Treating Patient Bias
For years, tolerating racism or other bigotry from patients was just another part of a doctor’s job. But such allowances can do more harm than good — for everyone
Early in his clerkship, Dr. Amr Hamour was in a rural family medicine rotation in Alberta when he overheard an in-patient tell a nurse that he hoped “to never see that crow again.”
It was a word that Dr. Hamour had never heard before. A Google search confirmed what he suspected — a racial epithet targeted at Black and Indigenous people.
For the next two weeks, the young trainee cared for the elderly patient. He never addressed the slur with the patient — or, indeed, anyone on the medical staff, including the nurse — and strived to give the patient the same quality of care he gave every other patient, even as he felt the patient’s antipathy towards him.
“It was extremely challenging, especially as a learner, when you are just not equipped to deal with that behaviour,” Dr. Hamour, now a resident in Otolaryngology — Head & Neck Surgery at the University of Toronto, recently told Dialogue after writing about the incident in the CMAJ Blog. “Here I was, so eager to learn how to be the best doctor for him, and this was the response I was getting,” he said.
The very first time Dr. Jillian Roberge took a patient history as a medical student, she was met with a bigoted response. As she greeted the patient, he remarked that he was pleased she was White as he was put off by the number of non-White students being accepted into medical schools. She told him that she was, in fact, Métis. That detail changed the patient’s demeanour and he accused her of not getting into medical school on her own merit.
When facing or witnessing biased patient comments or behaviour, “no one quite knows how to respond. There just is no playbook,” said Dr. Roberge, now an emergency physician in Hamilton. Words that one might use to confront a colleague who has demonstrated discriminatory behaviour can land very differently in a conversation with a patient, given the inherent power differential and the need to ensure a patient does not feel abandoned.
CPSO’s mandate is to regulate physicians in the public interest, but there are good reasons — ones that fall within our role as an advocate for quality patient care — for us to be concerned when patients target physicians with abuse. A 2019 study, which appeared in the Journal of the American Medical Association, sought to understand the effects of abusive patient encounters on physicians and trainees. The biased patient behaviour ranged from belittling comments to outright rejection of care, leaving physicians and trainees to deal with the emotional toll.
The study — called “Physician and Trainee Experience with Patient Bias” — found emotions linked to physician and trainee burnout, such as emotional exhaustion, fear, self-doubt and increased cynicism, were common responses and those emotions lingered long after the event.
Over the last two years, CPSO’s Dialogue magazine has addressed the concerning health consequences when physicians perpetuate bias against their patients. But CPSO also recognizes that attention must be paid when physicians themselves are the targets of bias, and attempts are made to diminish their self-worth and assail their identity. Physicians are, it goes without saying, owed respect in the workplace, and should be regarded with the same inherent value as any person. Much is expected of physicians as professionals, and they deserve to work in an environment that is free of biases, stereotypes, racism, and discrimination.
CPSO also needs to pay attention to the issue of patient bias because of its potential effect on patient care. Regular encounters with patients who are discriminatory can see some physicians experience burnout. Physicians with burnout are more likely to leave practice, which reduces patients’ access to and continuity of care. Dealing with biased or racist patients can also cause physicians to suffer other effects of burnout such as impaired attention, memory, impaired attention, memory, and executive function, leading to poor interactions with patients.
The Duty to Care
The duty to care for all patients is central to the health profession. But both Drs. Hamour’s and Roberge’s encounters capture the stress physicians experience as they take care of patients who don’t want them as their doctor — for reasons that have nothing to do with the quality of care they provide and everything to do with their race, ethnicity, sex, religion, sexual orientation or other aspects of their identity.
Patients are at their most vulnerable when they are sick and physicians know that professionalism requires them to accept a broad range of human behaviour in response to illness. But while difficult patient situations are part of every physician’s working life, some situations can drift into the realm of physician abuse.
A viral video that captured a parent’s racist rant at a Mississauga walk-in clinic four years ago certainly awakened Ontarians to the issue. The video showed an angry woman refusing the physician assigned to her young son’s care. She stood at the front desk, and demeaned the doctor’s appearance and his accent. She insisted her son be treated by a White physician instead. The behaviour was loudly denounced in many quarters and prompted a statement from the then Minister of Health. But many doctors recognized the behaviour, knew it was hardly an isolated event and said very little, even in response to media questions.
