I definitely think there may be some biases on the part of hospitalists,” says Ashish Boghani, MD, chief of the hospitalist service at Highland Hospital, Rochester, N.Y. As a young physician, he noticed some bias in his own thoughts and behaviors.
“But as I got more and more experienced,” he says, “if I was told by another provider that someone was a difficult patient, I left that outside the door. When I go into a patient’s room the first time, I start fresh—no matter what I read on the chart or heard from any staff or colleagues. … And it usually turns out that once you approach it like that … the situation turns out differently.”
In other words, if a physician doesn’t approach a patient with the bias of someone else’s interpretation, that patient will not necessarily be perceived as difficult. What about a physician’s own biases?
“A lot of a hospitalists’ interactions with patients are colored by our own experiences,” says Bilal Ahmed, MD, associate program director for the residency program and associate professor of clinical medicine, University of Rochester School of Medicine. For example, “when physicians see a patient who has COPD or cancer and is smoking,” he says, “there may be this thought at the back of their minds that this is something they brought upon themselves. [In that case] the empathy that you feel for that person may go down just a notch, which is a very human response.”
Dr. Ahmed often discusses remaining nonjudgmental with his residents. “But it is not that easy to always practice it, so it kind of creeps back in,” he says.
In particular, biases against obese patients are common and have been shown to affect a physician’s practice style. Research published in 2005 demonstrated that with regard to obese patients, poorer physical health, a lower level of education, and a lower income level were significantly associated with the doctor spending more time on technical tasks during primary care medical encounters, rather than engaging in educational interactions with these patients that encouraged health.1, 2
In a study of 62 severely overweight and 29 normal weight adolescents, satisfaction with affective aspects of the patient-physician relationship was negatively correlated with body mass index score.3 And although these were studies involving primary care, a physician’s specialty is irrelevant when it comes to these very human responses, says Howard Beckman, MD, clinical professor of internal medicine and family medicine at the University of Rochester School of Medicine and Dentistry.
In the once- or twice-monthly conversations Dr. Ahmed holds with his residents about the topic of obesity, “we look at the social, cultural, genetic, metabolic, and other components so we can understand that it is not just that the person is eating a lot,” he explains. “It’s multifactorial, and [there is] a complex set of facts that leads a person to be where they are.”
What’s Behind Bias?
“The areas where we judge other people may be just the areas where we are doing these things ourselves,” says Dr. Beckman. “Part of why we are the way we are with certain patients is that we fear that we may be like that person, and we want to blame them to let ourselves off the hook.”
Many types of patients may trigger an individual physician’s dislike or aversion, including passive patients, patients who smoke, overweight patients, depressed patients, patients who abuse various substances, non-adherent patients, whiny patients, passive-aggressive patients, and elderly patients.
“The movement in medicine is for insightful reflection about what the physician brings into the room,” says Dr. Beckman.
When he comes across a patient he does not like, Dr. Beckman asks, “This is someone I could not like, but do I want to not like them?” At that point, he is ready to make a conscious decision either to change his attitude or behavior or to seek a solution that protects patient care.
Insightfulness into the physician’s own history and family of origin is a cornerstone of the work being done by a number of physicians at the University of Rochester, including Dr. Beckman, an expert in physician-patient communication and the medical director for the Rochester Individual Practice Association (RIPA). For instance, was the hospitalist’s mother overly passive or his father an alcoholic?
Dr. Beckman addressed bias recently when he rewrote a chapter on difficult patients for a new edition of a behavioral medicine textbook.4 “One belief is that there are difficult patients; there is something about them that’s difficult,” says Dr. Beckman. “And in some cases that may be true. But what [investigators have now] recognized is that people who are difficult for one doctor [may] not [be] difficult for another doctor. And so it would appear that the variable is not the patient, but rather it’s the doctor.”
When this phenomenon was examined to a greater extent, “they tended to find that the type of person that the doctor doesn’t like, they’ve often seen before … usually in their family,” he explains.
Is Reflection the Answer?
Dr. Beckman believes it is the obligation of medical schools to help practitioners understand their own strengths and weaknesses, including their biases. He and a number of colleagues have just received a grant to study teaching the practice of such mindfulness to physicians. The study will investigate whether that education will ultimately affect a doctor’s cost of care. Essentially, Dr. Beckman says, it comes down to a question: Does knowing more about yourself change the way you practice?
At Strong Memorial Hospital in Rochester, N.Y., where Andrew Rudmann, MD, is chief of a hospital medicine division that includes 17 faculty members and 40 midlevel practitioners, physicians have not formally discussed having negative feelings toward their patients. But, “I think hospitalists would do well to reflect on their feelings about these issues,” says Dr. Rudmann, who is also associate director of the internal medicine residency program at Strong.
Reflection on what physicians bring to their medical encounters should take into account what Dr. Beckman calls “the three big pieces” of how humans work together in a medical encounter: “What is happening to the patient before the doctor walks into room, what is happening to the doctor before he walks into the room, and what happens in the room.” TH
Andrea Sattinger also writes about “vintage bugs” in this issue.
- Bertakis KD, Azari R. The impact of obesity on primary care visits. Obes Res. 2005 Sep;13(9):1615-1623.
- Robinson BE, Gjerdingen DK, Houge DR. Obesity: a move from traditional to more patient-oriented management. J Am Board Fam Pract. 1995 Mar-Apr;8(2):99-108.
- Cohen ML, Tanofsky-Kraff M, Young-Hyman D, et al. Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns. J Adolesc Health. 2005;37:163.
- Beckman H. Difficult Patients. In: Feldman MD, Christensen JF, eds. Behavioral Medicine in Primary Care: A Practical Guide. New York: McGraw-Hill Medical; 2003:23-32.