Survey data published in JAMA Internal Medicine indicate that biased behavior on the part of patients had a significant negative impact on physicians and trainees. Survey participants expressed a need for institutional policies and training programs to navigate patient bias.

Investigators conducted a qualitative investigation of physician and trainee experiences with patient bias. Convenience samples of physicians, residents, and students were recruited from the University of California, San Francisco School of Medicine. A total of 13 focus groups were held between May 9 and October 15, 2018, at which participants described their experiences. Focus groups were transcribed and coded by 2 independent investigators. The constant comparative approach was used to identify major themes regarding types of encounters, emotional toll of bias, and barriers to responding to bias.

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Overall, 50 individuals participated in study focus groups: 11 hospitalists, 26 residents, and 13 students. A total of 24 participants (48%) were nonwhite; 26 (52%) identified as women, 22 (44%) as men, and 2 (4%) as gender nonconforming. Incidents of biased patient behavior included racist, sexist, or homophobic epithets; inappropriate sexual/flirtatious comments; jokes reflecting racist stereotypes; and outright refusal of care. Less explicit biased behavior included patients questioning the participant’s role or credentials; gendered or flirtatious comments; and “aggressive inquiries” into the participant’s ethnic background. Many participants also expressed experience with “nonverbal” bias, including patients with tattoos with racist connotations. Biased patient encounters were associated with self-reported negative emotional effects, including “exhaustion, self-doubt, and cynicism.”

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Many participants reported difficulties learning or focusing in the presence of patient bias, although others indicated that such experiences improved their self-efficacy and determination. Participants described several barriers to confronting patient bias, including clinical priorities, fear of eroding the “therapeutic alliance,” and lack of experience in responding. Most participants expressed a desire for training or education on responding to biased patients. Additionally, participants endorsed the prospect of institutional guidelines for response to bias.   

As a qualitative study conducted at a single institution, results may not be generalizable to healthcare professionals as a whole. Even so, focus group data describe the substantial burden of patient bias in healthcare settings. “Addressing demeaning behavior from patients will require a concerted effort from medical schools and hospital leadership to create an environment that respects the diversity of patients and physicians alike,” investigators wrote.


Wheeler M, de Bourmont S, Paul-Emile K, et al. Physician and trainee experiences with patient bias. JAMA Intern Med. 2019;179:1678-1685.