A few years ago, a young physician reported the following experience:
During my internal medicine rotation…a patient called me a “colored girl” three times in front of the attending physician. The doctor did not correct the patient, nor did she address the incident with me privately. Despite all the other positive interactions I had with this teacher, her silence in this circumstance diminished my presence. I wondered if she thought of me as a “colored girl,” too (Okwerekwu, 2016).
This physician’s encounter with a prejudiced patient is all too common in the United States, as was her supervisor’s inaction (Garan and Rasmussan, 2019).
Health-care trainees only fairly recently began to report being demeaned by patients for their race, ethnicity, gender, sexual orientation, or religion (Grady and White, 2020; Tedeschi, 2017). A systematic review of harassment during medical school, for example, found that 35 percent of trainees had been the object of patients’ discriminatory verbal abuse (Fnais et al, 2014).
Historically, there has been little attempt to prepare trainees for biased patients, leaving both trainee and preceptor caught off guard and ill-equipped to respond effectively (Wheeler et al, 2019). Consequently, when trainees experience racial and other biases from patients, they frequently report not knowing how to respond and also doubt that their superiors would act upon the complaint (Morrison et al, 2019; Paul-Emile et al, 2020).
The trainees also report fearing faculty repercussions and being perceived as unprofessional or “playing the race/ethnicity card” and, having little trust in their situation, ultimately worry about jeopardizing their evaluations (Osseo-Asare et al, 2018; Wheeler et al, 2019).
A preceptor’s inaction might be understandable. Although most medical centers have policies on how to work with challenging patients, most lack policies addressing patients’ expressed bias against their clinicians (Paul-Emile et al, 2020). Regarding this lack of preparation, Whitgob et al (2016) conclude: “[T]o our knowledge, the literature offers no recommendations for how to respond.”
In this current and momentous era of the Black Lives Matter movement, the response to patient bias requires an urgent call for action. Because of students’ vulnerable status, our first-order question within audiology must be: How do AuD preceptors respond when patient bias is directed at students?
Per American Academy of Audiology Past President Catherine Palmer’s (2020) vision of an inclusive profession, in a very real sense, preceptors are positioned as inherent front-line allies by virtue of their direct responsibility for student safety and welfare, as well as training.
The goals of this article are to (1) review the long-term impact of patient bias, (2) introduce the concept of duty of care, and (3) offer our recommendations for ways to respond as student allies if and when patient bias presents. Our focus here is on students of color, although this information also applies to students targeted because of their gender, sexual identity, religion, or ethnicity.
Impact of Bias: Long-Lasting Emotional Harm
When targeted by biased patients, health-care workers report experiencing physical and emotional exhaustion, anger, fear, self-doubt, isolation, moral distress, cynicism, emotional labor, and stress that lingers after the event (Cottingham et al, 2018). Mitchell (2019) documents the effects of repeated exposure to discrimination resulting in “a cascade of biopsychosocial sequelae…including elevated blood pressure and cortisol, increased heart rate, hypervigilance, amygdala activation, aggression, risk of depression, and increased incidence of substance use or abuse.”
In a New York Times article, Khullar (2017) explains in depth: “Research suggests that discrimination is internalized over a lifetime, and linked to a variety of poor health markers and outcomes: more inflammation and worse sleep; smaller babies and higher infant death rates; a greater risk of cancer, depression and substance use. The cumulative burden of discrimination is linked to higher rates of hypertension and more severe narrowing of important arteries in the heart and neck. Even the telomeres at the end of our chromosomes, which act as a sort of timer for aging cells, can shorten.”
Trainees in health care are especially vulnerable, given their lower professional status and social power. When confronting patient bias, they have reported uncertainty, confusion, and pain associated with biased patient behavior, which can understandably undermine their learning (Cottingham et al, 2018; Grady and White, 2020). Nonaction on the part of the preceptor can compound the hardship, which at the minimum could convey a lack of care and responsibility for the trainee’s well-being, or worse, could be perceived as implicit agreement with a patient’s bias (Paul-Emile et al, 2020).
Trainees may feel forsaken during patient-bias experiences, but their preceptors, as witnesses, also feel moral distress as well as deep uncertainty about how to respond (Wheeler et al, 2019). In addition to lacking skills and strategies for a response, they may not be confident of support from their own supervisors or their institution, and may doubt the value of responding at all, either in real time or in a debriefing moment.
Does the profession of audiology and its preceptors have an obligation to respond to patient bias directed to our students? Student advocates say yes, we have a profound ethical responsibility to protect students from all types of harm, also described as a duty of care (Bryden and Storey, 2011; Razack and Philibert, 2019).
Duty of Care in Clinical Training
The general use of the concept of duty of care refers to “a duty to use care toward others in order to protect them from unnecessary risk of harm” (Merriam-Webster Law Dictionary, 2020). The duty-of-care concept recently has been applied to a university setting, wherein a court held that “universities have a special relationship with their students and a duty to protect them from foreseeable violence during curricular activities” (Regents of California et al. v. The Superior Court of Los Angeles County, 2018).
