Toxic Behaviors: Addressing Patient Bias and Discrimination

Laura M. Cascella, MA, CPHRM

Bias and discrimination are unfortunate realities that affect many social institutions, including healthcare. Research and literature about bias in healthcare often focus on how clinicians’ cognitive and implicit biases can undermine provider–patient relationships, lead to poor diagnostic and treatment decisions, negatively affect patient outcomes, and perpetuate health inequities and disparities.

But what happens when healthcare providers face discriminatory behaviors from patients? This problem has received more attention in recent years for numerous reasons, including increased scrutiny of race relations in the United States, the dire need to improve the mental and physical well-being of healthcare workers, and a growing emphasis on improving diversity, equity, and inclusion (DEI) within the healthcare environment.

Patient bias and discrimination against healthcare workers have been documented in various studies. A WebMD/Medscape survey of more than 800 healthcare professionals found that almost 60 percent had experienced bias from patients, and almost half reported that patients had requested another provider based on physical characteristics or background. Not surprisingly, the survey also showed that African American and Asian doctors were more likely to face bias than white doctors, and women were the targets of bias more often than men.¹

The types of bias and discrimination that healthcare providers encounter can vary widely and may include microaggressions, inappropriate comments, flirtatious behavior, degrading statements or jokes, stereotyping, questions about a provider’s qualifications, or refusal of care/demands for another provider. Yet, regardless of how bias and discrimination manifest, they can have immediate and long-term detrimental consequences.

Healthcare providers who endure bias and discrimination may find these incidents emotionally painful and upsetting. They may feel helpless, angry, or isolated, which in turn may contribute to burnout, low morale, staff turnover, and potential legal liability. Bias and discrimination also may hinder DEI efforts, reinforce salary inequities, create training and education gaps, and impede career advancement.²

Addressing patient bias on individual and institutional levels is highly complex for a multitude of reasons. Perhaps most significant is the need to balance competing legal and ethical obligations to both patients and providers, which involves consideration of informed consent rights, Title VII of the Civil Rights Act of 1964, the Emergency Medical Treatment and Labor Act (EMTALA), as well as other relevant laws.³ Other barriers include inadequate organizational policies and reporting mechanisms, lack of awareness of the problem, hesitancy to address a difficult and sensitive topic, fears about retaliation or career impact, and time/resource concerns.⁴

Although tackling patient bias is challenging, failure to do so can contribute to a toxic and psychologically unsafe environment that may have ripple effects for
provider–patient relationships, patient outcomes, quality of care, and staffing. Despite this, many healthcare organizations do not have policies, guidance, or support in place to deal with these situations when they arise. Thus, the following recommendations can help healthcare leaders, clinicians, and other staff members begin to consider various ways in which to address bias while maintaining ethical and legal obligations:

