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Patient And Coworker Mistreatment Of Physicians With Disabilities

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The mistreatment of physicians and physician trainees, including discrimination, harassment, physical harm, or threat of physical harm, is increasingly common, with damaging personal and professional consequences.1–3 Mistreatment can come from peers4,5 and patients,1,2,6–9 and experiences of mistreatment are often more frequent for physicians identifying with groups underrepresented in medicine.8,10–17

For example, Amarette Filut and colleagues’ 2020 systematic review of workplace discrimination research found a high prevalence of discrimination aimed at physicians of color, particularly Black men and women.11 Researchers have also extensively documented harassment and bias against physicians on the basis of their sex, gender, and sexual orientation.4–6,12,14,16–18 Emily Vargas and colleagues’ survey of a medical faculty at a single institution found that the vast majority of physicians (82.5 percent of women and 65.1 percent of men) experienced some type of sexual harassment within the previous year from “insiders.”6 In addition, 64.4 percent of women and 44.1 percent of men also reported being sexually harassed by patients or patients’ families.6

Research has also examined mistreatment directed toward medical residents. Yue-Yung Hu and colleagues surveyed 7,409 US surgical residents and found that nearly half had experienced some form of mistreatment during their residency training, including gender and racial discrimination, verbal or physical abuse, or sexual harassment.1

Mistreatment of physicians is a growing concern, given its link to physician well-being.1 Studies by Hu and colleagues1 as well as by Kathi Kemper and colleagues19 found that this mistreatment among trainees is associated with higher levels of burnout and suicidal thoughts. Similarly, a smaller cross-sectional survey of medical residents at a California teaching hospital found that the 25 percent of residents who had personally experienced mistreatment were almost eight times more likely to report burnout.20 Residents who had personally experienced mistreatment were also almost four times more likely to report symptoms of anxiety and depression than those who had not experienced mistreatment.20 Throughout the literature, mistreatment is correlated with burnout,20–22 depression,12 suicidality,1 and job attrition.23

Physicians with disabilities are among groups underrepresented in medicine, representing only 3.1 percent of the active US physician workforce.24 Physicians with disabilities offer unique, essential, and valuable contributions to a diverse and inclusive physician workforce.25–27 Understanding the prevalence of mistreatment of disabled physicians can inform workplace policies to promote and support diversity, inclusion, and equity. However, research examining the mistreatment experiences of disabled physicians is lacking. This study aims to fill that gap.

(Please note that in this article we use both person-first language [for example, “person with a disability”] and identity-first language [for example, “disabled person”]. This usage recognizes and respects the variation in preferred language among people with disabilities.)

Study Data And Methods

We used data from the Association of American Medical Colleges (AAMC) National Sample Survey of Physicians (NSSP), a nationally representative sample of 6,000 practicing physicians collected between February and March 2019. The data were weighted based on the American Medical Association Physician Masterfile to represent all practicing physicians in the US regarding specialty group, gender, age group, and international medical graduate status. Information regarding survey methodology has been published elsewhere.24 This study was deemed exempt by the American Institutes for Research Institutional Review Board.

Respondents were provided with the definition of disability from the ADA Amendments Act of 2008.28 They were then asked, “Do you have a disability as defined by the [Americans with Disabilities Act]?” Next, respondents reported the frequency (never, once, between two and five times, and greater than five times) of mistreatment by patients and coworkers within the past twelve months. Types of mistreatment included physical harm and threats of physical harm, unwanted sexual advances, and offensive comments regarding the respondent’s gender, sexual orientation, race and ethnicity, disability, or personal beliefs. Options for types of mistreatment were not defined further. These questions are also asked in the AAMC’s Graduation Questionnaire.29

Experiencing mistreatment is a relatively rare event and is unevenly distributed. To account for this, we dichotomized the mistreatment variables into “never” and “at least once” (including the frequency categories of once, between two and five times, and greater than five times).

