Posted with permission from STAT

This story was produced in collaboration with WebMD and Medscape.

Most doctors have absorbed racist, sexist, and other bigoted verbal remarks from patients under their care, according to a new national survey. And in interviews, physicians say these ugly incidents, while not frequent, can leave lasting scars.

African-American doctors told STAT they had been called racial epithets and been asked to relinquish care for white patients by family members - and even colleagues. Asian-American physicians reported being demeaned with longstanding cultural and racist stereotypes, and female doctors being sexually harassed by patients during physical exams.

A wide-ranging survey of more than 800 U.S. physicians, conducted by WebMD and Medscape in collaboration with STAT, found that 59 percent had heard offensive remarks about a personal characteristic in the past five years - chiefly about a doctor's youthfulness, gender, race, or ethnicity. As a result, 47 percent had a patient request a different doctor, or ask to be referred to a clinician other than the one their physician selected.

Fourteen percent said they had experienced situations in which the patient complained, in writing, about the doctor's personal characteristics.

African-American and Asian-American physicians were more likely to face such attacks, and female doctors were more often the victims of bias than males. But patients found targets in every imaginable corner: 12 percent of physicians, for instance, endured offensive remarks about their weight.

Amid a heated national conversation about open expressions of prejudice in America, the survey spotlights a facet of the issue that has, so far, received little attention: the biases patients direct toward their doctors in hospitals and exam rooms.

"I've certainly not read anything like this," said Dr. Beth A. Lown, associate professor of medicine at Harvard Medical School and medical director of the Schwartz Center for Compassionate Healthcare.

To explore issues raised in the survey, STAT interviewed Lown and eight other doctors and researchers around the country who are women or identify as members of minority groups. They described often disturbing encounters with patients.

Lown and others noted that patients have been more actively voicing their care preferences in recent years. "Has this changed socially accepted norms about what you can and cannot say to a health care professional?" Lown asked. "Is this ... unmasking attitudes that have been there all along and now, in our polarized societies, people feel less constrained in expressing them? Probably."

Medical researchers have studied clinicians' unconscious biases toward patients, said Kerth O'Brien, a social psychologist at Portland State University who studies discrimination in health care. "But much less is known about patients' biases toward clinicians, and that is why the current study is important."

"Why would patients allow their own irrational biases to get in the way of their health care?" she added. "Clearly we need to learn more."

The online survey of 822 physicians was conducted by Medscape's research team in July and August and has a margin of error of plus or minus 3.4 percentage points.

In the follow-up interviews, some doctors said they understand why patients might express their prejudices.

"Often we meet people at their lowest," said Dr. Nikhil "Sunny" Patel, a psychiatry resident at Cambridge Health Alliance in Massachusetts. "Sometimes we can have primitive responses to stressful situations, and one of them can be targeting of the other when we're feeling cornered or vulnerable."

But empathy only goes so far. Doctors who have been on the receiving end of verbal abuse said the medical system has barely acknowledged the issue, much less studied it or developed a response to it, leaving them largely on their own to deal with the psychic wounds.

In the survey, the vast majority of physicians said their organizations provided no training, or had no formal policies, on handling patient bias, or they didn't know about them.

The silence of well-intentioned supervisors who have never been trained in how to manage such situations can make matters worse, said Dr. Esther Choo, an associate professor at Oregon Health and Science University.

"There are a lot of people who've witnessed it, and who want to support their peers and simply don't know how. And in that void is more hurt," she said. "If you have a white preceptor and they're witnessing it and they don't say anything, the assumption is that they agree with it or they don't see it, or they see it but think it's not a problem."

Choo's Aug. 13 Twitter thread about her experience treating - or attempting to treat - white nationalists, unleashed a torrent of conversation among doctors who had endured similar experiences. In the wake of such dialogue, many researchers and health systems are looking at the issue formally for the first time.

Penn State Health Milton S. Hershey Medical Center is further along. Responding to an in-house study of discriminatory behavior by patients, it recently revised its "patients rights and responsibilities" policy to cover situations in which patients direct discriminatory behavior toward staff. The hospital now won't honor requests for a new physician based on patient prejudices.

The stakes are high, said Dr. Brian McGillen, Penn State Health's director of hospital medicine. "You come here and pour your blood, sweat, and tears for your patients, and then to have that stuff come up, absolutely it'll lead to burnout," he said. "There's no doubt in my mind."

Below, eight physicians who have felt the sting of discrimination recount their experiences, and how they coped.

While in medical school at Vanderbilt in the '80s, Patterson encountered an older gentleman from northern Alabama, who stopped him during their first meeting.