• Convene a multidisciplinary team of experts to review your existing policy on patient bias or to develop a policy addressing patient bias and discrimination. Make sure the team is diverse and includes individuals with expertise in laws/regulations, ethics, conflict resolution, security, etc.
• Be aware that a zero-tolerance or one-size-fits-all approach to patient bias and discrimination is likely not appropriate because of the intricacies involved with this issue. A more nuanced and flexible approach can help healthcare providers prepare for various situations.
• Make sure your policy on patient bias and discrimination:
  • Accounts for the range of provider types, care scenarios, and patient populations that characterize your organization.
  • Recognizes that some types of providers — such as nurses and residents — might be more vulnerable in situations involving bias. The policy should include specific guidance for how these providers can respond and escalate their concerns.
  • Offers guidance on identifying and managing various types of patient bias and discrimination, from subtle behaviors to overt displays of racism, sexism, homophobia, ageism, and so on.
  • Describes providers’ legal obligations (e.g., under EMTALA) to provide patient care as well as their rights to address bias and discrimination, including options for transferring or discharging patients from practice.
  • Prioritizes providers’ and staff members’ safety and well-being in situations in which they may encounter harassment, violence, or mistreatment. “If a clinician feels unsafe, it is their right to exit the patient encounter and seek help from a colleague or supervisor, report the incident to the appropriate organizational leadership, and consider transferring care.”⁶
• Consider developing an algorithm or decision tree to help providers and staff members navigate and respond to bias and discrimination. Offer scripts to help workers provide respectful, yet firm responses to inappropriate comments.
• Include language in your patients’ rights/responsibilities policies and materials that explains the organization’s antidiscrimination policy, commitment to diversity, expectations for respectful conduct, and potential consequences for engaging in discriminatory behaviors. Post this information in visible locations, such as the organization’s website and patient portal.
• Implement a reliable and centralized mechanism for reporting allegations of patient bias and discrimination. Include clear guidance in the patient bias and discrimination policy about how individuals can report these incidents, what will happen when they make reports, and how the organization will use the information reported.
• Support a culture that encourages reporting and promotes psychological safety. Providers should feel that their concerns will be taken seriously, and they should not fear that reporting will harm their careers.
• Use data collected through the reporting mechanism to identify trends in patient bias and discrimination, monitor the effectiveness of the patient bias and discrimination policy, and determine where additional support or training might be necessary.
• Incorporate information about patient bias and discrimination into provider and staff training. Educate providers and staff about:
  • The organization’s policy on patient bias and discrimination and the appropriate steps for reporting these patient behaviors.
  • Legal and ethical considerations in dealing with biased patients, including obligations to provide stabilizing medical treatment and considerations for transferring patient care. Providers and staff should have a clear understanding of their rights and responsibilities.
  • How to identify different types of bias and discrimination and strategies for responding to them, including roles for bystanders who witness these types of behaviors. Role-playing and simulation scenarios are valuable training tools for preparing providers for real-life scenarios.
  • How to assess patient encounters to determine whether behaviors that might appear discriminatory are actually the result of cognitive or emotional circumstances (e.g., a patient who has dementia that makes inappropriate comments or a sexual assault victim that requests a same-sex provider). These situations will require a different approach.
  • Strategies for de-escalating hostile behaviors, and how to respond when a patient threatens violence or a provider or staff member feels unsafe.
  • Expectations and guidance for documenting incidents of patient bias and discrimination.
• Develop support mechanisms to help healthcare providers who have been targets of patient bias and discrimination. Examples include debriefings and team meetings, peer support programs, and wellness initiatives.⁷

Patient bias and discrimination against healthcare providers are an ongoing concern in various practice settings, and these issues may become more problematic as the workforce becomes more diverse. Much of the research around this topic recognizes the complexity of dealing with patient bias and acknowledges that the response must carefully balance “patient preferences with the duty to treat and demands of justice and nonmaleficence.”⁸

Healthcare organizations can take proactive steps to address patient bias by developing comprehensive policies, implementing reporting mechanisms and championing their use, offering thorough training and education, and identifying ways to support victims of patient discrimination.

Endnote

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¹ Cajigal, S., & Scudder, L. (2017, October 18). Patient prejudice: When credentials aren't enough. Medscape. Retrieved from www.medscape.com/slideshow/2017-patient-prejudice-report-6009134

² Chandrashekar, P., & Jain, S. H. (2020). Addressing patient bias and discrimination against clinicians of diverse backgrounds. Academic Medicine, 95(12S Addressing Harmful Bias and Eliminating Discrimination in Health Professions Learning Environments), S33–S43. doi: https://doi.org/10.1097/ACM.0000000000003682

³ Paul-Emile, K., Critchfield, J. M., Wheeler, M., de Bourmont, S., & Fernandez, A. (2020). Addressing patient bias toward health care workers: Recommendations for medical centers. Annals of Internal Medicine, 173(6), 468–473. doi: https://doi.org/10.7326/M20-0176

⁴ Ibid.

⁵ Ibid.

⁶ Chandrashekar, et al., Addressing patient bias and discrimination against clinicians of diverse backgrounds.

⁷ Paule-Emile, et al., Addressing patient bias toward health care workers: Recommendations for medical centers; Chandrashekar, et al., Addressing patient bias and discrimination against clinicians of diverse backgrounds; Smith, T. M. (2019, July 11). Inside Mayo Clinic's 5-step process for handling biased patients. American Medical Association. Retrieved from www.ama-assn.org/practice-management/physician-health/inside-mayo-clinics-5-step-process-handling-biased-patients; Weiner, S. (2020, January 17). Pushing back against patient bias. AAMC News. Retrieved from www.aamc.org/news/pushing-back-against-patient-bias; Penn State College of Medicine. (n.d.). Faculty guidelines for responding to inappropriate comments from patients and family members in clinical environments. Retrieved from https://faculty.med.psu.edu/professional-development/inappropriate-comment-guidelines/

⁸ Chandrashekar, et al., Addressing patient bias and discrimination against clinicians of diverse backgrounds.

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