Statistical Analysis

We ran a multivariate logistic regression to assess whether physicians with disabilities were more likely than nondisabled physicians to experience mistreatment in their workplaces. To ensure that external factors did not influence the measured effects, we controlled for demographic variables (age, sexual orientation, marital status, and race and ethnicity), workplace characteristics (practicing primary care and employment type), and international medical graduate status. We used Stata software, version 14.2, to conduct the analysis.

To verify the robustness of our results, we also ran firthlogit and ordered logit model.30,31 We obtained similar results from each model, and therefore we report only the results of the multivariate logistic regression.

Limitations

Our study had limitations. First, disability status and experiences of mistreatment in our study are sensitive and were self-reported. Although the survey responses were confidential, disability status and mistreatment experience can be underreported because of fear of identification. Second, our study used the definition of disability provided by the ADA,28 which is short and might not fully capture the breadth of disability in this population. Third, our mistreatment variables were not defined, potentially leading to disparate interpretations of mistreatment by respondents. Finally, given society’s prevailing construct of disability, physicians with disabilities in practice might not identify as disabled, even if they would qualify as disabled under the ADA.

Study Results

Among the 5,851 participants in the NSSP who provided data on their disability status, 178 (3.1 percent) reported a disability (169 unweighted). A previous analysis of NSSP data to examine the characteristics of physicians with disabilities revealed that they were significantly more likely to identify as having a race or ethnicity that is traditionally underrepresented in medicine and to identify as transsexual, bisexual, gay, or lesbian.24

The majority of physicians with disabilities reported at least one type of mistreatment (64 percent; data not shown). Compared to nondisabled physicians, physicians with disabilities reported relatively more experiences of all types of mistreatment both from coworkers and from patients (exhibit 1). Compared with nondisabled physicians, a higher percentage of physicians with disabilities reported having received threats of physical harm from coworkers (27.6 percent versus 4.8 percent) and patients (39.9 percent versus 22.6 percent), and physicians with disabilities also more often experienced actual physical harm from coworkers (24.6 percent versus 1.8 percent) and patients (26.3 percent versus 5.3 percent). In addition, 31.3 percent of disabled physicians reported unwanted sexual advances from coworkers and 39.9 percent from patients in the previous twelve months.

Exhibit 1 Percent of surveyed physicians who experienced mistreatment at least once from coworkers or patients during the previous 12 months, by type of mistreatment and disability status, 2019
Coworkersa

 Patients
Types of mistreatment Physicians without disabilities Physicians with disabilities Physicians without disabilities Physicians with disabilities
Subjected to offensive sexist remarks 12.1% 27.1% 18.1% 35.8%
Subjected to racially or ethnically offensive remarks 11.8 28.4 21.3 33.3
Subjected to offensive remarks or names related to sexual orientation 5.3 23.1 6.1 22.6
Subjected to offensive remarks or names related to a disability 3.5 28.7 3.8 28.7
Subjected to offensive remarks or names based on your personal beliefs 10.6 24.5 13.5 27.8
Threatened with physical harm 4.8 27.6 22.6 39.9
Physically harmed 1.8 24.6 5.3 26.3
Subjected to unwanted sexual advances 7.5 31.3 16.4 39.9

Exhibit 2 illustrates the extent to which physicians with disabilities have experienced more bias, harassment, and physical harm than physicians without disabilities. Compared to their nondisabled peers, physicians with disabilities had a significantly higher likelihood (p<0.001) of experiencing every measure of mistreatment from patients and coworkers in the twelve months before the survey.

