Doctors, nurses and other staff members at the University of Rochester Medical Center are being trained in how to respond when patients take one look at them and say, basically, send someone else.
“Sometimes it happens when they first walk into the room,” said Adrienne Morgan, assistant dean for medical education, diversity and inclusion. “’I don’t want you to be my doctor because you’re black. I don’t want you to be my doctor because you’re Muslim. I don’t like your accent, I want somebody who speaks English.’”
Morgan said reports of implicit bias among patients have been increasing. She said the data are anecdotal, but the topic of patient bias is becoming a national conversation, and institutions are looking for ways to address the concerns because the encounters are taking a toll on providers.
To help providers respond and provide care, URMC is working with Theatre of the Oppressed, which uses creative and theatrical methods to resolve conflict. For the past month, Carli Gaughf of Theatre of the Oppressed has been artist in residence and has taught the techniques to nearly two dozen medical center employees so they can train others. The goal is to train workers throughout the medical center and then include staff on the River Campus.
“It engages the creative brain to discover what (people) can do to react to bias,” Gaughf said. “To become allies to people who are oppressed.”
Theatre of the Oppressed comes from the work of Brazilian Augusto Boal in the 1970s to help workers and the underclass rehearse for a revolution, Gaughf said. Its founder eventually was exiled.
It may be difficult to think of health care providers in the context of the oppressed. Often, health care is thought of as being biased against people of color and other marginalized groups. Morgan said the training eventually will address implicit bias on the part of providers, but right now the training is geared to address bias shown by patients.
The medical literature did reflect some patient bias toward providers, but mostly toward residents or other inexperienced doctors. The overwhelming number of articles were about provider bias toward patients of different racial or ethnic groups, or toward patients who are obese.
Morgan said bias against providers happens more often than people realize and want to admit. She said providers have written about it in non-academic journals.
She said the bias comes from a variety of patients, but she said the accounts she’s hearing are of white patients.
She said that being the recipient of bias causes distress among the providers and may give an impression that the medical center was unwelcoming. “We want to create an inclusive environment at the medical center and throughout the university. In order to do that, we need to ensure that everybody’s talents are respected.”
Theatre of the Oppressed is not a PowerPoint presentation where the speaker stands at the front of the room and reads slides. Participants role-play, do activities, write scenes and go from spectator to actor. The training teaches different ways to respond.
“In many cases it ends up with an ally who steps up and helps the colleague,” Morgan said. “A lot of times before colleagues wouldn’t step up as allies. We’re finding more and more people are stepping up and saying, ‘Can I help?’ Recognizing this is happening. Providers feel now they can openly talk about this.
Morgan said other academic medical centers are using Theatre of the Oppressed, and she has given presentations on how the program is working at URMC.
There may be a belief that outcomes are better when patient and provider are the same race.
A 2009 study on patient-provider race concordance reported inconclusive evidence that having a provider who looks like the patient was associated with positive outcomes for minorities. However, the study had a small sample of minorities and the authors wrote the more research was needed. There is inconclusive evidence to support that patient–provider race-concordance is associated with positive health outcomes for minorities. Studies were limited to four racial/ethnic groups and generally employed small samples of minorities. Further research is needed to understand what health outcomes may be more sensitive to cultural proximity between patients and providers, and what patient, provider and setting-level variables may moderate or mediate these outcomes.
Morgan said the providers aren’t being trained to change patients’ minds but to allow treatment to proceed. “A colleague may say, ‘I’m happy to help you, but Dr. So-and-So will still be your primary care provider.’ In an emergency situation, sometimes you have to roll with it. Maybe the patient says. ‘This time I’ll do it,’ but they may well find their care somewhere else.”