D Non-Discriminatory Requests for Provider Concordance or Reassignment

Identity Trait

Race/Ethnicity

Sexual Orientation/ Gender Identity

Non-Discriminatory Patient Requests for Provider Concordance or Reassignment

Do you have any Black heart doctors here? (from a Black patient)

Do you have a list of LGBTQIA+ or gender affirming providers? (from a LGBTQIA+ patient)

Gender No, I really want a female to do my gynecological exam. (from a female patient)

Provider Concordance and Reassignment Considerations

While some health care organizations promote the ability to choose your provider based on sex, race, and language spoken, this ability does not consider inpatient and emergency situations when providers are assigned to patients. Additionally, patient-provider concordance is not experienced during most encounters for racially/ ethnically diverse patients. One study found that 43% of respondents were “very” or “somewhat” concerned that their provider might not understand how their culture affects the type of treatment they would like to receive.28

As a result, hospitals need to equip providers to deliver culturally-informed and responsive care. Health care staff need to connect with all patients, regardless of observable concordance. Cultural competence training improves providers’ knowledge, understanding, and skills for treating patients from culturally, linguistically, and socio-economically diverse backgrounds.

Even if a request is not based in discrimination, it is not always possible to make a reassignment as it can disrupt workflow, impact the delivery of clinical care and set a precedent that cannot be consistently followed. In addition, race-based requests are not considered a bona fide occupation qualification exemption. As a result, hospitals must strive to increase the cultural competence skill of its providers to care for all patients, create policies, and educate staff on decision-making frameworks.

Hospitals must predetermine situations when they will attempt to accommodate requests for provider concordance or reassignment. Not all requests for concordance or reassignment are due to bigotry. Staff will need to identify when patients have reasonable motives that are clinically and ethically appropriate.

Patient requests that prompt consideration are:

1. Patient or family cultural and/or religious beliefs

Requests for gender concordance can occur for reasons of modesty, cultural beliefs and religious dictates. Examples include:

● Religious norms (such as Islam and Orthodox Judaism) that prohibit patients from exposing their bodies or being touched by gender-discordant physicians.29

● A request for providers to announce their entry and allow time before entering the room. For example, a male provider knocking on the door to allow for a Muslim female patient or family member to cover for religious reasons before the male provider enters.

● A request for a male provider to be accompanied by a female provider (or vice versa).

● A woman requesting a female physician for a gynecological exam.

● A person requesting a gender concordant provider to discuss sexual or reproductive health.

2. Rape, sexual abuse, assault, violence and trauma

In such cases, post-traumatic stress disorder symptoms or other psychosocial reactions may be elicited in the presence of a provider matching the perpetrator’s identity traits. This can include trauma experienced by prisoners of war, immigrants, refugees, and asylees.

3. Patient or family desire for culturally informed and responsive care

Some patients have justified mistrust or have previously experienced negative and biased encounters with providers. Examples include:

● A patient of color may request a provider of color

● A LGBTQIA+ patient may request a provider who identifies as LGBTQIA+

Patient accommodations should not be assumed without an explicit request from the patient or family—such as automatically assuming a patient will request a same-sex provider based on their appearance or implied religious background. Impacted provider(s) should be comfortable with the decision to accommodate non-discriminatory patients’ requests for concordance and reassignment. An administrator or provider must communicate the limitations of accommodating the patient, such as during an emergency or when staffing is negatively impacted. Refer to the Non-Discriminatory Requests for Provider Concordance and Reassignment Checklist in the Appendix for details.

Signage Considerations

● Door signs should never be used without explaining the specific accommodations to the patient, family, and health care team, including when and how they will be followed.

● If an accommodation is granted and signage is deemed necessary, inform staff not to use unapproved door or room signs.

● Inappropriate signage language includes, “Males Do Not Enter,” “No Women Allowed,” or “No Black Staff.” While staff may believe they are acting in the best interest of other team members (to protect them from being offended by the patient or family), they may unknowingly contribute to a hostile work environment.

● The hospital’s Interdisciplinary Working Group should consider whether door signs are necessary and create legally approved and ethically appropriate signage.

If signage is necessary, it should be translated into the most common patient-preferred languages at the hospital. Refer to the Appendix for examples.

