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Original Investigation
Physician Work Environment and Well-Being
October 28, 2019

Physician and Trainee Experiences With Patient Bias

Author Affiliations
  • 1Department of Medicine, University of California, San Francisco (UCSF)
  • 2Division of General Internal Medicine, Zuckerberg San Francisco General Hospital, San Francisco, California
  • 3Fordham University School of Law, New York, New York
JAMA Intern Med. 2019;179(12):1678-1685. doi:10.1001/jamainternmed.2019.4122
Key Points

Question  How do physicians and trainees perceive, react, and respond to incidents of biased patient behavior?

Findings  In this qualitative study of convenience samples of 50 trainees and physicians, participants reported a wide range of experiences with biased patient behavior ranging from belittling comments to outright rejection of care. Participants described a large negative effect on their emotional well-being and the clinical care environment, and many described uncertainty regarding appropriate and effective ways to respond to these encounters.

Meaning  Physicians’ and trainees’ reports of uncertainty, confusion, and pain associated with biased patient behavior indicate a need for training and institutional policies to deal with biased patients.


Importance  As the clinical workforce becomes more diverse, physicians encounter patients who demean them based on social characteristics. Little is known about physicians’ perspectives on these encounters and their effects. This knowledge would help develop policies and best practices for institutions and training programs.

Objective  To describe the range and importance of encounters with biased patients and the barriers and facilitators to effective responses.

Design, Setting, and Participants  This qualitative study recruited convenience samples of hospitalist attending physicians, internal medicine residents, and medical students from 3 campuses affiliated with 1 academic medical center. Data were collected from 50 individuals within 13 focus groups from May 9 through October 15, 2018. Focus groups were conducted using open-ended probes, audiotaped, and transcribed. Participants used their own definition of biased patient behavior. Each transcript was independently coded by at least 2 investigators. Data were analyzed from May 2018 through February 2019.

Main Outcomes and Measures  Major themes associated with types of encounter, importance to the participant, and barriers and facilitators to effective responses were abstracted through the constant comparative approach.

Results  Overall, 50 individuals (11 hospitalists, 26 residents, and 13 students) participated; 24 (48%) were nonwhite. At total of 26 participants (52%) identified as women; 22 (44%), as men; and 2 (4%), as gender nonconforming. Reports of biased behavior ranged from patient refusal of care and explicit racist, sexist, or homophobic remarks to belittling compliments or jokes. Targeted physicians reported an emotional toll that included exhaustion, self-doubt, and cynicism. Nontargeted bystanders reported moral distress and uncertainty about how to respond. Participant responses ranged from withdrawal from clinical role to a heightened determination to provide standard of care. Barriers to effective responses included lack of skills, insufficient support from senior colleagues and the institution, and perception of lack of utility associated with responding. Participants expressed a need for training on dealing with biased patients and for clear institutional policies to guide responses.

Conclusions and Relevance  In this qualitative study of physicians and medical students, encounters with demeaning patients ranged from refusal of care to belittling jokes and were highly challenging and painful. Addressing biased patient behavior will require a concerted effort from medical schools and hospitals to create policies and trainings conducive to a clinical environment that respects the diversity of patients and physicians alike.

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