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    Pushing back against patient bias

    From racial epithets to homophobic slurs, providers have long suffered patient bias. Now, medicals schools and teaching hospitals are saying “no more” with powerful steps to protect students and staff.

    A female doctor talking with man and woman patients in an office or clinic.

    It’s been three years, and Hyma Polimera, MD, a hospitalist at Penn State Health Milton S. Hershey Medical Center, still remembers the first time she was met with bias when trying to help a patient.

    Polimera was assigned a patient suffering from multiple medical problems, including dementia, but within minutes the man’s daughter requested a new doctor. “She looked at me, and without any hesitation or additional conversation, said she wanted an American,” recalls Polimera, who was born in India.

    “I was just shocked. Usually, I go home with immense joy knowing I helped patients, but that day was completely different. I could not stop thinking about it and not just that day but four or five days after. It was such a disturbing moment.”

    Indeed, bias against providers can be quite ugly. In a 2019 study, residents and students reported being called vicious names, including anti-gay slurs and racial epithets, and female students recalled enduring whistles and a host of offensive remarks.

    And the problem is widespread. Nearly 1 in 4 gay physicians suffered demeaning patient comments, and more than 1 in 3 black physicians experienced racist remarks in the past year, according to AAMC data. Another study found that nearly 30% of physicians have been rejected by a patient because of their race, religion, gender, or other personal feature.

    Such affronts are particularly worrisome at a time when medicine desperately needs to increase the diversity of the physician workforce, experts say. For example, Hispanic and black or African American people comprise just 10.8% of physicians but more than 30% of the U.S. population. In addition, chances for biased encounters are significant, given that nearly 1 in 3 U.S. doctors now hails from a foreign country and women currently comprise more than half of medical students.

    And facing bigotry can fuel provider burnout: Surgical residents who experienced discrimination or harassment several times a month were three times more likely to feel burned out, a 2019 study found.

    “The negative impact can be huge," says David Acosta, MD, chief diversity and inclusion officer at the AAMC. “Often it triggers disbelief, fear, and resentment. It also can cause significant self-doubt. A learner may think, ‘How can I be a doctor if I can’t handle this?’”

    For years, absorbing patient bias was simply considered a part of providing care, but medical schools and teaching hospitals are increasingly saying, “No more.” At some institutions, leaders were inspired by a groundbreaking 2016 New England Journal of Medicine (NEJM) article on how to handle racist patients. Others say the need to respond to bias became more apparent in the wake of the #MeToo movement and the post-2016 political and cultural climate.

    "Everybody talks about patient rights, but we also need to talk about patient responsibilities. … Patients absolutely have a duty to treat providers with respect and dignity.”

    -Karen Smith, PhD, Henry Ford Hospital & Health System

    To tackle this issue, institutions are providing several types of guidance and support. In the past couple of years, many have begun offering trainings to help practice responses before participants are faced with real-world bias. Some have also been working to encourage increased reporting of discriminatory incidents. And a growing number are crafting anti-bias policies that tell patients flatly: Act badly, and you may be asked to leave.

    “Everybody talks about patient rights, but we also need to talk about patient responsibilities,” says Karen Smith, PhD, director of ethics integration at the Henry Ford Hospital & Health System, which launched its anti-bias policy in 2018. “Caregivers work so selflessly. We have to take this issue very seriously. Patients absolutely have a duty to treat providers with respect and dignity.”

    Policies designed to protect staff

    As a black woman, Uche Blackstock, MD, says she’s been called a racial slur and her opinion has been discounted by patients. She calls such experiences “horrible and humiliating,” so she felt great empathy when one of her emergency medicine residents at NYU Langone Health experienced patient bias.

    It was not long after NYU launched its anti-discrimination policy in 2018. The patient was rude and dismissive, insisting he did not want care from a Muslim doctor. Often in the past, Blackstock says, victims and supervisors would not know how to respond to such a situation, but now the policy provided clarity.

