Table 2.
Exemplar statements from thematic analysis.
| Theme | Exemplars |
|---|---|
| A continuum of aggression | “I would say I felt like sometimes you do not hear the words but it’s the body language. I do pay special attention to people’s body language and how they communicate.” (Participant 1, p. 2) |
| “[S]o they say, well, I do not want this provider because he has a foreign medical degree…and they are clearly prejudicing…” (Participant 1, p. 5) | |
| “If the physician is a minority the patients tend to talk to the medical student and not the attending physicians, um, just kind of the way that, I think um especially female physicians tend to have that problem.” (Participant 5, p. 3) | |
| “I feel like the darker you are, the more prejudice there is.” (Participant 8, p. 8) | |
| “[T]hey used a few choice words at me and they said something along the lines of, “Go back to where you came from,” and then hung up on me.” (Participant 9, p. 1) | |
| “And there was a child in the room that said, ‘I have a question.’ And I was like, ‘Yes, what is your question?’ The child said, ‘Well when is the doctor going to come?’ and this is a child of color … so I said, ‘Well I’m actually the doctor.’ And with the straightest face, without pause, without hesitation, the child said, ‘You cannot be, because you are not. You’re black.’” (Participant 13, p. 3) | |
| “[S]o they scheduled and then when they found out that (resident) physician was actually Muslim, they were like, ‘Oh we do not want to … We do not want to see anybody like that.’ And like, I had to intervene there and talk to the patient, saying like, … ‘You either see them or you can see care elsewhere.’” (Participant 14, p. 4) | |
| “[T]he biggest one would be like, almost the veiled compliment of, ‘Oh you speak English really well,’ like with an assumption of ‘Oh, you are from somewhere far away…so it’s kind of like a micro thing.” (Participant 14, p. 1) | |
| “But when I first got here…there was a lot of like, ‘eye-stretching’.” (Participant 15, p. 1) | |
| Professional growth through adversity | “So, I have learned in a way to look beyond not the reaction but what was the cause of the reaction.” (Participant 1, p. 6) |
| “There are times when it’s curiosity … and I do not know if I’m reading too much into it either, because if this is coming from someone who is an immigrant themselves, I assume it’s curiosity.” (Participant 2, p. 4) | |
| “I’m more comfortable, um, explaining to patients of what my boundaries are, where, what the expectations are and where, what our, what our goals are and where we are in the patient-doctor relationship.” (Participant 5, p. 7) | |
| “So, the more experienced I’ve become, the more I’ve worked with, um, others both in my professional and personal life, the more I’ve evolved in terms of, um, responding to these types of situations.” (Participant 9, p. 4) | |
| “I think the main thing I tell myself is, ‘Do not take it personally.’ Maintain a professional relationship and respectful and um, you know with time, people will know who you are, what kind of doctor you are… Model yourself in a way that you are yourself. Hopefully. I try to educate myself not to be judgmental, not to have the bias, and hopefully the patient can see that too. I think through role modeling, through setting the example. That’s my philosophy.” (Participant 10, p. 5–6) | |
| “I feel like I have gotten better because I have ‘tools in my toolbox’ for how to address, um, a racist or a prejudiced patient because of what I’ve learned.” (Participant 15, p. 8) | |
| “[E]arlier I used to get mad or upset or annoyed about it. Now I’m, you know, it’s kind of like water on a duck, it kind of just rolls off me, unless it’s just egregious. Right? And even if it’s egregious, like it’s I’m annoyed or made for maybe 5 or 10 min and then I move on.” (Participant 12, p. 4) | |
| “So before, where I did not feel comfortable, I may not have felt comfortable speaking up because I was a resident who was lowest on the totem pole and of all the things in medicine the one thing, I probably do not like about it most is this concept of hierarchy…where the intern is the lowest person on the totem pole so they feel the most vulnerable, they feel the most unprotected and then they are the ones who are going kind of through the most changes, um, trying to establish themselves. Um, so you know when I encountered something, when I was an intern, I-I ignored it…I never reported anything to anyone, not once…. so when I –when I encountered them as a resident, it probably made me angrier sooner or faster or longer. Now, I’m a bit-I’m a bit dismissive about that. Dismissive just because of repeated, you know repeated offensives, right?” (Participant 12, p. 13) | |
