In 2013, in her new role as supervisor to an intern in the emergency department, Emily Whitgob wanted to ensure a positive experience for her trainee. However, she found her ability to do so was challenged when confronted with an awkward situation her intern had with a patient’s family member.
“She came back after seeing a patient and was telling me about the child and the child’s family,” explains Whitgob. “The medical problem was very well controlled, and she said, ‘By the way, the father looked at my name badge and asked me if my last name was Jewish.’” The father proceeded to tell the intern that he didn’t want a Jewish doctor because he was from Palestine. “I gasped,” Whitgob says, “thinking what do I do now? How do I make this intern feel safe? This was not something I had experienced before. The first thing I thought of was [taking her place].”
Although the intern was in fact not Jewish and said she was comfortable continuing to work on the patient, Whitgob, MD, MEd — who is a medical fellow in the Department of Pediatrics at Stanford University Medical Center — was shaken by the incident. Yet, experiences like this are not unique for healthcare professionals today.
In a 2017 survey of more than 800 U.S. physicians conducted by WebMD and Medscape, 59 percent reported hearing offensive remarks from patients about personal characteristics in the past five years, mostly regarding a provider’s age, gender, race, or ethnicity. Of those patients, 47 percent requested a different doctor. Additionally, the majority of physicians surveyed said their institutions offered no training or had no formal policies in place regarding how to handle patient bias and discrimination, or they were unaware of such policies.
Some medical centers and hospitals have even noticed an uptick in this type of behavior by patients as of late, which some attribute to the biases personally expressed by President Donald Trump.
While much research, literature, and education have been dedicated to addressing bias directed toward patients from providers, the opposite problem.— bias and discrimination from patients.— is rarely researched and less often discussed in health professions schools and medical institutions.
“This is a new area. I think it’s very important and even harder to control,” says Whitgob. “We can try our best to train practitioners … and let them know what bias means, but we can’t train our patients. We cannot control who walks in the door.”
Finding very little information on this issue, Whitgob decided to do her research project for residency on this topic. In hopes of informing how trainees, faculty, and providers could best respond to situations of patient bias, she and two of her colleagues interviewed a sampling of pediatric faculty leaders at Stanford in 2014. Individuals were asked how they would respond to scenarios involving discrimination against trainees based on race, gender, and religion.
“Participants wanted trainees to feel empowered to remove themselves from care when necessary but acknowledged that removal was not always possible or easy,” the study states. “Nearly all participants agreed that trainee and faculty development was needed.”
According to Whitgob, four key themes emerged from the interviews, which in turn led to the development of a four-step approach for providers confronted with discrimination or bias: 1) in an emergency, ignore such comments; 2) focus the encounter on the shared goals of treatment; 3) depersonalize the event; and 4) foster a community of support within the hospital.
In addition to this research, in 2015 Whitgob and her colleagues surveyed all pediatric residents at Stanford and discovered that not only had 15 percent of respondents personally experienced or witnessed mistreatment, but 50 percent reported not knowing how to manage these instances when they occurred.
“I think people have been taught over the years to just swallow [these situations] and move on,” says Whitgob, “and we’re trying to make it something that providing patient care doesn’t mean that you have to be disrespected.”
Despite the critical nature of these issues, many health professions organizations and agencies — such as the Association of American Medical Colleges, the American Association of Colleges of Nursing, and the American Dental Education Association — do not have specific guidelines or policies in place requiring that schools train students how to respond to patient bias or discrimination. Additionally, the majority of health professions schools don’t appear to address such situations in their curricula, and hospitals and other healthcare facilities rarely have policies in place dictating how providers should handle incidents.
However, one institution that’s been proactive in this area is Penn State College of Medicine and Penn State Health Milton S. Hershey Medical Center. In a push by Dean of Penn State College of Medicine A. Craig Hillemeier, MD, the board of directors approved a patients’ rights and responsibilities policy in May meant to affirm the institution’s commitment to its medical staff.