    “Once we checked for a few things, like that the patient was stable, I told him that kind of behavior and language were not allowed in the hospital. I said that if he continued, he would have to leave — and he left.” Blackstock, now CEO of the Advancing Health Equity consulting firm, greatly appreciated the policy. “It makes a huge difference knowing that your institution backs you up. It can be so empowering.”

    NYU is not alone in rejecting biased requests for replacement providers.

    Penn State launched a similar policy in 2017 that lists personal traits — national origin, sexual orientation, and a dozen others — around which disrespectful patient interactions will not be tolerated. And at least eight other institutions have adopted or are creating similar policies, says Kimani Paul-Emile, JD, a Fordham University Law School professor who advises medical schools and teaching hospitals.

    Of course, patients have a right to reject care for any reason — but they have no right to be abusive, explains Paul-Emile. Additionally, a hospital has a legal obligation to protect its staff against discrimination. That means it usually can reject a bias-based request for a different provider and instead offer the possibility of a transfer to another hospital.

    Yet certain circumstances make matters more complex. Several institutions therefore have created a flow chart based on one that Paul-Emile and co-authors published in the NEJM article. The charts address several essential questions — Is the patient deathly ill, for example? Mentally competent? Acting disruptive? — in a straightforward decision chain. Different answers yield various outcomes, including persuading the patient to keep biased thoughts to themselves.

    Establishing such an anti-bias policy is no simple matter. At Henry Ford, finalizing a document took a year and involved many departments, from human resources to chaplaincy to risk management. But the work paid off, and other institutions now come seeking Smith’s guidance. “There’s been a huge explosion in interest,” she notes. “I get emails about this at least once a week.”

    Part of the policy-drafting process involves identifying when a request is reasonable rather than discriminatory. Is it okay for a woman to request a female gynecologist, for example?

    “Not recognizing these situations sends the message that the person is just supposed to bear it. We can’t stop patients from expressing bias, but we can change how institutions train people to support and validate those who experience it.”

    -Mehreen Iqbal, MD,  Stanford University School of Medicine

    At Mayo Clinic, the answer is “sometimes.” Sharonne N. Hayes, MD, cardiologist, and director of diversity and inclusion, says she’s generally squeamish about gender-based choices. “This is a workload and educational issue,” she argues. “It’s not fair — or effective — if female trainees see more female patients or if male trainees are barred from learning about women’s health.” However, Mayo does make exceptions for patients who observe religious restrictions or have experienced a trauma like rape, Hayes explains.

    To ensure that patients are aware of its anti-bias policy, Penn State has been developing a broad outreach plan. Individual departments have already upped their communication efforts, but chief diversity officer Lynette Chappell-Williams, JD, also hopes to post messages in key spots, including elevators, TV screens, and scheduling letters that go out to patients.

    “We are committed to showing you our absolute level of respect,” reads some of the draft text. “Our expectation is that you and your families and visitors respect people who work here as well.”

    What can I say?

    One Mayo Clinic office learned the hard way that it needed to train staff in how to handle patient bias.

    Because of increased patient demand at a practice a few hours away from Mayo’s main campus, specialists from diverse backgrounds began traveling there last spring, explains Hayes. “Some patients at the rural practice said things like, ‘I want my white doctors back,’” she recalls. “Appointment coordinators trying to be helpful said they’d see what they could do, which is completely opposite to our policy. So we went in and trained that entire staff on how to respond. Wow, did they step up,” she says. “Everything turned around.”

    Mayo’s training includes online modules and several videos — including two for faculty on how to support learners — that drew thousands of staff in the first three months following its launch in May 2018. Designed to help staff understand and implement the new policy, the trainings should eventually reach all 60,000 employees, says Hayes. First-year medical students also began receiving related training in their ethics and science of health care delivery courses that year, with practice scenarios that involve racist, Islamophobic, and gender-based remarks.

    Institutions often suggest specific tactics to guide staff and learners. Be empathic, advises Henry Ford’s training, since stressed patients may just need reassurance that a provider is well-qualified. Asking open-ended questions also helps, explains Smith. “You might say, ‘Can you tell me more about your request?’ You want to show a genuine desire to understand concerns.” Sometimes, thoughtful conversations can yield a non-discriminatory solution that works for both staff and patient.

