For years, healthcare has focused on addressing providers' implicit biases toward patients and their adverse effects on health.
But hospitals have been slow to recognize clinicians' growing concern over prejudice against their race, gender, sexual orientation, culture or religion by patients. Experts say it's an issue that could have large implications for healthcare in the future as its workforce becomes increasingly diverse.
"It has long been an open secret among minority physicians," said Dr. Alicia Fernandez, professor of medicine at the University of California San Francisco.
Fernandez co-authored a study published this week in JAMA Internal Medicine that found clinicians reported experiencing a wide range of biased behavior from patients, ranging from requests to be treated by another clinician to making racist, sexist or homophobic remarks.
The study found most clinicians who experienced bias did not know how to respond to the patient or who to turn to for help, which led to many of those incidents going unreported.
"I think hospitals need to do all they can to encourage diversity and inclusion as community values," Fernandez said. "This includes written policies and leadership support for physicians and staff who deal with biased patients."
These events can cause ethical dilemmas for clinicians who want to protect themselves against discriminatory behavior yet uphold their duty to provide patient care.
"Clinicians can work to set limits with patients while maintaining a therapeutic alliance," Fernandez said. "In order to do so, they need to have clear policies in place, particularly for more egregious instances such as refusal of care."
But hospital policies may further complicate the situation. Some providers allow patients to refuse care from a particular clinician without necessarily forfeiting their care. While that can protect patients from potential discrimination from a provider, experts warn those policies can also be used by patients to discriminate against a clinician if hospitals don't set parameters.
"Individual physicians need to know that their employer—hospital, academic medical center, health plan—understands this problem and does not tolerate biased disrespect," Fernandez said.
A 2017 survey suggests the problem may be more common than hospitals acknowledge. It found 59% of more than 820 doctors surveyed reported that a patient made an offensive remark to them in the past five years. Only 10% of physicians who experienced patient bias reported those incidents to management while 60% of clinicians reported they did not know if their institution had a formal process they could initiate in cases involving patient bias.
Patient bias can adversely impact clinicians and spark emotions linked to professional burnout.
Dr. David Acosta, chief diversity and inclusion officer for the Association of American Medical Colleges, said incidents involving patients making bigoted comments or more broadly exhibiting bias towards clinicians have appeared to increase over the last few years based on discussions he has had with hospital leaders.
While a few providers have worked on addressing patient bias, many have yet to develop policies or programs that offer clinicians support, he said.
"It has to be a system change," Acosta said. "There has to be a culture change within that environment that actually is very supportive and nurturing but also one that espouses philosophies and concepts around equity and inclusion."
The American Medical Association's House of Delegates is currently examining an effort to offer clinicians more clarity on how to respond to patient bias. It will vote on a proposal to amend the organization's current ethical guidance for physicians on dealing with disruptive patients in November. The changes would add language calling on physicians to encourage their institutions to "promote a safe and respectful working environment and formally set clear expectations for how disrespectful, derogatory, or prejudiced behavior by patients will be managed."
Teaching hospital and medical school leaders recently looked at developing standard approaches that clinicians and institutions can use to address patient bias, Acosta said.
Dr. Rahma Warsame, assistant professor of medicine and diversity chair in the hematology division of Mayo Clinic in Rochester, Minn., said the clinic has had a conduct policy since 2017 that strictly prohibits intolerance or mistreatment of any member of the healthcare team. The policy also states that a patient's care could be terminated over an egregious act if they aren't critically ill and unstable.
Mayo prohibits patients from selecting their clinicians based on their "personal characteristics," with exceptions in cases that could lead to patient harm.
Part of creating a safe healthcare work environment includes establishing clear rules and consequences for patients who exhibit bias behavior, Warsame said. Clinicians need to know that reporting incidents will lead to actual changes.
"It is key to have commitment from the executive leadership that this type of behavior will not be tolerated, and that employees deserve to feel safe and work in areas that are not hostile," Warsame said.
Mayo's effort included developing a five-step process for reporting and responding to situations involving patient bias. Called "SAFER", the model involves stepping into situations when bias behavior is observed, addressing the behavior with the patient, focusing the conversation on hospital values such as respect, explaining the zero-tolerance policy on patient bias behavior, and reporting incidents.
In addition to the policy, Warsame said supervisors are expected to check in with employees who experienced bias to ensure they felt supported. Mayo offers an online toolbox with scripts, videos, potential responses and literature to help workers deal with these situations.
Like Acosta, Warsame said establishing the environment that ensures staff are supported when they experience patient bias requires changing how the entire system views incidents, not just the individual.
"It takes time for culture change, but reinforcing the ideals we want to uphold and providing support when incidents do occur will help create that culture," Warsame said.