Physicians and trainees experience a range of discriminatory patient behavior, ranging from mildly disparaging comments to openly stereotypical comments to refusal of care, according to a study published in JAMA Internal Medicine.

As the health care workforce becomes increasingly diverse and inclusive, the study authors suggest that medical schools and hospitals need to devise institutional policies and training helpful in a clinical environment that respect the diversity of patients and physicians alike.

The novel qualitative study, led by Margaret Wheeler, MD, et al., collected data from 50 individuals (11 hospitalist attending physicians, 26 internal medicine residents and 13 medical students) from 13 focus groups held from May 9 through Oct. 15, 2018 at three campuses affiliated with one academic medical center.

Of the participants, 52 percent identified as women, 44 percent identified as men and 4 percent identified as gender nonconforming. Nearly half (48 percent) were nonwhite.

Researchers found that clinicians experienced a range of biased behavior based on social characteristics, such as race, ethnicity, sex, gender conformity, sexual orientation and religion. These encounters are painful and confusing and influence the professional development of medical students and residents.

Participants in the study who were targets of biased behavior reported an emotional toll that included exhaustion, self-doubt and cynicism, and undermined well-being, learning and occasionally patient care.

Notably, bystanders who were not targeted also reported feeling moral distress because they did not know how to protect their colleagues.

Barriers to appropriate responses included a lack of skills in confronting patients exhibiting biased behavior, lack of support from colleagues and guidance from the institution, and uncertainty about whether responding to these experiences would be perceived as unprofessional. The authors write that "professionalism does not require physicians to readily accept attacks on fundamental aspects of their identity and self-worth."

The authors concluded that institutional guidance for biased patient encounters are needed to protect residents and physicians and to improve the work environment for all. Medical curricula training should equip all physicians with the skills to deal with biased patients and faculty development may be needed.

"Training should focus on both individual and team responses and include setting limits, appropriate deflection, team plans, debriefings, and support for the offended physician or trainee," researchers write.

In a corresponding editorial comment, Lisa A. Cooper, MD, MPH, et al., write, "Physicians and health care institutions must remain committed to the welfare of patients; however, when anyone, including a patient, exhibits biased and disrespectful behavior, silence is not golden. It is tacit approval." They conclude, "We all have the responsibility to speak and act."

"Respect is a fundamental component of effective human interactions, including patient-caregiver communications. In the absence of legitimate concerns (for example religious constraints that preclude examination by a member of the opposite sex or specific concerns regarding caregiver competency), health care delivery is hurt by biases in either direction. This is a two-way street," says Pamela S. Douglas, MD, MACC.

"Caregivers should be provided with the tools to manage disrespectful or biased patients and families, including personal skills, clearly articulated institutional support and bystander training. ACC's Diversity and Inclusion Initiative is planning to address this important issue through an upcoming Health Policy Statement."

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Wheeler M, de Bourmont S, Paul-Emile K, et al. JAMA Intern Med 2019; Oct. 28:[Epub ahead of print].

Keywords: ACC Publications, Cardiology Magazine, Schools, Medical, Focus Groups, Organizational Policy, Students, Medical, Caregivers, Hospitalists, Ethnic Groups, Uncertainty, Delivery of Health Care, Data Collection, Health Policy, Patient Care, Qualitative Research

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