“The policy provides that our expectation is that patients do not discriminate against our employees because of an aspect of diversity,” says Lynette Chappell-Williams, JD, chief diversity officer and associate dean for diversity and inclusion. “It also provides that we will not honor patient requests for a change of provider based on race, ethnicity, religion, sexual orientation, or gender identity and that we will only honor [such] requests based on gender when there are extenuating circumstances, such as religious requirements.”
Following the implementation of the policy, Chappell-Williams invited Whitgob to come share her research with senior leaders at Penn State to help inform how the institution will move forward, which Chappell-Williams says may involve developing a mechanism to track incidents of patient bias and requests for a change of provider. Whitgob also met and reviewed her research with students, as well as provided strategies, including her four-step approach, for how to respond to such occurrences. In addition, Penn State implemented training for students, led by Kelly Holder, PhD, director of the Office of Student Mental Health and Counseling, who shared strategies on caring for oneself after experiencing such instances.
At the medical center, all nurses are made aware of the patients’ rights and responsibilities policy during new-nurse orientations, as well as receive brief guidance around how to intervene when situations occur. This inclusion intervention, as Penn State calls it, is designed to help employees who witness the mistreatment of a colleague by a patient or their family members, Chappell-Williams says.
“We used the bystander intervention that’s used in sexual assault cases as the model for that, but we modified some of the scenarios to relate to patient bias,” she explains. “Our hope is that [colleagues] will step in and ask the patient why they are asking for a different provider, that they will share that this is an individual who is very qualified — someone who they would want their own family member to see — and that in talking with [that provider] afterward, not downplay the incident.”
Chappell-Williams believes the existence of such a policy benefits not just students and medical staff, but also the institution as a whole, and that it will ultimately help Penn State attract and retain top talent. “Because of our commitment to creating an inclusive environment, we thought it was the right approach from a retention perspective and from a patient care perspective to implement this,” she says. “It’s important that we value our medical staff.”
“They appreciate the fact that we have the policy and that we’re providing techniques for how to address the situation,” she adds. “If a provider doesn’t feel that they are supported by the organization, they’re not going to be fully engaged; then you can potentially have retention problems because they may seek out organizations where they will be supported.”
Rutgers School of Dental Medicine (RSDM) has also begun to delve into the issue of patient bias and this year began conducting small-scale training around managing such situations. Through case scenarios, students are educated on how to deal with bias and discrimination, says Rosa Chaviano-Moran, DMD, assistant dean of student admissions and recruitment.
“Most diversity training … is focused on healthcare providers’ assumptions and biases toward their patients. At RSDM, we know that the reverse can also be true.— and rather prevalent as the healthcare workforce becomes more diverse,” she says. “As we discuss with our students strategies to enhance cross-cultural skills in the delivery of … care and how to reflect on our cultures and assumptions, we [examine] scenarios [regarding] how patients and dentists can have different perspectives, values, and beliefs about health and illness and how that may impact the delivery of care.”
Considering that patient bias is a new area of focus in healthcare, developing training and policies around it currently requires a certain amount of ingenuity. “There isn’t anything out there in terms of how to approach it, so we are sort of navigating very uncharted territory,” says Chappell-Williams.
However, according to Kimani Paul-Emile, PhD, JD, an associate professor of law at Fordham University, this is an area that many institutions across the country, particularly large teaching hospitals, are currently grappling with. Having expertise in law and biomedical ethics as well as anti-discrimination and health law, she has researched and written extensively on topics related to patient bias. The matter, Paul-Emile indicates, is not an easy one to address.
“These issues raise many thorny, legal, ethical, and clinical challenges for patients, providers, and healthcare institutions,” she says.
In an article she co-authored in The New England Journal of Medicine titled “Dealing with Racist Patients,” Paul-Emile details the legal considerations and implications of addressing incidents of patient bias. The most important thing in these situations, she says, is balancing provider and patient rights.
Providers have the right to a workplace free from discrimination, according to Title VII of the Civil Rights Act of 1964, and institutions that force doctors to “accede to a patient’s request for reassignment on the basis of a worker’s racial or ethnic background may violate Title VII,” the article states. This — along with providers being forced to continue to see patients who have discriminated against them — is an area that can lead to lawsuits by employees.