Language Access Service Considerations

Scenario: Priyanka is a resident on morning rounds with other residents and an attending physician. The attending wants to demonstrate some skin findings on a patient, a Haitian woman with limited English proficiency who has an immunologic condition. The attending physician briefly explains, in English, to her and the residents, what they will be looking for. The patient gives a hesitant nod. He asks the patient to remove her gown and after a few moments of silence she begins speaking in Creole. Having spent a year working on a public health initiative in Haiti, Priyanka happens to speak Haitian Creole and explains to her in Creole that this is a teaching session.30

Providing care in the patient’s preferred language is a component of delivering safe, quality, and equitable care. Language Access Services should be fulfilled by a medical interpreter or qualified bilingual staff member (language concordant provider). The patient’s family or friends should not be used as interpreters. Ad hoc interpreters should only be used when there is an imminent threat to the safety or welfare of the patient and a qualified interpreter is not immediately available.31

Priyanka served as an ad hoc interpreter in the scenario. We do not know if her Haitian Creole language skills have been assessed and whether they are strong enough to interpret medical information in both languages and secure informed consent for the examination. Knowing there was a patient with limited English proficiency, the attending physician should have secured interpretation services for the patient before the encounter or upon noticing the need, requested an interpreter. Interpreter services should be accessible during all points of care, whether through phone, videoconference or in-person services.

- Ethical Considerations

A patient’s request for language assistance can be fulfilled by any language concordant provider or interpreter qualified to provide interpretation, regardless of their race, ethnicity, color, or national origin. For example, if a patient identifies as Haitian with a preferred language of Creole, the person serving as the interpreter does not need to also identify as Haitian to provide medical interpretation from English to Creole, as in the case of Priyanka. However, the interpreter’s language skills must be formally assessed. Language assessments are tailored for roles and available through language access companies.

An interpreter who shares the same ethnicity and/ or culture in addition to language may better understand the patient’s traditions and views on health care. There are rare circumstances where a limited English proficiency (LEP) patient may request an interpreter reassignment. Ethical situations that prompt consideration for medical interpreter reassignment are:

● The medical interpreter’s ethnicity or gender triggers trauma for the patient. This includes the experiences of enemy combatants, prisoners of war, refugees, and asylees.

● The patient has a relationship with the medical interpreter (family member, friend, or neighbor) that makes impartiality and confidentiality difficult.

- Legal Considerations

Patients who identify as LEP are protected under the American Disabilities Act and/or Title VI of the Civil Rights Act of 1964. Title VI prohibits recipients of federal financial assistance from discrimination based on race, color or national origin. Under Title VI, the patient’s preferred language is considered a component of national origin. The failure of a hospital to provide language assistance to a patient may constitute discrimination based on national origin.

Discriminatory Patient Requests for Concordance and Reassignment

In an Annals of Family Medicine article, J. Nwando Olayiwola, M.D., M.P.H., F.A.A.F.P., who describes herself as Black, of African descent, a woman, and someone with a long last name, recounts experiences of a White, swastika-bearing patient saying all Black, Hispanic, Asian, and Jewish doctors should be burned alive, another encounter with a patient who said she would rather die than be touched by a filthy Black doctor, and bartering with a patient on where her Black hands could touch them.32 Patients may begin an encounter with bias and microaggressions and escalate to making discriminatory requests for provider concordance or reassignment.

F IGURE E Discriminatory Requests for Provider Concordance or Reassignment illustrates the continuum of how a biased or demeaning comment can result in a discriminatory patient request.

When Microaggressions Become Discriminatory Requests for Provider Reassignment

Identity Trait

Common Patient-to-Provider Biases and Microagressions

Language (Said to a bilingual provider)

- You have an “accent.”

(Said to an Asian provider)

- Do you speak English?

Race/Ethnicity (Said to Black provider)

- Are you the doctor?

- No, where is the doctor?

Sexual Orientation/ Gender Identity

(Said to a provider wearing a rainbow flag pin)

- Oh, so are you gay!?!

Gender (Said to a female provider)

- The doctor didn’t see me yet.

- I thought you were the nurse.

Discriminatory Patient Requests for Provider Reassignment

I want a provider who speaks “English”. I want an “American” provider who speaks English.

I don’t want any Black providers to take care of me.

I don’t want “that gay person” to touch me! I want another provider.

Can I get a male doctor?

Can I get a real doctor?