| “[W]hen that happens you just try to deliver the best care that you can because that’s what we are trained to do and that’s what we want to do. I mean, I’m not going to let you affect my character. I’m going to treat you like I would treat my mom.” (Participant 15, p.3) | |
| Organizational interventions/issues | “Every institute should have their own policies about this.” (Participant 1, p. 8) |
| “Um so long as we are within this model of patients are, we are rating providers like an Uber driver um and I mean, the issue is that there should be reciprocity, right?…If patients also had a you know, a point system where they would not have a physician if they had a certain star system or whatever in the same way as providers are then they would behave themselves in a more appropriate way, however that’s not something we would ever want to encourage…I’m just pointing out how flawed the system is.” (Participant 5, p. 8–9) | |
| “[W]hen they, patients have unpleasant experience with the physician provider or our physician provider they go to patient care representatives and they inform them and the patient representatives come back to the provider and they get information too and try and sort out what the issues are and address the issue…so I think there should be something like, I’m not, um, I do not know if he can go and report that to the patient care…but like instances like bias or prejudices, I do not know if there’s a means for us to go to somebody in the system and say, ‘Hey, this is what I had experienced and is there any way you can speak or communicate with the patient and say that this is not appropriate.” (Participant 6, p. 6) | |
| “I think letting them know we cannot have them [prejudiced patients] here anymore, which seems very extreme but I think it supports, um supports your providers rather than the patients.” (Participant 7, p. 5) | |
| “[I]n our faculty meetings we have been having like, there’s been a lot of like, um, kind of how to be more like, proactive about these situations and how to be more of an upstander and so in some of those conversations there’s been a few strategies and one of them was like basically just trying to just acknowledge without supporting it.” (Participant 14, p. 1) | |
| “Um I think the biggest, like comes to like being a unified front as an office. So, I think like enforcing policy. Like we have great policies written down, but I think, you know, from a scheduling level to a if they call in and mispronounce someone’s name, like correcting them…kind of like nipping those microaggressions in the bud, but I think as a united front.” (Participant 14, p. 9) | |
| “And then, you get evaluated on your patient satisfaction scores and I think you have probably already seen the research that black and brown people have lower scores generally speaking…is it just because we are worse at our jobs collectively? Doubtful.” (Participant 15, p. 6) | |
| Role of colleagues: positive or negative | “I’m not saying it’s always a problem with the patient, sometimes it could be the physician prejudice and bias as well.” (Participant 6, p. 6) |
| “And, um, so work as a team, this way you do not feel lonely. I truly feel I’m not lonely. I truly feel like I have the support, you know my nurses, my front desk, and my medical director and ah, we all work together very well and we respect each other very well and ah, help each other. At least I perceive it that way.” (Participant 8, p. 9) | |
| “I’ve had experiences being treated by both attendings and by patients, ah, as being like, less smart or less confident, or less capable because I think being a woman and being a colored woman.” (Participant 8, p. 10) | |
| “It’s really good to have, to work in an environment that you feel like you are, you know, colleagues to support you and can talk to you and you can talk to them too.” (Participant 10, p. 7) | |
| “Some of our colleagues…still believe that because you sound different, because you look different, ah, because you were not trained as well, you are less competent than them until you sit down and test…then you realize that they were completely wrong… so my final word is like, it starts here at work…the change starts here.” (Participant 11, p. 8) | |
| “I’ve had patients say that to my face, ‘I do not want you as my doctor.’ See, I’ve had nurses text me that like, ‘Oh the so-and-so patient says they do not want you to come back into the room’ again.’ Right? If I’m the only provider then it’s not an option for them, it just is not. That’s the reality of how healthcare works in the hospital.” (Participant 12, p. 11) | |