Dr. Cécile Bensimon, Director of Ethics and Professional Affairs at the Canadian Medical Association, said the video, while shocking, was not surprising. “I don’t know how often (CPSO) hears about this kind of behaviour, but we certainly hear about it. And it’s a lot more common than anyone wants to admit.”
In a recent survey of Black physicians and trainees in Ontario, more than 70 percent of respondents reported negative experiences based on their race. The study, which appeared in the Academic Medicine journal, found Black physicians were regularly mistaken for floor aides, housekeeping, personal support workers or nurses. They also expressed various experiences of being “othered”— repeatedly being asked where they were from, even when they were born in Canada. Some respondents to the survey wrote that they felt as though their competence was occasionally called into question with patients not on board with their plan until a White physician agreed with it.
A few survey respondents say patients walked out of a room, or asked for a “lighter doctor,” with one recalling a patient protesting, “I don’t want that N– – – – – – taking care of my kid.”
The participants also reported a lack of action when experiencing prejudice or racism in the presence of their White peers or supervisors. After a patient made a racist comment in front of one respondent and their preceptor, the respondent wrote: “My White preceptor apologized to me after, but didn’t say a word to [the patient]. I will never forget the way I felt having to be in that room.”
For years, tolerating patient bias was simply seen as part of providing care in hospitals. In fact, if a patient requested a change in physician for reasons that only had to do with bias, medical staff would most likely make efforts to accommodate the patient. But a 2016 article in The New England Journal of Medicine called “Dealing with Racist Patients” suggested, perhaps for the first time, that acceding to race-based reassignment demands could do more harm than good for physicians and patients alike.
The lead author of that article is Dr. Kimani Paul-Emile (PhD), a professor of Law at Fordham Law School’s Center on Race, Law and Justice. In a recent interview with Dialogue, she discussed what prompted the article. “I was having lunch with friends who were clinicians and one of them started discussing this experience that she had [of a patient requesting another doctor based on bias], and I was just stunned that it was accommodated by the hospital.”
In her investigation of the issue, Dr. Paul-Emile found it was an open secret that patients routinely refused treatment based on the assigned physician’s racial identity, and how typically medical staff yielded to patients’ racial preferences.
“Competent patients have the right to refuse medical care, including treatment provided by an unwanted physician, but the willingness to accommodate patients’ racial preferences with respect to their choice of physician raises all sorts of concerning ethical, clinical and legal issues,” said Dr. Paul-Emile. And in yielding to such patient requests, hospitals run the risk of appearing to be complicit in bias, thereby compounding the pain, confusion and internalized suffering of the physicians involved.
Accommodation also presents a risk to quality care. “Besides fueling burnout, it can threaten the therapeutic alliance necessary for the provision of care, undermine clinical standards and hinder workflow, even jeopardizing the care of other patients,” said Dr. Paul-Emile.
Over the past several years, she has been called on to speak at grand rounds in different hospitals about the issue. Hospitals, she said, want to keep their talented physicians of colour on staff, and are now realizing that if they feel demeaned and unsupported, they won’t stay.
“Under the best of circumstances, the practise of medicine is a very difficult job. Then you throw in a level of discrimination and hostility from enough patients with bias, and you can see why a lot of health care professionals would despair. I can see how discrimination could drum certain demographics right out of the profession,” she said.
A perfect storm of factors is putting the issue at the forefront for many hospitals, she said. An increasing percentage of patients have felt emboldened to freely express prejudices they may have kept hidden in a different political climate. The physician population in North America is becoming more racially and ethnically diverse, which may also trigger an increase in race-based reassignment demands. And a societal shift, led mostly by younger physicians, is demanding change.
“I think they have a much more capacious idea of equality and equal treatment as it pertains to women’s rights, gay and lesbian rights, trans rights and racial justice,” said Dr. Paul-Emile, “and I think they understand that we need to strike a better balance between patient autonomy, the rights of medical personnel and the duty to treat. Acceptance of biased patient behaviour is just not a defensible norm for hospitals any longer.”
That was certainly the determination that the Mayo Clinic came to in 2018. The environment created by patient bias was becoming so toxic that ignoring the situation was no longer an option.
With an increasing number of patients requesting physicians with or without specific personal attributes, Mayo convened a working group to investigate the issue. The group conducted a survey to determine the extent of the situation. It found:
- 17 percent of staff who reported being targets of patient misconduct stated they considered leaving their department or leaving Mayo Clinic.
- 80 percent of respondents reported bringing the stress of these incidents home with them.
