's pharmacy didn't stock his brand of insulin. When Jain tried to offer a solution, the man yelled, "Why don't you go back to India!" Jain, who was born in New York, said he "exited the room in a cold sweat" and transferred the patient to another doctor.
"I think medicine is a profession that requires you to give your soul and develop a therapeutic bond with someone," he says. "If someone has a hateful perspective towards you, it naturally gets in the way of your ability to deliver that kind of care, because you're not necessarily able to develop that therapeutic bond."
He stresses that most patients never express biased views or behaviors. "But over long careers, these types of episodes do happen. And they sit with doctors for a long time."
Those experiences also stay with the nurses who encounter them -- including Valda Boyd Ford, a registered nurse.
Ford says that on her first day of work at a Jacksonville, NC, hospital, a patient told her to "get my black [email protected]# out of his room."
"It felt ugly, but I didn't have a choice. I had to go back in there. That particular day, we were swamped," she says. "Even though I wanted to cry … I had a job I had to do, and I did it."
Nurses may be even more vulnerable to abuse than doctors because of the extra time they spend with patients. "The doctors may be in the room for 3 to 5 minutes. The nurses can be in there for an hour or more," says Ford, who is founder and CEO of the Center for Human Diversity. The center aims to improve communication between people of different racial, ethnic, social, and cultural backgrounds.
The survey found that nurses (23%) and nurse practitioners (18%) were more likely to hear comments about their weight than other health care professionals.
Incidents of bias in health care settings have also attracted attention thanks to social media.
Last summer, a video circulated on the Internet of a woman demanding a "white doctor" for her son at a Canadian walk-in clinic. The woman asked an employee, "Can I see a doctor please that's white, that doesn't have brown teeth, that speaks English?"
Security escorted the woman from the building, and a doctor treated the child.
Tamika Cross, MD, an African-American doctor who volunteered to help a sick patient on a flight, says she was told by a flight attendant they were looking for “actual physicians or nurses.”
“Whether this was race, age, gender discrimination, it's not right,” Cross wrote on a Facebook post detailing the incident.
Bias: The Patient’s Experience
Bias can go both ways.
Eleven percent of patients who had visited a health care professional in the past 5 years said they had heard offensive remarks from them. While that percentage is much lower than for health care professionals, the two don’t provide a valid comparison. That’s because most doctors see hundreds of patients over the course of 5 years, while most patients may see only a small number of doctors.
A Medscape survey earlier this year found that 50% of doctors said they had biases toward specific groups of patients. Korean, Vietnamese, and Japanese doctors were most likely to say they had biases. Among doctors who admitted they had biases, the most common types were overweight patients, those with perceived emotional problems, and those with perceived low intelligence.
The patient survey also revealed that at times, people do show bias in their choice of doctor or other health care professional.
Nearly one-third (29%) say they would be inclined to avoid a health care professional based on personal characteristics. When choosing a primary care doctor, women (28%) are more likely than men (12%) to say they prefer a woman like themselves. After gender, consumers are more likely to prefer a primary care doctor with the same:
- Sexual orientation (11%)
- Ethnicity (8%)
- Religion (7%)
- Political views (6%)
- Race (5%)
But what appears on the surface to be a case of bias might just be a poorly explained preference. For example, a woman could ask for a female gynecologist because she's more comfortable having a doctor of the same gender perform her pelvic exam. An African-American or Hispanic patient might request a doctor of the same ethnic background because they've had negative experiences with doctors of other ethnicities in the past.
When patients request another doctor based on personal characteristics, most of the doctors surveyed (72%) said they comply. Yet the doctor that patients end up with might not have the ideal expertise to treat their condition.
When Leon McDougle, MD, was a resident with the Naval Hospital Camp Pendleton's obstetrics unit, he was asked to care for a woman in labor. As he entered the room, "The husband informed me that he didn't want me taking care of his wife. And it was based on race," said McDougle, who is African-American. "What the father didn't know was that out of all 12 interns, I had received the most obstetrical education as a medical student."
Jain says a big challenge in health care is “the notion that all patients and physicians are right for each other.”
“We need to more closely match patients with physicians along a number of dimensions,” he says.
In a paper, Jain wrote that patients may naturally be more comfortable with someone of their own race. Is that bias, or is having a doctor with a shared connection valuable? He cites research showing that patients who have doctors of the same race find their visits more satisfying and are more likely to use health care and seek preventive care.
“If medicine is to truly embrace patient-centered care, we must try to match patients with the physicians with whom they will forge the strongest relationships and attain the best health outcomes,” he wrote.
How Doctors and Patients Respond to Prejudice
Doctors who experience bias are often caught off-guard, because they haven't been taught how to deal with this issue. "It's not a typical part of medical training to know how to respond to hate speech or hateful rhetoric from the patients we serve," Jain says.
The survey found that among doctors:
- 24% have documented an incident of bias on a patient’s medical record.
- 10% have reported the bias to their administration or other authority.
- 9% have refused to care for a patient who expressed bias toward them.
McDougle says when an incident does happen, "you have to take those extenuating circumstances into account when the discussion takes place. Typically it's going to involve a neutral person coming in and talking to that patient and trying to decide the motivation for the request," says McDougle, who is a professor of family medicine and chief diversity officer at the Ohio State University Wexner Medical Center.
Emily Whitgob, MD, of Stanford Children’s Health, says better training in medical school could prepare doctors to handle discrimination when they encounter it. "If you've role-played through what you can do in this setting, when it does happen, you're able to talk to your supervisor, tell the higher-up what happened, and decide what you want to do."
The American Medical Association Code of Ethics says doctors have the right to "Terminate the patient-physician relationship with a patient who uses derogatory language or acts in a prejudicial manner only if the patient will not modify the conduct. In such cases, the physician should arrange to transfer the patient's care."
Yet the medical association acknowledges that doctors' rights are often a sticky issue. "These can be complex situations given the health system's focus on soliciting and honoring patient preferences -- a core tenet of patient-centered care," says Robert Mills, an association media representative.
Just as hospitals have a patients' bill of rights -- a document that guarantees them fair treatment by medical staff -- Whitgob says doctors should have their own bill of rights ensuring fair treatment by their patients. "It's two-way respect. You expect good care and respect. We expect respect in return."
Among the 11% of patients who experienced bias from their doctor, 42% of them said they would not do anything about it. Of the 58% who had or planned to take some action:
- 26% said they changed their health care provider
- 15% confronted the health care provider
- 13% said they planned to change their provider in the future
- 11% wrote a negative review online
- 7% filed a formal complaint
Jain says bias has no place in a medical setting, whether from doctor to patient or patient to doctor.
“Unfortunately, they are a reality for both,” he says. “Health care delivery organizations need to build guardrails that protect both patients and physicians against racism.”