    At the University of Rochester Medical Center, training takes a more theatrical tack.

    Using a technique called Theater of the Oppressed that was created in Brazil in the 1970s, participants watch a scene of bias unfold: A patient spews vitriol at a black resident while a white resident stands by. Soon, a facilitator rewinds the scene, inviting audience members to stop the play if they have thoughts on how to improve the outcome. Volunteers then replace the two residents to try different approaches.

    “The participants get multiple opportunities to practice how they would respond and see how it goes. We debrief and ask the audience how they think each encounter went,” explains John Cullen, PhD, Rochester’s director of diversity and inclusion. “It’s very nontraditional for academic medicine, but it works very well.”

    In fact, the approach works so well that Cullen has been asked to present it elsewhere several times since it launched in 2017, including at AAMC meetings. Back at Rochester, the program is increasingly being woven into the curriculum — it's now required for first-year students, for example — and has already reached hundreds of staff and learners.

    “He yelled at her, called her stupid and incompetent, and said … he wanted a man to come in and take over. … We had the type of conversation you want to have to help the person get away from shame and blame."

    -Sharonne N. Hayes, MD, Mayo Clinic

    Those involved say such trainings are invaluable not just for the guidance they offer but also for the sense of support they convey.

    Mehreen Iqbal, MD, wishes she had been trained in how to get help back when she was a medical student in Georgia eight years ago. Iqbal recalls that she and a colleague were conducting a home visit with a man who had suffered a spinal cord injury and a stroke who soon grew increasingly agitated toward the two women of color. “He asked us where we were from and when we answered ‘Atlanta’ he said, ‘You may live there, but you sure as hell are not from there,’” remembers Iqbal. Although he was wheelchair-bound, the man even threatened them physically.

    The patient eventually calmed down, and the two students later tried to comfort each other. “We didn’t think we could do anything else,” says Iqbal, now a pediatric cardiology fellow at Stanford University School of Medicine, where she says there is a great deal of support when bias occurs.

    “Not recognizing these situations sends the message that the person is just supposed to bear it,” she believes. “We can’t stop patients from expressing bias, but we can change how institutions train people to support and validate the victims.”

    The value of reporting

    In the past couple of years, institutions have also been ramping up efforts to encourage victims and bystanders to come forward. At Mayo, for example, employees can report incidents — anonymously if they’d like — via a button on the intranet homepage. Every entry gets reviewed carefully to ensure the incident was addressed properly and that staff get any needed support.

    Hayes recalls a recent patient whose husband demeaned a female resident. “He yelled at her, called her stupid and incompetent, and said he didn’t want her as his wife’s doctor. … He wanted a man to come in and take over.” Support was swift and thorough, including a senior supervisor arriving in the wee hours to convey the resident’s qualifications and a follow-up meeting with Hayes.

    “We had the type of conversation you want to have to help the person get away from shame and blame. ‘I thought I should be able to handle this myself,’ the resident said, and she seemed to believe she may be brought it on. I made clear to her she didn’t do anything wrong and told her that this is what attendings are for.”

    Henry Ford also emphasizes the importance of reporting incidents, in part to accumulate a valuable body of data. In fact, leaders there hope to have gathered enough numbers by next year to better understand which types of incidents occur most frequently and where. “Data can help us see how incidents are getting resolved and figure out how best to support our staff,” notes Smith.

    Joselle Cook, MD, a Mayo trainee born in Trinidad, thinks efforts to encourage reporting make a big difference. “There’s not just a shoving of it under the carpet,” says Cook, who has repeatedly suffered bias. “In the past year and a half, my co-fellows are reporting incidents more and more. You also see many leaders reaching out and supporting staff to deal with incidents they’ve faced.”

    What’s more, she believes Mayo’s anti-bias efforts may be paying off not just with staff, but with patients too.

    “I think patients could be behaving better because of Mayo’s policies,” she says. “They’re recognizing that they want to be here at Mayo Clinic. So they see this is the policy, and they need to keep to it."