“It was becoming evident that the effects on staff were significant,” said Dr. Anjali Bhagra, the physician tasked with helping eliminate racism at Mayo Clinic, Rochester.
Dr. Bhagra, who personally has experienced patient bias, says such encounters leave physicians grappling with burnout, feelings of isolation, minority stress and rejection. Significantly, she said, it also leads physicians to suffer imposter syndrome, which, loosely defined, sees individuals doubt their abilities and feel like a fraud.
Mayo developed its “SAFER model” to address instances in which patients request team members with characteristics unrelated to care, as well as when patients or their visitors behave in a discriminatory, harassing or demeaning manner toward staff.
The Mayo SAFER model recommends the following responses:
- Step in when you observe behaviour that does not align with Mayo Clinic values.
- Address the behaviour with the patient or visitor.
- Focus on Mayo Clinic values (such as respect and healing).
- Explain Mayo’s expectations, and set boundaries with patients and visitors.
- Report the incident to your supervisor and document the event using the patient misconduct form.
The model is reinforced by a decision tree for responding to inappropriate behaviour and navigating requests for specific characteristics of care team members unrelated to patient care, such as race, religion, ethnicity, gender identity or sexual orientation. The essence of the policy states that patients may not select their health care professionals based on personal characteristics with very limited exceptions that relate to potential harms to a patient if a request is not granted.
“Fundamentally, it is the needs of the patient — not the wants of the patient — that must be considered,” said Dr. Bhagra.
Both Drs. Bhagra and Paul-Emile believe a zero-tolerance approach — such as denying all patient requests for specific preferences regarding their clinical care team — is not the best solution. There are times when accommodation can be a reasonable option, such as when a patient is not rejecting a clinician, but instead seeking an ethically or clinically appropriate form of concordance, such as language concordance for improved comprehension.
A patient’s past trauma is also reason to consider a more nuanced approach. Dr. Karen Hill, a Mohawk physician from Six Nations of the Grand River Territory, says some patients asking for another physician need to be managed with a trauma-informed approach. Insisting a patient with a history of sexual assault, for example, see a doctor they are clearly uncomfortable with would only create more harm.
Dr. Hill remembers, as a resident, being rejected by a patient who did not want to be treated by her. She agreed to find another doctor and left the room. “I ended up getting serious pushback from the senior resident who insisted that I care for that patient. I told him that it was not healthy for me and that it was not good for the patient. I didn’t know what the patient’s issues were, but we need to be aware that some patients have trauma and forcing a situation is not to anyone’s benefit.”
Though overt sexism is decreasing, female physicians continue to face microaggressions based on their gender. Dr. Yvonne Chan, Chief of Otolaryngology at St. Michael’s Hospital in Toronto, says she believes that being a female, especially in the male-dominated surgical culture, can intensify challenges. She remembers recently introducing herself to a patient and his family to discuss a proposed medical procedure. After a fulsome discussion of the surgery, they left her office, only to go, unexpectedly, and sit in the waiting room. One of Dr. Chan’s assistants noticed their presence and asked if they had a concern that still needed addressing. They replied that they were just waiting to meet with the doctor.
“I have been mistaken as the physio, the speech therapist, the volunteer, the nurse,” said Dr. Chan. “It doesn’t help that I look 12 years old. So, I needed to do this,” she said, pointing to an oversized name tag with her doctor title.
No patient has ever outright refused care from Dr. Chan and asked for a male physician instead, but some patients have thrown up obstacles. “I walk in, introduce myself and the patient will make a comment that disses women doctors,” she said. “I just ignore it, usually, and start explaining their medical issue to them, and talking to them at length and answering their questions. And slowly, I can see their body language change as they become more receptive to me. But I am very aware that I have to build a rapport with them and earn their respect in a way that my male colleagues don’t.”
Dr. Chan forges a therapeutic alliance with patients as a way to address these situations. She obtains that alliance through building rapport and trust with the patient, and by making it clear they share the goal of addressing the patient’s health needs.
Getting at the patient’s real fears can help build that trusting relationship, said Dr. Chan. “If you’re willing to listen to them, and explore such issues as what they are most worried about and what they hope can be achieved, for example, it begins to build trust and confidence, which is really critical in helping you move forward,” she said.
Vulnerability of Learners
It’s perhaps no coincidence that both Drs. Hamour and Roberge were targeted when they were learners. Trainees are particularly vulnerable to patient bias. A recent US study showed 15 percent of pediatric residents at an academic medical institution personally experienced or witnessed mistreatment, and of these instances, 67 percent involved mistreatment by patients and families.
