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Abstract
Biased patient behavior negatively impacts resident well-being. Data on the prevalence and frequency of these encounters are lacking and are needed to guide the creation of institutional trainings and policies to support trainees. To evaluate the frequency of resident experiences with and responses to a range of biased patient behaviors. A retrospective survey was sent via email to 331 second- and third-year internal medicine residents from 3 academic medical centers in California and North Carolina. First-year residents were excluded owing to their limited interactions with patients at the time of participant recruitment. Data were collected from August 21 to November 25, 2019. Descriptive statistics were used to report the frequency of experience of various types of biased patient behavior, residents' responses, the factors impeding residents' responses, and residents' experiences and beliefs regarding training and policies. Overall, 232 of 331 residents (70%) participated; 116 (50%) were women; 116 of 247 (47%) were White (participants had the option of selecting >1 race/ethnicity); and 23 (10%) identified as lesbian, gay, bisexual, transgender, or queer. The frequency of resident-reported experience of types of biased patient behaviors varied. The most common behaviors-belittling comments and assumption of nonphysician status-were reported to be experienced 1 or more times per week by 14% of residents (32 of 231) and 17% of residents (38 of 230), respectively. Women, Black or Latinx, and Asian residents reported experiencing biased behavior more frequently. Forty-five percent of Black or Latinx residents (17 of 38) encountered instances of explicit epithets or rejection of care. All 70 Asian residents reported experiencing inquiries into their ethnic origins. Most women residents (110 of 115 [96%]) experienced role questioning behaviors, and 87% (100 of 115) experienced sexual harassment. The need to prioritize clinical care and a sense of futility in responding were the most common factors (cited by 34% of residents [76 of 227] and 25% of residents [56 of 227], respectively) significantly impeding responses to biased behaviors. Eighty-five percent of residents (191 of 226) never reported incidents to their institution. Eighty-nine percent of residents (206 of 232) identified training and policies as necessary or very necessary. This survey study suggests that biased patient behavior is experienced frequently by internal medicine residents. Non-White and women residents reported experiencing a disproportionate burden of these incidents. Residents' responses rarely included institutional involvement. Residency programs and health care systems should prioritize training and policies to address biased patient behavior and support affected residents.
Highlights
Patients who demean physicians on the basis of physicians’ social characteristics pose multiple clinical and ethical challenges.[1,2] Biased patient behaviors arise when patients encounter physicians whose social identity is not compatible with their notion of a competent or appropriate health care professional
Eighty-nine percent of residents (206 of 232) identified training and policies as necessary or very necessary. This survey study suggests that biased patient behavior is experienced frequently by internal medicine residents
Study Setting and Participants We administered an electronic survey to second- and third-year internal medicine residents at 3 academic medical centers in California and North Carolina (University of California, San Francisco; University of California, Los Angeles; and Duke University)
Summary
Patients who demean physicians on the basis of physicians’ social characteristics pose multiple clinical and ethical challenges.[1,2] Biased patient behaviors arise when patients encounter physicians whose social identity (eg, race, ethnicity, or gender identity) is not compatible with their notion of a competent or appropriate health care professional. Data on the frequency of these occurrences among trainees—and even more so on physicians’ responses to them—are limited, as much of the literature consists of first-person physician accounts of interactions with racist patients or online surveys of practicing physicians.[5,6,7,11,12,13,14,15,16,17,18] A recent national survey of general surgery residents reported that 43% of residents experienced discrimination on the basis of gender identity and 47% experienced racial/ethnic discrimination from patients or patients’ families.[17] The same study found that residents who experienced demeaning behavior were more likely to experience burnout and to have suicidal thoughts. Internal medicine residents who encountered biased patients reported experiencing painful emotions including fear, self-doubt, exhaustion, and cynicism; residents who did not have these encounters reported moral distress and uncertainty about how to respond and support their colleagues when these situations arise.[3]
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