"He said, 'Why are you asking me all these questions?' I said, 'Well, sir, you agreed to allow students to interview you, examine you and so forth.' And he looked at me and said, 'Yeah, but when I said that, I didn't know Vanderbilt had [racial slur] in their classes.'"

Once people are entrenched in their beliefs, Patterson said, "there's not a lot you'll be able to do to change that attitude. So the way I've always dealt with it is to just move on. Take it in, try to stay on your feet, stay balanced and keep moving forward.

"But anybody who says they're not bruised by these encounters, we're sort of kidding ourselves."

The bruising can also come from the thoughtless reactions of colleagues. Patterson recalled that on his first day at George Washington University Hospital, he started an IV line for an older white patient.

The family soon objected to Patterson's care because he is black, and they met with his attending physician - a white woman who later approached Patterson with a compromise: He could enter the patient's room as long as he was accompanied by a white colleague.

"It was a little disappointing that someone who was supposedly a mentor and a teacher would think that solution would work. We both refused to do it. And I don't know if our attending ever really got it."

Patterson was eventually named as the director of the medical school's teaching program, where, at one point, a patient refused care from a team of trainees because they all were African-Americans.

"So we go down to the emergency room to greet this patient and she ... says, ‘Well, I want to talk to the person who's in charge of the teaching program.' And I said ‘You're looking at him,'" Patterson said.

But by the end of her hospitalization, Patterson added, "she came to me and said, 'I really apologize. I started off on the wrong foot. These young women took phenomenal care of me.'"

The most extreme examples of patient bias, Choo said, involve people who refuse to be treated by anyone but a white doctor. "It's not uncommon, but it's not every day," she said.

For her, the bias is expressed in a multitude of ways. "It's questions like, 'Do you feel like you can practice western as well as eastern medicine?' Or, 'Where are you from? Because we definitely hate Chinese doctors, but, oh, thank God you're not Chinese.' I just happen not to be. Or they'll say Oriental instead of Asian, or say other stereotypes about Asians they'll joke about or talk about in this weird way."

Her experiences with patient bias started as soon as she began her medical education, she said.

"I remember being surprised and embarrassed and humiliated as a medical student when people would say these things. ... When it happens to you as a trainee, you tend to think it's your fault on some level. I know that's weird. You think, ‘Maybe it's because I'm not competent or maybe I am less smart than a different doctor. Or maybe I shouldn't be here?' There's a lot of shame in being the target of racism, and I think that's part of it.

"It hardly every bothers me anymore. I usually make a joke out of it or deflect it, but the big question is how it's affecting our trainees and our junior doctors. What is the scope of this problem, and what's the sequelae?"

The questions loom large, she said, for an industry that is trying to grow more diverse.

"How do you do that when it's a really challenging and hard and long path, and on top of that, let's just tell you you'll experience racism - this extra burden. It's like running a race that's super hard. But one person's carrying an invisible heavy boulder on their back. They have to work so much harder."

Bigoted behavior can essentially paralyze doctors, Lown said. "Because of our sense of professionalism and our code of ethics, we're committed to letting that stuff roll off our backs, but meanwhile all your emotions are boiling inside, and you're thinking, 'Oh, my God, what do I do now? What do I say? How do I behave?'

"I'm very petite. I'm like 5 feet tall. So when I first started out, everybody would say, 'You don't look old enough to be a doctor.' All the time. Get me somebody who's a grown-up was the implication. ... It makes you very anxious - which exists in high titers anyway when you're in medicine."

More recently, one longtime patient, during an exam, suddenly turned the conversation to Jews, she said: "Like, 'All they're interested in is money, and they're out to cheat you, they're money grubbers' - the old stereotypes, and how you have to be on your guard all the time.

"I did nothing. And I was very upset with myself that I said nothing. But I didn't know what to say. I thought, 'Do you know that I'm Jewish? Are you really saying this to me?' ... I didn't tell anybody. There was no one to talk to about it. No one talks about this stuff.

"You just have to set it aside and compartmentalize it, and pretend somehow, somewhere that it didn't happen. My job is to be a professional, maintain some compassion and just don't let it influence your care. And that's a struggle."

Saha is one of the few who has researched patient bias, and he has also experienced it. "I'm a brown person who works in the VA, so we treat a lot of older white men who have kind of older white men's attitudes sometimes," he said.

One patient, for instance, asked to change doctors because he hated the smell of curry. "As if I'd come into the office with curry on my breath," said Saha, who is of Indian descent.

He eats curry infrequently, he said, and had not done so before seeing the patient.

Saha agreed to transfer the patient to another doctor. "When there is bias expressed by a patient, it's basically a deal killer, because to have an effective doctor-patient relationship, rapport is everything. And if you've got a patient who's disrespectful or untrusting for any reason, it basically poisons the relationship."

