How should hospitals respond to bias from patients? Experts offer a playbook

All too often, health care workers are the target of biased or bigoted behavior from the patients they’re caring for — but many medical centers don’t have formal policies in place to help clinicians handle those incidents or the impact on staff.

A new set of recommendations, published Monday in the Annals of Internal Medicine, offers health systems a blueprint for better responding to incidents of patient bias. They say a “one size fits all” approach won’t work, and instead urge health systems to take a sweeping set of actions to make sure they’re prepared to handle such problems, which have long been documented. 

A 2017 STAT survey of 800 U.S. physicians, conducted in partnership with WebMD and Medscape, found that 6 in 10 doctors had absorbed abusive remarks from patients. Many felt that there was little support to help with coping with the trauma of their encounters. Women and people of color often bear the brunt of such incidents. The STAT survey also found Black and Asian physicians were the most likely to hear biased comments from patients. 

“We wanted to understand what’s going on out there, and more importantly what is the effect on physicians when this happens to them?” said Margaret Wheeler, a physician at Zuckerberg San Francisco General Hospital and Trauma Center and a co-author of the paper. “And then what made things better? What were the barriers that needed addressing? What were people doing that helped?” 

Wheeler and her colleagues acknowledged there are barriers to drafting and enacting patient bias policies. But they also said there are clear ways to overcome those challenges, and that doing so is critical for the well-being of their staff. 

“What I was seeing at some institutions was them saying, ‘Look it’s just too complicated — we’re gonna have a zero-tolerance approach we’re just not going to accommodate,’” said Kimani Paul-Emile, a law professor at Fordham University School of Law and lead author of the paper. But, she added, that doesn’t always work. 

“We created a framework for how health care institutions should think through these scenarios when they arrive,” she said. 

Here’s what that framework looks like. 

Have a specific policy for patient bias

Having something in writing creates the road map for navigating these sensitive issues. The policy should be written by individuals with knowledge and expertise in conflict resolution, medical ethics, legal advice, security services, and counseling support, the authors said. 

And having specific procedures for every role in the health care system — from nurses and physician assistants to doctors — is important, too. 

The authors also recommend developing protocols specific to trainees, such as interns.  The authors suggest that if a student is targeted by a biased patient, that student should be allowed to opt out of taking care of that patient. If the student decides to opt in, the trainee can work with physicians who offer clear guidance on how to handle such patients. 

Consider the needs of all staff, not just physicians

Nurses are on the frontlines of patient care and often have more one-on-one interaction with patients than any other member of the health care team. That can prove exceedingly difficult when dealing with patients exhibiting explicit bias. The authors suggest the rules to protect nurses, like those that deal with bias targeting physicians, need to be nuanced. That includes allowing nurses to decide when they want to be reassigned from a patient’s care and supporting them in that decision. It also means giving nurses permission to get consultation from colleagues when they are experiencing bias from a patient without first getting a physician’s signoff.

Create a system for reporting issues and supporting staff

“Written policies are only effective in a climate that supports reporting,” the authors write. That means medical centers need to create a formal system for reporting incidents of patient bias. The authors say that verbal policies can intimidate health care workers and discourage them from speaking up. Giving employees an anonymous, written system to report incidents of patient bias can help remove some of those hurdles. 

It’s also important, the authors argue, to have a dedicated team to field those reports, support the staff, and implement procedures. A strong support team that creates a safe environment can also encourage staff to disclose experiences of patient bias. A robust reporting system and a support team can also help health centers evaluate how well their procedures for dealing with patient bias are working. Those insights could prove useful in developing further trainings for employees. 

“Research on the experience of trainees and physicians underscores the need to include debriefing and team meetings as key components to encounters with biased patients,” the report says. A discussion with the entire team can help raise awareness about the many different ways bias can play out.