From the Journals

Demeaning patient behavior takes emotional toll on physicians

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“We all have the responsibility to speak and act”

The results of the patient bias study from Wheeler et al are troubling, but not surprising.

As the physician workforce becomes more diverse in regard to race, ethnicity, sex, gender identity, and sexual orientation, considering and addressing the negative impacts of demeaning patient interactions becomes increasingly important. And though a recent analysis stated a decline in biases between 2007 and 2016, discriminatory and disrespectful treatment remains the norm for members of many minority groups.

Strategies to address these behaviors include codes of professional ethics offering guidance on responding to disrespectful behavior, antidiscrimination training for all health professionals, and health care leaders themselves practicing and preaching respectfulness and civility within their institutions.

Patients can only be expected to behave respectfully towards physicians if the culture of health care is also respectful.

When anyone, including a patient, exhibits biased and disrespectful behavior, silence is not golden. It is tacit approval. We all have the responsibility to speak and act.

Lisa A. Cooper, MD, and Mary Catherine Beach, MD, of Johns Hopkins University in Baltimore; and David R. Williams, PhD, of Harvard University, Boston, made these comments in an accompanying editorial (JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4100). They reported no conflicts of interest.



Despite an increasingly diverse workforce, a new study has found that many patients remain biased toward certain physicians, which can produce substantial negative – and occasionally positive – effects.

“Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” wrote Margaret Wheeler, MD, of the University of California, San Francisco (UCSF) and her coauthors. The study was published in JAMA Internal Medicine.

To determine the perspectives of physicians and trainees in regard to patient bias, along with potential barriers to responding effectively, the researchers led 13 focus groups attended by internal 11 medicine hospitalist physicians, 26 internal medicine residents, and 13 medical students affiliated with the UCSF School of Medicine. In terms of gender, 26 participants identified as women, 22 as men, and 2 as gender nonconforming. In terms of racial and ethnic diversity, 26 were white, 8 were Latinx, 7 were Asian, 3 were South Asian, 1 was Middle Eastern, and 5 were black.

In describing biased and demeaning patient behavior, the participants recalled remarks that ranged from refusal of care and questioning the clinician’s role to ethnic jokes, questions as to their ethnic backgrounds, inappropriate flirtations or compliments. The effects of these behaviors on the participants included negative responses like carrying an emotional burden and withdrawing from work, along with positive responses like an increased desire for self-growth and to pursue leadership opportunities.

Barriers to addressing these behaviors included a lack of support, uncertainty as to the appropriate response, and a fear of being perceived as unprofessional. Deciding how to respond – or to respond at all – was often dictated by the level of support from colleagues, a professional responsibility to peers, and the presence of a positive role model who would’ve done the same.

The authors acknowledged their study’s limitations, including only knowing the views of those who were interviewed. In addition, all participants came from a medical school located in a diverse city that embraces different cultures, meaning their findings “may not reflect the experiences of physicians in other geographic regions.”

The study was supported by the Greenwall Foundation. The authors reported no conflicts of interest.

SOURCE: Wheeler M et al. JAMA Intern Med. 2019 Oct 28. doi: 10.1001/jamainternmed.2019.4122.

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