Physician mistreatment emerges as crisis that can ripple through U.S. health care

Further, close to 20% of responding physicians had experiences in which patients or their family members or visitors refused to allow the physician to care for them because of the physician's racial or ethnic attributes or gender.

"This is a staggering number," says Lotte Dyrbye, MD, senior associate dean of faculty and chief well-being officer at the University of Colorado School of Medicine. "Simply having patients or family members say, 'No, you can't provide care because of the way you look' -- not because of competency - is really heartbreaking."

In research published today, Dyrbye and her co-researchers surveyed more than 6,500 physicians nationwide about their experiences with mistreatment and discrimination in the course of doing their jobs. The research was conducted in collaboration with the American Medical Association (AMA).

"We wanted to understand how often it was happening, who it was happening to, and what are some of the intersections between race, ethnicity, and gender and physician mistreatment," Dyrbye explains. "We were interested in exploring the relationship between having negative interactions with patients, visitors, and family members and physicians' likelihood of being burned out."

Physicians frequently experience discrimination

Throughout her career, Dyrbye, who joined CU this month in her new role, has conducted extensive research on clinician burnout. She co-authored "Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being," a consensus study for the National Academy of Medicine, and co-developed the Well-Being Index, a validated online self-assessment tool for clinicians.

Her research has considered the stressors associated with working in health care, including aspects of the work environment that can lead to physician burnout. Among those stressors are racially or ethnically offensive remarks, unwanted sexual advances, and gender-based discrimination that can be a significant factor in physician burnout.

Dyrbye and her co-researchers have partnered with the AMA on large national surveys tracking trends in physician burnout for more than a decade. The first survey was in 2011, followed by 2014, 2017, and 2020.

After creating a survey that could be completed online or on paper, Dyrbye and her co-researchers launched the study more than six months into the COVID-19 pandemic, a time when clinicians were not only dealing with intense pressure at work, but public sentiment that could swing between honoring them as heroes to science-doubting harassment.

More than 6,500 clinicians completed the survey, "and the first thing that really struck us was how often these experiences of mistreatment and discrimination happen," Dyrbye says. "It's more common for women, and more common for racially and ethnically diverse physicians relative to white physicians, but the frequency of these experiences is what really stood out."

For example, 40% of Black male physicians and 40% of Indigenous female physicians reported having such experiences. And almost 25% of respondents reported experiencing unwanted sexual advances from patients or patients' family members or visitors.

"We have to support physicians"

The shocking prevalence of mistreatment of and discrimination against physicians by patients and their family members or visitors is a serious concern for the U.S. health care system. This study demonstrated that physicians who experience mistreatment and discrimination are more likely to have burnout, and previous research has demonstrated physician burnout is a factor in physician turnover and poor patient outcomes.

"It's a ripple effect," Dyrbye explains. "Burnout can lead to physicians cutting back on clinical time, which costs U.S. health care tons of money and magnifies workforce shortages, reducing access to care. Also, if physicians are burned out, they're more likely to have substance use issues, more likely to have thoughts of suicide. It's not only horrible by itself that these things are happening, but it's horrible because burnout has adverse consequences for patients and for society."

The research data add to existing evidence that there is a need for a multi-faceted approach to improving the crisis of physician burnout. Part of the response must happen in the work environment, Dyrbye says.

"Some organizations are implementing policies and procedures for patients who have repeated episodes of discriminating against physicians and other members of the health care team," she says. "There also are opportunities for chief wellness officers to partner with chief diversity officers to promote a culture of diversity, equity, and belonging within an organization."

She says there are steps that a clinician can take in the moment with a patient or their family members or visitor who makes an inappropriate comment. These include stepping in and saying something when a behavior does not align with organizational values, addressing the behavior with the patient or their family or visitor, setting expectations and boundaries, and if needed, reporting the behavior to leaders so that steps can be taken to terminate health care relationships with patients.

"You certainly can't abandon patients and you're going to tolerate behavior more from patients who are delirious, demented, or not competent," Dyrbye says. "But for the rest of the world, we can have higher expectations."

The responsibility to create an environment where every health care worker can thrive applies at every level of an organization, from policies and procedures to mitigate harassment and bias from patients, families, and visitors, to ensuring that all clinicians feel supported. It also requires providing training on unconscious bias and stereotype threat, and supporting clinicians in practicing self-care and crafting jobs that offers them meaning and purpose.

"It's also important for the general public to understand how burnout can impact them," Dyrbye says. "Why should they care that doctors are burned out? They should care because physician turnover and cutting back on hours directly attributable to burnout costs the U.S. health care system $4.8 billion every year. Burned out physicians reduce clinical time, they're twice as likely to leave practice, so then you're having to find a new doctor. Burned out physicians may also deliver more expensive and lower quality care. If we want high-quality, affordable health care, we must support physicians."