“It’s hard being a doctor who receives abuse, but it is even more challenging dealing with these kinds of situations when you are a learner. You are just so vulnerable, and you are just not equipped with the tools to manage these types of situations,” said Dr. Hamour.
It’s an issue very much on the radar of medical faculties as they determine the best way to support their learners at the hospital bedside.
The prevalence of patients mistreating trainees is complicated by their position in the medical hierarchy, says Dr. Bernice Downey, Associate Dean of Indigenous Health for the Faculty of Health Sciences at McMaster.
“I don’t think we are even hearing half of the incidents that are occurring,” she said. So many learners simply choose to stay quiet about abusive encounters with patients because they don’t want to challenge power and authority or seem weak or risk repercussions on their evaluations, she said.
Dr. Parveen Wasi, Post-Graduate Dean at McMaster, says her medical school is committed to addressing the issue, but the challenges of doing so are numerous. Hospitals and medical schools have so many other relationship dynamics to manage that patient bias has not yet received the attention it deserves. To date, the bigger priorities are managing interprofessional relationships and addressing bias perpetuated by physicians against patients.
She does, however, have the sense that residents are coming forward to report incidents much more frequently than they did even five years ago. “And I think that’s a real change, and a great change and it may actually just reflect that people are willing to listen,” said Dr. Wasi
But she also says faculty are stymied as to how to handle these situations. “For example, we have had incidents where Muslim residents have been targeted by patients, and there was a whole effort with faculty about how to best approach this issue with a population that is vulnerable and unwell. And to be honest, we just really do not know. “
She said it is an issue where medical schools need to be in full partnership with their hospitals. “In one of the cases, we phoned hospital risk management and patient relations, [and] they didn’t have a protocol. Neither did the Chiefs of Staff. So, then who do you call for advice in such instances? Who is the person who is going to talk to the patient? Will Patient Relations protect the physician who steps in and tells the patient — in a professional, but nonetheless clear manner — that abuse is unacceptable? And what happens if the patient launches a complaint against the physician, or against the resident? We need that support. And I don’t know whether we have that right now in a systematic way.”
A systematic response is exactly what Dr. Curtis Sobchak, an PGY3 at McMaster, would like to see. “A lot of us are feeling more comfortable voicing our concerns when patients act in a biased manner. But if we know the problem exists, where is the formal process? Multiple residents have asked whether their report just goes into a black hole. If so, how is that any different than sucking it up and moving on without making a report?” said Dr. Sobchak, who is Indigenous.
It’s clearly an issue where we need all partners pulling together in the same direction, said Dr. Wasi. “We can’t afford to have post-grads, undergrads, faculty and hospitals sitting in their own silos on this issue,” she said.
But moving forward needs to begin with data-gathering, say Drs. Wasi and Downey. Work is already underway at McMaster to determine the scope of the issue, the trends, the causes and the impacts of biased patient behaviour.
Ms. Anita Balakrishna, Director of Equity, Diversity and Inclusion at Temerty Faculty of Medicine at the University of Toronto, says the school has been conducting regular surveys of its learners to determine the extent of abuse and where it is happening. Patients and patients’ families were found to be the source of the majority of discrimination and harassment faced by learners. Muslim women wearing hijabs were singled out for particular abuse, noted Ms. Balakrishna.
Given that complete prevention is impossible, awareness and preparation are crucial. A medical school’s best strategy is to teach learners — both those who are likely to be targeted and bystanders — how to manage these patient encounters.
“We don’t want the responsibility for responding to rest on the shoulders of students who are receiving these comments. We want to ensure that other students, the faculty, all the witnesses to the behaviour will intervene and interject when they see patients or their visitors treating students badly,” she said.
Recently, Ms. Balakrishna and Dr. Hamour developed a case-based workshop for clerkship students that explored issues presented by patient bias. During the workshop, students were taught a compassion-informed four-step approach: 1) check your own visceral reaction, 2) assess illness acuity, 3) determine whether to respond at the bedside or in a subsequent encounter, and 4) attempt positive regard towards the patient, while giving yourself room.
It’s been several years since Dr. Hamour was called a “crow” by his angry patient and he thinks about that experience now as a wasted opportunity. He now believes that staying silent was a disservice to both him and the patient. “I wished that I could have broached the issue with him in the spirit of compassion, as an opportunity to get to know him, rather than just pretend that I did not hear it.”