In one of Saha's research projects, he studied patients' comfort with people from other racial backgrounds. Patients who had negative views of other racial groups tended to rate their doctors worse in general.

"That might just be a reflection of the fact that people who have negative racial attitudes just have negative attitudes, period. But the white patients who had negative racial attitudes gave particularly low marks to minority doctors."

The discrimination has financial implications, Saha said, because it seeps into physician ratings, which can determine a doctor's compensation levels.

Faiz, who is 27, moved to Boston from the Bronx earlier this year to begin her residency as an emergency physician. Patients' sexist behavior has challenged her throughout her training.

"Patients making advances at me is degrading to say the least. Especially after all I've been through to get to this point. ... A lot of the patients I've worked with are very marginalized and disenfranchised - so it's not coming necessarily from a place of malice. They're sick. So I cope with this by not considering it a personal offense. But still, as with any sexist remarks, I walk away from those situations feeling totally unclean, even if I didn't do anything, and it was done to me.

"You're wearing professional clothes and you have the knowledge, and you're still being put in situation where people are asking about your personal life and asking completely inappropriate questions. I'm trying to work at it, and take time and reflect and step back, so I don't get disenchanted with the patients I'm serving and feel resentment toward them."

Patel said he was in his first year of residency training when a patient raged at him because the patient believed - evidently based on Patel's beard and the color of his skin - that Patel was a member of ISIS.

"It was like, 'Go back to where you came from; this is going to be our country again, you [expletive] raghead.' He decided to just leave the hospital and he stormed out. And I was actually very worried about him."

Patel said the experience shook him.

"That was probably the first time I've ever felt that othered. That feeling like, 'Wow, I've trained at decent institutions; I thought that would be a protective factor. I thought my clinical acumen would be protective against violent vitriol. I was deluded in that belief. This country I call home - is it home? Then where is home? I thought this country was a country of immigrants.

"And things can be less insidious than that. Like 'Wow, your English is so good.' Yeah, not to be arrogant, but I went to grad school twice. But that's not the point. The conceptualization of me, as a bearded brown man, is of the other."

Patel said that he has found support among a group of physicians that discusses such matters, but that the broader medical community should place more emphasis on addressing racism in the hospital.

"Our job is to be caretakers, but it's also to care for each other. To speak up for other health professionals on the team and not be punitive about it, but set the tone that we can't tolerate a culture where people feel targeted."

McGillen said patient discrimination against some of his staff members persuaded him to survey doctors at his hospital more broadly.

"I was not close to expecting the huge response I received: sexual orientation, ethnicity, suspected religion, female residents on the basis of gender. ...

"One patient's son pushed [a doctor] against the wall and called him a [homophobic slur] and asked him where he parked his camel."

Penn State Health convened a workshop on the topic, which helped convince hospital administrators to revise the patients' rights and responsibilities statement. That statement now explicitly prohibits patients from requesting a change of doctors on the basis of the physician's ethnicity, or religious or sexual identity. Women may still request a female doctor. And doctors who receive discriminatory complaints can switch the patient to another provider if they wish.

"In this day and age when people walk into hospitals and open fire, we need to be sure our workforce feels protected," he said. "We all want to honor this notion of patient experience - and improving that is certainly a goal, but you can swing the pendulum too far, and at the risk of damaging your staff, who you really need to be healthy and not be burned out by this stuff."

Like Saha, Whitgob has helped spearhead the study of patient bias toward physicians. She, too, has experienced such behaviors during her training.

"I remember being in a situation with male patients, in a surgical clinic at the VA, and I had to do general exams, and they made jokes asking whether am I enjoying it. People almost laughed it off, like 'Well, now I experienced it too.' I didn't stop to think, 'Am I being threatened?'"

Whitgob said her VA rotation was done in a month, "but if, day-in and day-out, that's what you have to deal with, or you're a nurse who deals with this every day, there's no escaping it."

Trainees, she said, have the option of declining to care for patients who direct abusive behavior at them. But supervisors must understand the importance of properly communicating the trainee's decision to patients.

If the supervisor tells a patient that the trainee has been removed, she said, "the patient who didn't want the trainee in the room is getting what they want. That wouldn't be the intention, but that would be the effect."

Whitgob said most hospitals support their medical staffs when it comes to biased patients, but they only do so in a "reactive" way, and not proactively state their policies in the manner of Penn State's new initiative.

"Ideally if every hospital system could adopt this policy, patients would say, 'I expect my doctor to respect me,' and doctors would say the same.

"We need to keep better records of this, because it's happening more than we know, and once people start talking about it, they bring up stories from 10, 15 years ago that they never thought they could talk about."