| “So, I feel like the policy is great, but the execution is maybe not perfect because I think everyone’s natural tendency is to be like non-confrontational, so if a MOA at the front is like, getting a phone call they are more likely to say, ‘Oh so and so has a slot here, just go see them’…they do not like, make a stand because that’s more work.” (Participant 14, p. 5) | |
| Consequences for provision of care | [Recalling an incident in medical school where a patient was openly racist]: “And they brought security in and escorted her out. That did change our interaction and the care she got because she got escorted out of the clinic.” (Participant 2, p. 7) |
| “If you have a bad patient/doctor relationship, does that ultimately affect something in the patient interaction? And I would say yes, because a lot of medicine actually has nothing to do the actual treatments that would do. It’s actually the patient interaction.” (Participant 4, p. 7) | |
| “And so I think it’s easy to separate and still give good care. Maybe not the most personal care because you tend to then wall off a little bit and not say oh how’s your family or how’s your…the silly things you ask about especially in pediatrics…you just tend to be a little more quiet.” (Participant 7, p. 3) | |
| “And when I see that patient back, I know, that I do not feel as, I like them less naturally…I probably, to some level, do not spend as much time like following up with them or investing in their care, um, just because I did not appreciate how they treated, you know, our coworkers…I think that’s sort of natural…, the more you, the patients who are sort of nicer and respect the time you give them… you are going to give them more time.” (Participant 8, p. 5) | |
| “I mean, I think, it’s something that a lot of providers are used to, or you know, recognize that it’s just part of their job, and trying to separate like emotional reactions or personal feelings making sound medical decisions, so it may have led to like less lab work with the patient, maybe less frequent communication, um maybe, but I think in-in general, like in terms of the quality of medical care and providing the right diagnosis, or testing or treatment, I have not witnessed that being different.” (Participant 8, p. 6) | |
| “[S]o sometimes it’s being extra nice or taking extra time too with that patient or doing maybe you order more tests than you normally would because you do not want to displease this patient.” (Participant 12, p. 8) | |
| “But medically speaking I-medically speaking, I-I, if anything, medically speaking I’m actually, I try to be more, um, conscience-conscious of my own, ah, feelings towards that patient. Make sure that I’m doing what, I’m doing my due diligence right? And I’m not simply doing something because I, one, I’m dismissive of what they are saying, or because I do not like them.” (Participant 12, p. 9) | |
| “So, you have to, so I cannot say that it’s not going to affect some kind of care, if all you are feeling is disrespect for that patient. Does that mean you want to get them out of the hospital faster? It might. Does it mean you want to hand him off sooner? …And you-and you already know it. Is it-there has been tons of data, tons of literature, it shows the more ah, physician hand-offs, the more patient hand-offs you have had between physicians, the more families fall through the cracks, the more mistakes happen, the more bad outcomes, right? So even though we are handing these-we are handing these difficult patients off, that means information is inexplicably being lost, it’s being, information is just being lost, right? A new provider cannot know everything that happens with that patient prior to them taking it over. They just cannot. They can read as much as they can, but data’s going to fall through the cracks. Slight things: little conversations; little phone calls you have had with other consultants. So, like, so definitely at some level patient–patient care is being affected. (Participant 13, p. 3) | |
| “[Y]ou have to take that unfortunate truth and place it aside to deliver the care that you have been trained to deliver. Um, so I do not think it is impacted. Ah, for me, at least in my few instances it has not impacted what I, the caring I provide. I would still advocate for those patients the way I did regardless of the surrounding circumstances or situations.” (Participant 15, p. 3) | |
| “Um, but we have to admit that-that happens, and so, when that happens, you just try to deliver the best care that you can because that what’s we are trained to do and that’s what we want to do. I mean, I’m not gonna—I’m not going to let you affect my character. I’m going to treat you like I would treat my mom.” (Participant 15, p. 3) |