How Best to Care for Biased Patients

I want to kill all the Jews,” shouted the man accused of killing 11 people and wounding seven others in the Tree of Life synagogue in Pittsburgh on October 27, 2018, as he arrived in the emergency room of Allegheny General Hospital in need of treatment after being shot by police. Among the team that treated him were several physicians and nurses who were Jewish, and the president of the Hospital, Jeffrey K. Cohen, MD, a congregant of the synagogue, stopped by the man’s room after treatment to check in on him. “We’re here to take care of sick people,” Dr. Cohen said, as reported in The Washington Post. “We’re not here to judge you.”

This pledge to care for all patients, regardless of bias and circumstance, underwrites the code of conduct and belief that healthcare workers commit to in a profession devoted to caring for people in need. And yet, what do physicians and healthcare workers do when a patient treats them with hostility or resistance because of bias—most often based on race/ethnicity, sex, or religion?

“There is a rising prevalence of explicit acts of xenophobia in the country,” said Howard W. Francis, MD, MBA, professor and chief of the division of head and neck surgery and communication sciences at Duke University Medical Center in Durham, N.C. “We need to be prepared to quickly and effectively address this issue when it arises. To do otherwise will compromise our efforts to build inclusive, diverse, and effective teams.”

A recent poll shows that 70% of African American and 69% of Asian American physicians report they are more likely to hear biased comments from patients, and 41% of women were far more likely to experience bias based on their sex. More men than women are likely to experience bias based on their religion. Although no hard data are available to show whether the incidence of patients expressing biased beliefs toward physicians has increased in recent years or whether the reporting of such incidences has increased, what is known is that the challenge of caring for patients who are biased is emerging as a critical issue among healthcare workers who need to balance their oath of caring for all patients with the need for respect from patients that is required for good medical care.

“In medicine, we have this deep and honorable value in taking care of all people no matter what their beliefs are, where they are from, what they say, or even what they do,” said Margaret L. Plews-Ogan, MD, associate professor of clinical internal medicine in the department of medicine at the University of Virginia Health System in Charlottesville, Va. “Unfortunately, however, that can also translate into not directly confronting patients when they exhibit disrespectful and, in some cases, racist and sexist behavior because we’re held back by the belief that we should care for them no matter what.”

“The solution cannot be isolated to the potential victim of racism but must represent a unified front by administration, senior physicians, and nursing that reflects the values of inclusion and mutual respect of the organization.” —Howard W. Francis, MD, MBA

“So we need to figure out a way to carry out both of those values, how to create an environment of respect where everyone is treated with respect and also one in which we care for people who have very different beliefs from us,” she said.

Physicians in Training: A More Diverse Profession

Although the opening scenario may be extreme, shared to dramatize just how challenging it may be to care for a racist patient, a far more common scenario in daily clinical practice is the patient who questions the credentials of a physician, often one in training and often based on race/ethnicity or gender, or asks to be treated by a physician who looks more like them.