Navigating Biased Patient Behavior—What Next?

On Monday, April 14, nearly 30 students, clinicians, and administrators responded by logging into a zoom call to engage with the topic of navigating biased patient behavior. Sponsored by the Racism and Bias Initiative (RBI) and facilitated by the Dean of Diversity and Inclusion, Ann-Gel Palermo, and the Dean for Medical Education, David Muller, this group joined together to tackle a powerful force in this crisis: racism.

To metaphorize the crisis, one might think of COVID-19 as an orchestra, each nefarious gene a different instrument, producing the vibrations that directly impact the listener, our patients. Racism then is one of many conductors (this is a special orchestra), determining tone, frequency, and direction. What we know from the news is that vulnerability to COVID-19 is inequitably distributed across this country, targeting Black, Brown, and Indigenous communities.

As many RBI discussions begin, we started with visualizing the issue at hand.

What comes to mind when we think of patient bias? Broadly, we could qualify patient bias as happening when patients make assumptions or assertions about clinical competency based on race, ethnicity, gender, etc. A definition however does not quite capture the spectrum of bias that physicians experience. From a patient jokingly asking for a Jewish doctor, to a comment about a physician’s “attractiveness,” all the way to refusing care from a Black physician, our group quickly came to understand that that bias takes many forms and therefore so must our responses.

One of these sites of response the group focused on was resilience. Some physicians shared personal experiences on how they learned resilience from patient bias. An interesting point was that resilience itself takes different shapes over one’s career. It may start as “anticipatory protection,” that stealing away before seeing a patient. But with time, resilience may look more like “embrace,” respectfully engaging the patient on their bias. When the patient asks, “But where are you really from?,” you may no longer feel this as a direct hit but rather smile, answer the question, and move along. While there was an unspoken sense that resilience can and will be learned, particularly by physicians from marginalized groups, Dean Muller posed a lingering and troublesome question to the group, “What happens to empathy for our patients when we are on guard?”

For students, this discussion not only fostered the passing down of lessons learned, but also modeled the oft unseen introspective work that a physician must do to ensure they provide the best care possible. While first-year students have limited clinical exposure, they have ample life experience. One student succinctly described the effects of bias as, “making you feel small.” Delving into the effects of “feeling small,” one student wondered if a patient’s bias towards them might stunt their burgeoning self-confidence and negatively impact quality of care in that moment and in the future? One of the greatest strengths of RBI Chat’s for Change is the diversity of the group in attendance. Not only are the possibilities for learning widened, but even student speech becomes powerful as it radiates across different spheres of stake-holders. While we do not end with formal “to do’s” administrators and faculty might leave with an eye towards the student burden of “feeling small.”

This Chat for Change came to its close around a dialogue on the roles of whiteness, silence, and bystanders in enabling patient bias. One participant asked, “Do your white colleagues understand this reality? Is it part of their education? Are they equipped to be allies?” Some barely audible “no’s” and “yeah’s” came through, lost to the muddling that sometimes happens on Zoom.

Undeniably, there was no resounding “Yes!” To this point, participants discussed the need to be “upstanders,” trained on how to professionally intervene on behalf or yourself or other healthcare providers. One participant offered Mount Sinai’s Morchand Center as a site already offering practical training along these lines. But “upstanders,” cannot be trained into existence; this work needs to be sanctioned and supported by the institution.

A physician shared that one way health institutions undermine “upstanders” is the lack of policy on acceptable reasons to transfer care to another physician. One participant shared how the carte blanche granting of change of care silently corroborates a patient’s belief that a differently raced, gendered, or identified physician might provide better care. Despite an institutional barrier, this physician became an agent of change when they consulted with their leadership and found them to be receptive, even garnering a verbal commitment to more closely examine these requests.

Deeply imbricated in the history and present of our health institutions and health crisis, racism is not a task, nor even a conglomeration of tasks. We did not leave this chat knowing what to do, instead, we challenged ourselves to be troubled by “what’s next,” and to ask it of ourselves with frequency and rigor.