The goal of expressed patient bias is oppression, described as a structural form of violence (Hamilton, 2020) and, while such incidents often cannot be foreseen, the statistical likelihood of occurrence is reason enough to acknowledge our duty of care in this regard. Knowing the enduring harm experienced from patient bias, preceptors have an ethical obligation to support students before, during, and after these painful moments (Garan and Rasmussen, 2019). As Paul-Emile (2019) sees it: “Preparedness is imperative because prevention is impossible.”
How to Prepare?
Noting the dearth of training support in this area, Paul-Emile (2019) developed an organization-wide protocol that includes the following steps: advocacy, debriefing, team meeting, tracking/data collection, and organizational culture change. However, not all of these steps apply to an audiology training site.
Additionally, we note the absence of a vital pro-active planning session to prepare for potential patient bias before trainees begin their clinical placements. As a starting point, then, we propose a smaller scale and modified protocol suitable for most audiology settings involving three steps: advance planning, real-time responses, and debriefing.
Full preparedness should mean creating a response plan before an event occurs. Student clinicians have no reason to automatically trust new preceptors; working toward trustworthiness requires candid and no doubt difficult conversations about the potential risk of patient bias, the student’s concerns, and the preceptor’s commitment to the student’s right to a safe learning environment.
Given students’ lack of power, the conversation must be initiated by the preceptor. For example:
“Neither of us can predict if or when a patient will express bias against a clinician. I am responsible for your safety, so I’d like to co-create with you a response plan: for instance, how to signal to me if you want me to address it. If you want to address it, I will back you up. If it gets worse, you can walk away. I can’t promise I will be skilled or effective, but I will try. If something occurs when I am not present, I ask that you let me know as soon as possible. How would you like us to proceed?”
Among the options is the audiology student’s right to respond directly. However, we now enter unchartered territory. There is virtually no guidance on how a trainee involved with patient care might effectively manage that option.
Pean and Hart (2019) recommend using verbal de-escalation techniques, but the examples given in their reference (Richmond et al, 2012) are designed for agitated patients in emergency situations, not typical audiology settings. Input from the field is urgently needed to support this area of professional development.
If the preceptor is present during an incident of bias, and if the student has indicated a preference for the preceptor to intervene, Warsame and Hayes (2019) suggest terminating biased comments and behaviors with firm responses such as: “Our clinic trains the best and brightest people to care for our patients, regardless of their race” or “We want to provide you with excellent care and believe our trainee is the right person to do so.”
If more directive responses are warranted, the patient should be advised that the observed biased behavior or comment is against institutional policies. An example of this kind of response is offered by the Mayo Clinic: “If patients’ or visitors’ behavior to staff is derogatory or abusive, it will not be tolerated and, if persistent, could result in termination of care…” (Warsame and Hayes, 2019). Needless to say, such policies must be developed, shared with patients prior to their appointment, and readily available in writing as needed.
Whether or not the preceptor is present during an incident, both preceptor and student must carve out time to review the situation and discuss how to respond the next time something similar occurs. Mitchell (2019) recommends using affective labeling (naming one’s emotions) as a coping strategy, because it has been well documented that discussing emotional reactions helps make sense of one’s feelings and frees the individual from being controlled by them.
Being able to “name it to tame it” can de-personalize the intended attack and validate one’s reactions as legitimate and just (Barrett et al, 2001; Creswell et al, 2007; Torre and Lieberman, 2018). The overarching goal of debriefing is to confirm with the student trainee that tolerating discrimination is never acceptable and that the preceptor is vigilant to his or her duty of care.
Now Is the Time!
There is much work to be done in this area—and it must begin now.
Patients can express bias in many ways, with overtly inappropriate language and with other actions that may be termed microaggressions, which are defined by Sue et al (2007) as “brief, everyday exchanges that send denigrating messages to people of color because they belong to a racial minority group.” Examples heard in health-care settings include comments on intelligence (“You are very articulate.”) or an assumption of “second-class citizenship” (Oh, I thought you were housekeeping staff.”) (Garan and Rasmussen, 2019).
Microaggressions are commonplace daily indignities (Sue et al, 2007) that many individuals experience. When these indignities are related to race, will a White preceptor be able to notice them?
Williams (2020) cautions: “Microaggressions are invisible to many White people because they are socialized not to see racial inequities…[and] as dominant group members, accurate identification is not necessary to ensure personal safety and well-being.”
Once sensitized, however, a responsive skill set must be developed beyond the suggested protocol offered here. Moving forward, whatever actions are taken, we must acknowledge that we are at a point where “quiet acceptance of biased patient behavior is not a defensible norm” (Paul-Emile et al, 2020).
Sue DW. (2015) Race Talk and the Conspiracy of Silence: Understanding and Facilitating Difficult Dialogues on Race. Hoboken, NJ: John Wiley & Sons, Inc.
Wheeler DJ et al. (2019) Twelve tips for responding to microaggressions and overt discrimination: When the patient offends the learner. Med Teach 41(10):1112–1117.