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Groundbreaking study seeks to quantify patient bias

Yale Medicine Magazine, 2018 - Spring


Doctor bias toward patients is well known, as are efforts to combat it. Classes at every medical school teach the ethics of health care and how to interact compassionately with the sick. Physicians have always taken this aspect of their profession seriously. They’re one of the few professions with an oath or code, and the Hippocratic oath’s requirement that doctors “do no harm” testifies to the great power they wield.

There’s another side to this: patient bias toward doctors. Surprisingly, far fewer studies have explored this problem. Funded by a grant from the AMA’s Joan F. Giambalvo Fund for the Advancement for Women, Yale researchers are attempting to quantify this old and pernicious form of discrimination.

“We’ve invested a lot of research into looking at physician prejudice toward patients, and how much of a role that plays in delivering effective health care,” said Basmah Safdar, MD. “Up until now, we haven’t really looked at it from the other side.”

Safdar is one of four experts from different disciplines who have come together to measure how patients feel about doctors of different races and genders. She and Rachel Solnick, MD, Gordon Kraft-Todd, a psychologist, and Kyle Peyton, a political scientist, aim to create a statistically and scientifically sound foundation on which further studies can be built.

“There’s been some research in this area over the past couple of decades,” said Solnick. “But this is the first study that’s experimentally isolating the physician’s race and gender to see if those elements are changing the patient’s ratings” of their doctors.

Kraft-Todd agrees. “I’m not aware of any studies specifically in the direction of patients’ attributes toward doctors about race or sex bias,” he said.

One inspiration for the study was a widely reported incident in 2017, in which a black female doctor was dismissed by airline attendants after responding to a request to render aid during a passenger’s health crisis.

Another inspiration was the wealth of anecdotal experiences of doctors, such as Esther Choo, MD ’01, MPH, who has written about her professional experiences with prejudice as a mother, a woman, and a person of color.

“Women physicians are perceived differently,” said Safdar. “It’s something that we often talk about, whether in the larger national community, or within specialties or among peers. People understand it and acknowledge that there is a disparity in perception, and then … they just move on.” Safdar hopes that if the hypothesis of the study—that patients demonstrate bias toward doctors—is proven, a baseline can be established that can help advocates find ways to make being a doctor safer for physicians. Especially given the phenomenon of physician burnout.

Based on extensive anecdotal evidence and prior studies that focused on doctors rather than patients, Solnick and the other researchers believe there could be a connection between bias and doctors becoming overstressed, reaching their emotional limits, and having to reduce hours or stop working altogether.

A 2007 study in JAMA: The Journal of the American Medical Association “found minority medical students who had reported adverse effects due to racial prejudices also reported higher amounts of burnout,” Solnick said. “Similarly, other studies report racial stressors for minorities. From this perspective, there’s a solid research base for this experiment.”

The study, “Race, ethnicity, and medical student well-being in the United States,” established a clear correlation between the racism that minorities in medical school experienced and lower quality of life as well as higher rates of depressive symptoms and burnout.

Another JAMA article described how doctors who are mothers experienced higher rates of burnout. This study, which started as a conversation in a Facebook group, was highlighted by Choo in an op-ed piece in the Huffington Post in 2017.

While bias may be just one cause of physician burnout, the issue has attracted attention at the highest levels, with tens of millions of dollars of productivity at risk.

Patient bias may also play a role in determining how and why it’s so difficult to close the pay gap between men and women in medicine. Patient satisfaction is one important factor in determining promotion and compensation, and if patients are inclined to be less satisfied with care provided by female or minority doctors, those women and minorities may be viewed as less valuable to their institutions.

“The recent focus on patient-centric care emphasizes quality metrics as the best way of measuring a patient’s experience,” said Solnick. “That’s important and necessary. But we need to determine how a patient’s internal prejudice may be playing into those quality metrics.”

Hospitals, clinics, private practices, and academic institutions actively seek ways to make medicine an equitable profession for everyone, while creating the most comfortable environment possible for patients seeking treatment. In some cases, these two imperatives may come into conflict.

Discussions of progress and personal testimony are good, but anecdotal evidence hasn’t been sufficient, according to Safdar. “Creating awareness based on feelings and perceptions is one thing, but concrete changes require data—especially when it comes to deep-seated cultural norms,” she said. From Safdar’s perspective, this experiment and others like it are crucial for continuing efforts to reach professional and social equality.

The study, which began in February and will likely be completed in April, relies on a web-based interface. It draws on technological advances that have been repeatedly validated in other studies.