Imagine a patient who, during a consultation, says to a clinician, “You sure are an attractive doctor. I wish I could date you,” or, “I don’t want a foreigner taking care of me. Can I see a real doctor?” or, “I was hoping for a white doctor.”

How should physicians respond when confronted with biased and offensive remarks from patients? An instinctive response could range from surprise, anger, frustration, disgust, to pity.1 The moral outrage at being discriminated against often is justifiable, even when if it threatens our role as health care professionals. But strong negative emotional responses may interfere with our ability to respond effectively and disrupt our professional commitment to patients.

These difficult clinical encounters become ethical concerns when physicians find themselves caught between competing professional values. There is the expectation, and in some cases, a legal right for health care professionals to practice in a workplace free of discrimination. Simultaneously, there is the professional obligation to ensure patient primacy, to hold unconditional regard for all patients no matter how objectionable their behavior, and to put their interests above those of the health care professional. Both of these values are needed for the delivery of safe, effective, patient-centered, respectful health care, and both may be subject to ethically appropriate limits.

Kicking patients out of a medical or surgical practice is almost an instinctive response when confronted with unjust discrimination. However, “firing” patients or removing them from a clinical practice can undermine their access to care, especially in underserved areas. Doing so also minimizes the profession’s ability to help the patient. Rather than prevent a patient from seeing us in our clinical practice, setting clear limits on problematic behavior is an important strategy to manage these encounters. Prior to doing so, however, clinicians have a number of considerations and conditions they should address.

First, by virtue of their illness, not all patients are necessarily fully responsible for their behavior. Patients with advanced neurological illness or dementia may be sexually disinhibited as part of their disease process. Patients with post traumatic stress disorder (PTSD) may have biased perspectives or behave inappropriately as a result of their illness. For example, veterans with combat-related PTSD from their military service in the Middle East may have trouble accepting care from a Muslim provider.2

Reasonable accommodation may be appropriate to address a patient’s legitimate needs and preferences and, in some cases, may be necessary for good care.3 Women frequently request to have a female gynecologic provider, which is often willingly accommodated and without controversy. Physicians should accommodate similar requests that are based on legitimate values and preferences.4 For example, a patient’s request to be examined by a member of the same gender in order to adhere to their sincerely held religious practice should be accommodated. African-American patients cared for by a physician of the same race have higher satisfaction, improved trust, and better health outcomes. Accommodating such a patient’s request for a race-concordant physician would be reasonable and promote quality care. Accommodation, however, does not mean that health care professionals should tolerate disrespectful comments or behaviors. Physicians need not condone comments or preferences that are clearly rooted in sexist or racist ideology.

Clearly and directly confronting a patient’s inappropriate comment when it arises is an effective way to address any potential concern and promote the patient’s continued involvement in their care. As in most challenging situations with patients, responding with anger is not likely to be effective and may escalate a conflict. Patients can be calmly informed that such comments are not welcome and that the shared goal in a health care relationship is to promote the patient’s care. This ensures that health care professionals advocate for themselves and a respectful work environment, while promoting the patient’s continued care. Clinically stable patients who willingly and continually ignore or disregard a physician’s appropriate behavioral limits should be referred for care to another colleague of equal competency.

Let’s return to the hypothetical patient described earlier to play out the scenario. What if a patient were to say to a physician, “I think you’re attractive. I wish I could see what you look like without that white coat,” or, “I didn’t realize my doctor was going to be a foreigner. Did you train in a real hospital?” The physician can pause to collect his/her thoughts and allow themselves to remain calm. The physician can then respond, “Your comments make me uncomfortable. I will not permit you to talk that way with me. I trust that you know that you will receive excellent care from me. I’m here to help and I wish to do that. Now, tell me what you hope to get out of today’s visit.” If this phrasing doesn’t work for you, or doesn’t seem like something you would say, consider modifying it to fit your personality. Whatever works for you, you should practice it so that you are prepared to say it confidently and calmly if the need ever arises.

Health care professionals have the right to protect themselves from unjust discrimination. Doing so, however, should not interfere with their professional commitments to promote patients’ access to care, even when their behavior is objectionable. These competing values should be managed, balanced, and addressed so that we continue to meet our professional obligations to our patients and ourselves.

David J. Alfandre MD, MSPH, is a health care ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York.

The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.

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References

  1. Jain SH. The racist patient. Ann Intern Med. 2013;158:632.
  2. Kheirbek, RE. At the VA, healing the doctor-patient relationship. Health Aff. 2017;36:1848-1851.
  3. Anstey K, Wright L. Responding to discriminatory requests for a different healthcare provider. Nurs Ethics. 2014;21:86-96.
  4. Paul-Emile K, Smith AK, Lo B, Fernández A. Dealing with racist patients. N Engl J Med. 2016;374:708-711.