Language and Accent Considerations

A Journal of General Internal Medicine study found physicians with a primary language other than English had twice the odds of experiencing racial/ethnic bias than their comparators.33 In some instances, requests for provider reassignment due to language and accent can be difficult to navigate.

The AMA Journal of Ethics cites an example in which a Black patient requests a Black physician instead of Dr. Chen, a physician who is East Asian. The patient states, “Dr. Chen is good, but sometimes I can barely even understand what he’s saying. You know? The accent?” At this point, the team member surmises the patient has difficulty communicating with Dr. Chen.

The patient continues and says, “I mean, everywhere you go now, it’s immigrants. Sometimes you just want someone who looks like you, you know?” Now, the team member must determine the patient’s primary motivator. Is it xenophobia, difficulty in communicating with Dr. Chen and/or increased comfort with a physician who identifies as Black?

Decision-Making Framework Considerations

Hospitals need in the-moment guidance to respond to patient requests for concordance or reassignment. The following table has been developed using guidance from Paul-Emile, K. et al. 34 and Chandrashekar & Jain.35 Refer to the Appendix for sample decision-making frameworks.

F IGURE F Provider Reassignment Considerations CONSIDERATION RATIONALE

The patient’s medical condition

The patient’s medical condition and the clinical setting should drive decision-making. In an emergency situation with a patient whose condition is unstable, the physician should first treat and stabilize the patient. Reassignment requests based on bigotry may be attributable to delirium, dementia, or psychosis, and patients’ preferences may change if reversible disorders are identified and treated. Patients with significantly impaired cognition are generally not held to be ethically responsible.

The patient’s decision-making capacity

Patients with impaired cognition may have reduced decision-making capacity and are not held to be ethically responsible. Examples include dementia, traumatic brain injury, psychosis and intoxication. Providers should proceed to treat the patient.

If the patient has capacity and refuses treatment from the available provider, then the refusal should be accepted. The refusal should be thoroughly documented to confirm the patient understands the risks, benefits and alternatives to their request.

Reasons for request

Identify the rationale for requesting concordance. Does the request stem from intimate privacy, religious, or cultural reasons? Or a biased or discriminatory rejection of a provider based on race, ethnic background, religion, or other identity traits?

Providers and hospitals should not grant discriminatory requests.

Effect on the patient

Determine if the patient’s health would be adversely affected if the request is not granted. Consider quality of care, safety, and potential delays in treatment.

Patient and Requests for Provider Concordance and Reassignment, 2023

Options for responding

Uncertainty about who should respond is cited as a barrier to responding. It can be difficult for the provider being targeted to respond to the patient. Discuss who will respond to biased patient behavior, such as the most senior person or a provider who is not of the group being targeted.36 The selected person can vary based on the situation.

Inform the patient that hateful, racist, or discriminatory speech or behavior is not tolerated.

Establish mutually acceptable expectations and conditions for patient care.

Determine if family members can persuade the patient to accept medically necessary treatment.

Identify if other physicians are available.

Allow a medical resident or nurse to evaluate the patient while maintaining responsibility and informing the patient that the standard of care is not being met.

Negotiate with the patient to provide care until another physician is on duty.

Inform patients in stable condition who persist with bigotry to seek treatment elsewhere if they object to assigned physicians. Outpatients can seek treatment elsewhere and inpatients can be transferred.

Effect on the provider

Is the provider safe during the encounter? While terminating a patient-provider relationship is not typically advised, there are situations when the negative effect on the physician may warrant termination. Consider the provider’s safety, well-being, potential for abuse and the impact of enduring a hostile work environment.

Does the provider want to continue care? If a provider feels unsafe, it is their right to exit the patient encounter, seek help from a colleague or supervisor, report the incident and consider transferring care.

As a cardiology resident at the Mayo Clinic, Sharonne Hayes, M.D., encountered male patients who commented, “You’re too beautiful to be a doctor,” and then proceeded to describe, in detail, what sexual acts they wanted to engage in with her.

And Kali Cyrus, M.D., M.P.H., a psychiatrist at Sibley Memorial Hospital, supervised a female trainee who reported that a male patient grabbed her crotch during a physical exam.37

Providers may decide to reassign care to avoid racist or abusive behavior from a patient. Refer to sample Guidelines for Staff Requests for Reassignment in the Appendix.