If a patient refuses care from a healthcare practitioner because of their race or sex, should their request be accommodated?
In a recent blog on Medscape entitled “No, You Can’t See a Different Doctor: We Need Zero Tolerance of Patient Bias,” Cleveland Francis Jr, MD, argued no.
Francis, who is Black, is a recently retired cardiologist who practiced for 50 years. He is currently Diversity, Equity, and Inclusion Advisor at Inova Heart and Vascular Institute in Falls Church, Virginia.
When Francis was a medical student and was preparing to take a patient’s history and perform a medical exam, the patient refused and requested a “White doctor,” he recounted.
“I can remember the hurt and embarrassment, as if it were yesterday,” he wrote.
The blog, especially the title, drew strong reactions. Close to 500 readers weighed in.
“The title of my blog sounds harsh,” Francis said, “but in reality, a simple conversation with the patient usually resolves these issues. The difference is that in the old days, there was utter silence, and the wishes of the patient would be granted”
Healthcare practitioners “should expect to be treated with respect,” he concluded his blog.
Readers agreed on that point, but they debated whether being uncomfortable with a healthcare practitioner of a different sex or race always constituted “patient bias.”
Some noted that difficulty understanding a practitioner’s accent, for example, is a legitimate reason for asking for another clinician.
Accents and Understanding
“If I am struggling to understand you because your accent is too thick…or because hearing aids can only do so much, I need to ask for someone else,” a reader commented.
Another chimed in: “My elderly parents changed PCP’s frequently during the final years of their lives, mainly due to language barriers encountered with foreign-born providers. Due to progressive hearing loss, they simply couldn’t understand them.”
“It is important to remember that there is a Patient Bill of Rights,” she noted, “the first part of which states, ‘You have the right to safe, considerate, and respectful care, provided in a manner consistent with your beliefs.’ “
A former charge nurse added: “If a request for change was substantive (poor communication, perceived incompetence, trauma history, etc.) I would move mountains to accommodate it, but IMHO [in my humble opinion], the belief in honoring patient preference doesn’t necessarily need to include rearranging the world in order to accommodate racism, sexism, etc.”
Bias Against Female Doctors, Male Nurses
Many commenters described how they gladly traded when a patient requested a practitioner of the opposite sex.
A female hospitalist related how she contacted the senior male doctor working with her to arrange a patient trade, adding “I do agree that racial discrimination ought to be discouraged.”
Similarly, a male ICU RN commented: “Over 13 years, I have had a handful of female (usually older) patients request a female nurse. I have always strived to make this happen.”
However, an older woman related how at first she “had some bias against a male nurse touching me and also felt self-conscious,” she said. “So, I tried to relax…and let him do his job. He was one of the most compassionate, kind and sensitive nurses I’ve ever had.”
“I think in some cases,” she noted, “some women have had a history of some sort of abuse by a male, whether it’s sexual or psychological,” but in other cases, “it’s often just a personal preference, not a bias.”
A physician assistant (PA) who worked in a rural ER recounted how “there was only 1 physician and 1 PA on at any given evening/night shift, both usually White males.”
“Sometimes, you just have to cope as best you can with whomever is available, and in doing so,” he said, “they might just end up being pleasantly surprised.”
Don’t Take It Personally, Move On
“If a patient doesn’t want to see me for whatever reason, then I would rather not treat them,” was a common sentiment.
Patients “should feel comfortable with their provider even if it’s with someone other than myself,” a reader wrote.
A female physician chimed in: “I frequently have older male patients refuse to see me…While this is irritating on a several levels, I recognize that it is the patient’s choice, sigh, and move on to the next patient.”
“There are many more patients who specifically ask to see me, so I don’t waste my time and energy on being bothered by those who refuse.”
Similarly, a female mental health provider and sometimes patient wrote: “If any patient tells me that they prefer a male…or someone of a particular race or religion or whatever, I don’t take it personally.”
A female Hispanic doctor chimed in: “Honestly, if a patient does not want to see me due to my race, I’m OK with that. Patients need to feel comfortable with me for the relationship to be therapeutic and effective,” she said.
“Forcing the patient to see me is adding injury to insult to ME! Not to mention increase[d] workload since that patient will take [so] much more time.”
Similarly, an Asian American doctor commented: “There are people who choose not to see me because of my ethnicity. However, I strongly believe that it should always be the patient’s preference. Whatever the reason, do not force the patient to see you in the name of Diversity, Equity, Inclusion, or whatever hurts your feeling. Let the patient go.”
Patient Bias vs Patient Preference
A physician referring to Dr Francis’ experience suggested that “perhaps there was an opportunity to explore this misconception directly with the patient. If not, your supervising senior resident or attending should have been informed and brought into the process and conversation.”
“If / when I were rejected by a patient for whatever reason,” another physician commented, “I would gracefully accede, and hope that my colleague would tactfully point out to the patient their error.”
“Having a nurse ask the patient…what they need style-wise (keeping race, gender, etc. out of it) might help identify whether or not the underlying issue(s) are based on style/needs mismatch match rather than bias,” a reader suggested.
A healthcare worker commented: “We generally assure patients that we are professionals and think nothing of situations that they might find uncomfortable, but don’t realize that our comfort does not translate to theirs.”
Maybe a Different Strategy Is Needed
“Having been the target of bias many times,” a reader said, “I understand the pain that is inflicted. Unfortunately, a patient bias policy, while a good idea, will not prevent patient bias. This is a much larger societal problem. But we can at least tell patients that it is not okay. On the other hand, I would not want to be the provider for a patient who was biased against me and held me in disdain.”
“I do not like Zero Tolerance policies ever. They are too absolute,” another reader commented. “Sometimes, there are reasons and we do have to listen to our patients for why. …I do not think a policy of zero tolerance will fix the problem of racism.”
“Instead of trying to educate the general public about how not to be jerks,” another reader suggested, “perhaps it would be easier to provide elective classes for doctors and employees who believe themselves to be at-risk for discrimination, providing them with a ‘toolkit’ of strategies for responding to discrimination in the moment, processing it emotionally later on, and reporting the most egregious events through designated channels.”
Another commenter agreed and wrote that, “While we as doctors need and deserve protection, we are also called to act with compassion. So, rather than ask the system for ‘zero-tolerance’ in either direction, we could encourage our health systems to provide education, support and mediation to any party who feels or fears that they are not being well served. Such a model would include support for physicians who have been the victims of bias and hurt.”
Marlene Busko is a freelance writer for Medscape.
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