Bigoted Patient Behaviors All Too Common for Residents of Color

Nearly all medical residents reported that patients had made belittling comments or asked to change providers within the past year, but women and residents of color reported experiencing the most bias, according to an online survey in California and North Carolina.

Among 232 second- and third-year internal medicine residents, 98% said they witnessed some biased behavior in the past year, and roughly one-third reported experiencing belittling or demeaning stereotypes at least once a month, reported Alicia Fernandez, MD, of the University of California, San Francisco, and colleagues.

Women reported having patients question their role as a physician twice as frequently as male residents did (96% vs 42%), and 87% of women reported experiencing sexual harassment, the researchers wrote in JAMA Network Open.

Black or Latinx residents had patients say explicit epithets or blatantly reject the residents' care in the past year close to twice as frequently as white residents (45% vs 28%), while all 70 Asian residents surveyed reported that patients had intrusively asked about their country of origin. Residents also said they frequently witnessed discrimination targeted toward the Islamic faith (40%) and sexual orientation (42%), according to the survey.

"The high prevalence of biased patient incidents may be largely unknown by residency program directors and academic medical center leaders as evidenced by the 80% of residents who stated that they never reported biased patient behavior 'up' within their institution," Fernandez and co-authors wrote.

Instead of reporting these instances to leadership, residents responded to patient bias most often by limiting the setting with the patient (30%), debriefing with friends or family (35%), or talking about it with a team member (34%), the researchers reported. About three-quarters of residents said they had been trained in some fashion to respond to bias (72%), but the majority said the training was inadequate (74%).

Underrepresented doctors also face bias from within institutions, sometimes under the guise that they must adhere to "professionalism," and assimilate into their environments, suggested another survey of hospital staff in New Jersey, Delaware, and Pennsylvania published Monday.

Among 3,506 healthcare workers, women were significantly more likely to value "institutional professionalism" than men (adjusted odds ratio 1.8, 95% CI 1.4-2.3), and Asian and Hispanic individuals were both about twice as likely to value this as white respondents, reported Jaya Aysola, MD, DTMH, MPH, of the University of Pennsylvania in Philadelphia, and colleagues.

Gender and sexual minority groups were also significantly more likely than heterosexual respondents to consider changing jobs because of unprofessional behavior at work (aOR 1.5, 95% CI 1.2-1.8), as were Black respondents compared with whites (aOR 1.3, 95% CI 1.2-1.4), the investigators wrote in JAMA Network Open.

Underrepresented healthcare workers also reported greater infringements on their professional boundaries, increased scrutiny over their actions, and a tension between inclusion and assimilation in the workplace in a qualitative analysis.

For example, one respondent wrote that a physician had grabbed her arm and pulled it towards a patient to compare her skin color to the color of the patient's diarrhea.

"Does it look like her arm or is it lighter?" He then asked the patient, and then "chuckled and said 'your skin is the perfect color for this job,'" according to the study.

Another respondent noted that, "[R]esidents of color seem to get criticized for things that the majority do not, even if they do the same things," and that there was "this microscope that is applied to them which ... is subtle, yet present."

This idea of professionalism "can center norms associated with a singular majority culture and inadvertently marginalize minority groups," the team wrote.

When medical professionalism is displayed through the unequal application of standards, it can become "weaponized," Aysola explained. "This weaponization ... can damage individuality and identity and cause conformity, shrink efforts to increase the diversity of the workforce, create harmful environments, and force marginalized populations to assimilate in an attempt to be included."

Repeated microaggressions stack up, leading to physical and mental health consequences, imposter syndrome, and "racial battle fatigue," commented Rhonda G. Acholonu, MD, and Suzette O. Oyeku, MD, MPH, both of The Children's Hospital at Montefiore and the Albert Einstein College of Medicine in New York City, writing in an accompanying editorial.

But diversity should be seen as a solution and not a problem, to quote Marc Nivet, EdD, MBA, the former chief diversity officer at the Association of American Medical Colleges, they noted.

Still, Acholonu and Oyeku cautioned against the "minority tax," or leaving underrepresented individuals to shoulder the majority of diversity and inclusion initiatives.

Achieving equity and inclusion goes beyond recruitment, the editorialists said, adding that there also needs to be response programming in place when microaggressions occur, a way to hold leadership accountable for enforcing it, and a means to collect data on the prevalence of these incidents.

"Leaders of academic medical centers must recognize the microaggressions and subtle indignities that affect their workforce's daily lives, which are currently magnified by their personal lived experience," Acholonu and Oyeku wrote.

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