“A challenging scenario might involve a physician who decides, ‘You know what, I don’t want to be reassigned. This happens more often than I would like, and if I were to step aside, I would never see patients.’ If the hospital were to continually mandate that the physician refrain from treating such patients, then it could run afoul of antidiscrimination laws,” explains Paul-Emile.
She says that doctors and trainees need to be allowed — and empowered — to make their own decisions as to whether or not they want to continue to see a patient.— for many reasons. “There’s the reality that physicians are sued all the time, even when things go right,” Paul-Emile adds. “So if a patient doesn’t like the assigned physician, rejects him or her, and then something goes wrong, the patient may be more likely to sue the physician.”
While patients have the right to request a different physician, hospitals also have the right to refuse such requests. Where things get more complicated is in the emergency room.
The Emergency Medical Treatment and Active Labor Act requires that “hospitals evaluate people who come to the emergency room to see if they have an emergency condition and provide stabilizing treatment, if necessary,” explains Paul-Emile. “The law was created to prohibit hospitals from dumping patients based on their inability to pay; however, it could raise challenges for a hospital that has a patient who needs to be stabilized but who says, ‘I don’t want the assigned doctor.’”
“Patients are going to be making these requests, so prevention is impossible,” she adds. “The question then becomes, how should hospitals and healthcare workers respond?” Paul-Emile recommends that doctors consider several key factors when determining whether or not to accommodate a patient’s request for a new provider. The first step is assessing the individual’s condition.
“If the patient requires stabilizing treatment, then the physician may look to see if there’s a nurse or resident who is of a race or background that’s acceptable to the patient and have that person conduct the initial evaluation, while making clear to the patient that this is outside of the standard of care and that the doctor is still in charge,” explains Paul-Emile. Additionally, she recommends that providers attempt negotiation and persuasion before resorting to accommodation. However, “if the patient is cognitively impaired,” she says, “then the physician might have to accommodate his or her reassignment demands.”
When it comes to developing policies around how to handle instances of patient bias and requests for accommodation, Paul-Emile emphasizes the importance of being flexible in order to “fully address the ways in which bias operates in medical practice.” At times, what we may think is bias is something else entirely.
“Many studies show that medical practice remains rife with implicit racial bias, so I can envision a scenario where an older black patient who has experienced several instances of discrimination and ill treatment by non-black physicians says, ‘I really want a physician who will show me respect, whom I can trust, who will listen and understand my concerns, and in my experience, I’m more likely to get that with a black physician. So if I can’t get a black physician, I’m not going to the hospital,’” Paul-Emile explains.
“Gender concordance comes from the same types of sensibilities,” she adds. “Some female patients might want a female physician who they believe will understand their concerns, whom they can trust. Because trust is such an important element in the physician-patient relationship, I would advise a protocol with more nuance.”
While Paul-Emile believes it is critical to consider each case individually and to allow healthcare professionals to make their own decisions, she also thinks it is important for medical institutions and schools to have policies and training in place. “Many medical schools have scripts for training future doctors on how to deal with difficult or challenging patients — why not have [one for] the racist patient?” she says, adding that nowadays, this type of training is more critical than ever. “In this new political climate, it seems like people feel freer to express their racial opinions and biases, and I think that is also coming into play.”
In Whitgob’s experience, many healthcare professionals want this type of training. “In an academic [health] center, people often don’t want one more training module, one more lunch-time lecture,” explains Whitgob. “But everyone we spoke with said, ‘No, we would really like to have more training on this because we see the need for it; we see that it’s a problem, and we don’t know how to make it better.’”
She believes health professions schools should be facilitating these discussions early and often — “in the orientation to medical school, in the orientation two years later when you’re starting clinical rotations, and then at the beginning of your intern year, all the way through,” says Whitgob. “[I’m] not just talking about medical doctors; this also extends to anyone in nursing, social workers — anyone who is providing patient care.”
Alexandra Vollman is the editor of INSIGHT Into Diversity. Penn State College of Medicine and Penn State Health Milton S. Hershey Medical Center is a 2017 INSIGHT Into Diversity Health Professions HEED Award recipient. Lynette Chappell-Williams is a member of the INSIGHT Into Diversity Editorial Board.