Which of the following is the most appropriate action when the patient comes into the office for a singular problem and wants to discuss many problems with the physician?

The burden of discrimination can compound the stress of practicing medicine for physicians who are cultural and religious minorities. Hospitals have policies protecting against workplace discrimination at the hands of colleagues or supervisors. But when a patient is racist or biased towards a physician or other health care provider, there is often no recourse.

Through silence and inaction on this issue, hospitals may reinforce the isolation that clinicians of racial and religious minorities can sometimes feel in medicine. Particularly at a time when some Americans feel emboldened to speak and act in bigoted ways, clinicians need support managing patients who make derogatory and abusive remarks.

In the last rotation of my final year of medical school, I was asked to apply pressure to the femoral artery of a woman who had undergone cardiac catheterization to open her blocked coronary arteries. Since she was wide awake, and I would be standing next to her bed holding gauze firmly to her bleeding right groin for at least 30 minutes, I tried to break the ice by saying, “Guess we should get to know each other.”

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The patient was an elderly white woman who had spent 40 years teaching at a nearby suburban high school. She complimented me on making it to medical school and, without warning, gave me this advice: “Now, don’t waste your affirmative action.”

I was offended by her unspoken assumptions about my educational pedigree. What other presumptions had she made about me as a black American? In my head, much like a sitcom freeze frame, I imagined telling her off, delivering my curriculum vitae line by line as proof that I’d earned my spot in medical school and forcing her to acknowledge her racial bias. In real life, I just smiled and kept the pressure on her artery.

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Patient bias can be even more direct. I recently cared for an elderly veteran who, after being introduced to my intern, a Muslim American female with a last name that highlights her heritage, offered his complete thesis on how Islam was ruining the world and that all Muslims are terrorists. Although she was insulted, my intern did not confront the patient. After we had finished admitting him to the hospital, we commiserated on similar experiences. We used his age and possible post-traumatic stress disorder to soften the blow of his bigoted candor. In spite of his commentary, we cared for him competently and respectfully, just as we care for all of our other patients.

In the days following that encounter, I asked my colleagues if they had ever experienced anything similar. A Vietnamese physician told me about being called a “dirty incompetent g**k” by an angry patient experiencing alcohol withdrawal. During physical examination, a colleague discovered a large swastika tattooed on the back of her patient. Another was told by a patient that he looked more like “a common street thug” than a doctor.

A 2011 survey found that among 377 family medicine trainees, 35 percent experienced intimidation based on race, gender, or culture during their residencies. Recusing oneself from the treatment team is an option for some physicians, but most of those I spoke with ignored the racist or derogatory comments and kept working.

Guidelines for managing patient prejudice are hard to come by. A 2016 article in the journal Academic Medicine suggested a four-step approach for physicians confronted with a patient’s racism: 1] ignore such comments in an emergency; 2] focus the encounter on the shared goals of treatment; 3] depersonalize the event; and 4] foster a community of support within the hospital.

A New England Journal of Medicine article, “Dealing with Racist Patients,” offers an approach that incorporates consideration of the patient’s decision-making capacity and an attempt to understand his or her reasoning when, for example, a clinician of another race is requested. There are, after all, nuanced distinctions between patients who refuse care based upon a practitioner’s race for reasons rooted in bigotry and those who make similar requests based on religion or culture. Some data suggest that religious and cultural concordance between patients and their health care providers is associated with increased patient satisfaction, comprehension, and trust.

While that makes sense, it seems disingenuous to retreat to protocol without addressing the harm that a patient’s bigoted comment can have on a practitioner. Racism in medicine has been identified as a stressor for African-American physicians, and it is not a stretch to say that the distress caused by patients’ racially charged commentary may contribute to burnout.

Some degree of ignoring such comments and “rising above” the situation may be warranted to maintain workflow and professionalism. Yet physicians should also have the right to work without being targets for verbal abuse, threat, and intimidation based on race, gender or religion.

At its extreme, some have suggested racism could be included in the Diagnostic and Statistical Manual of Mental Disorders [sometimes erroneously called the bible of psychiatry] as a psychiatric illness of delusion. If we extend this logic, then doctors have a requirement to diagnose and treat racism when it presents in their exam rooms in order to prevent harmful acts by deluded individuals against targeted social groups.

If my colleagues and I err by ignoring patients’ bigoted comments or actions, then what should be the appropriate response? The answer isn’t simple.

Many institutions have committees on social medicine, multicultural affairs, or diversity and inclusion. Through the efforts of these groups — often led by minority physicians and students — teaching hospitals have integrated cultural awareness and sensitivity training into medical education. Such training has focused on coaching physicians to examine their own biases and how they influence patient care.

These are important steps in the right direction, but they alone aren’t enough. Medical education has fallen short in modeling the dialogue between health care providers and patients about patient-held biases. The result? Minority health care providers are often silent about their experiences with racism, religious discrimination, and other forms of bigotry in medicine. Majority providers, when they witness such acts, often fail to intercede on their colleague’s behalf.

In an ideal world, hospitals would categorically disavow cultural and religious discrimination. Hospital administrators would publicly refuse to cater to culturally biased demands and express a lack of tolerance for derogatory comments towards physicians and staff as a part of patient non-discrimination policies. All health care providers would receive training on how to facilitate dialogue that can productively challenge a patient’s racist or biased behavior. Hospital support networks would exist so minority providers could candidly discuss moments in training and practice where they’ve felt discriminated against.

The conversations we must have with our colleagues and patients are difficult and uncomfortable. Yet openly discussing bias is how we will put pressure on hospitals to consider how policies can be revised to better support minority physicians who are victims of demeaning remarks or actions. Our ethical responsibility to provide unbiased clinical care to all comers makes hospital administrators unlikely to take on this issue without pressure from physicians and other providers.

We will never eliminate racism and religious discrimination, but we work diligently to — at the very least — ensure that our hospitals are safe and affirming environments for health care providers to discuss how cultural and religious differences affect how we are perceived and treated by those whose lives we have sworn to save.

Lachelle Dawn Weeks, MD, is a resident in internal medicine and chair of the Social Justice Committee at Harvard-affiliated Brigham and Women’s Hospital in Boston.