Exhibit 2 Odds ratios for physicians with disabilities having experienced workplace mistreatment at least once during the previous 12 months compared to physicians without disabilities, 2019

Exhibit 2

SOURCE Authors’ analysis using data from the 2019 National Sample Survey of Physicians, developed by the Association of American Medical Colleges. NOTES These coefficients are odds ratios. The logarithm of the odds ratio is the difference of logits of the probabilities. Each dot represents the odds that physicians with disabilities were more likely than physicians without disabilities to have experienced that form of mistreatment by a coworker or patient; the corresponding line represents the 95% confidence interval. All odds ratios are significantly different from 1.0 (p<0.01). Analyses controlled for the following: age, gender identity, sexual orientation, marital status (married), race and ethnicity, employment type (hospital-based), primary care (pediatric, emergency, internal, and family medicine), and international medical graduate status. See the appendix for full regression results (note 32 in text).

For example, physicians with disabilities were more likely to have been threatened with physical harm by coworkers (odds ratio: 8.03) and patients (OR: 2.6). Disabled physicians were also more than seventeen times more likely to have been physically harmed by coworkers and 6.5 times more likely to have been physically harmed by patients, and they were 5.8 and 3.6 times more likely to be subjected to unwanted sexual advances from coworkers and patients, respectively. The full model is in the online appendix.32

Discussion

This study found that 64 percent of physicians with disabilities experienced some form of mistreatment in 2019, putting them at much greater risk of mistreatment than the general population of physicians. These findings mirror previous research showing that physicians from historically marginalized communities are at higher risk of mistreatment.1,8,10–17 Given the pervasive negative views of people with disabilities,33,34 the lack of knowledge about treating disabled patients,26,33 and the disabled community’s long history of poor experiences with the health care system,34,35 these findings are not surprising. Furthermore, personal accounts from physicians reflect deeply embedded ableist attitudes in the workplace from peers36,37 and patients.25,38

Disabled physicians face unique and nuanced challenges in their training and employment environments.

Disabled physicians face unique and nuanced challenges in their training and employment environments. For trainees and physicians with disabilities, the pathway to successfully training and working may include using accommodations, necessitating disability disclosure.39 However, fear of bias, stereotype, stigma, and workplace mistreatment may result in low disclosure rates.40 Researchers investigating mistreatment in the LGBTQ+ population suggest that nondisclosure leads to internal stress, cognitive preoccupation, and hypervigilance among trainees.5 Indeed, fear of bringing one’s authentic self to the workplace to evade mistreatment may create internal stressors,5 increase cognitive load, and foster a “grin and bear it” mindset.40 Nondisclosure may also necessitate workarounds without accommodation, resulting in additional fatigue, physical or mental distress, and feelings of isolation.

In addition, our findings may partially explain the declining prevalence of people with disabilities across the medical education-to-practice continuum. Research on the prevalence of people with disabilities in medical school, residency, and practice shows a decline in prevalence as trainees enter residency, with more significant declines as they progress to practice (8.3 percent, 7.5 percent, and 3.1 percent, respectively).24,29,41 If the employment climate includes high levels of mistreatment, including verbal and physical harm, physicians with disabilities may choose to exit the workforce.

Mistreatment of disabled physicians also may affect patients and the community at large. Given the known association between mistreatment and burnout1 and the negative impacts of burnout on patient care,42,43 mistreatment of disabled physicians could harm the patients they serve.

Mistreatment and discrimination against physicians with disabilities carry ethical and legal implications. First, the ADA protects people with disabilities against discrimination in the workplace, with consequences for discriminatory workplace behavior. Second, the horrendous treatment of people with disabilities revealed by our study suggests a frightening disconnect between the avowed commitment to increase diversity within medical organizations and the effectiveness of their actions to protect those they employ.

Data, Disability Training, And Reporting Mistreatment

Institutions should explicitly collect data about disability,44,45 allowing for monitoring of recruitment and retention in the workplace and helping identify where attrition of disabled physicians might occur. In addition, reporting systems for mistreatment must be shared broadly, be incorporated into trainee and employee onboarding, and allow individuals to report encounters where disability is the root cause of the mistreatment. Policies must provide clear expectations for employees and patients specific to multiple elements of harassment, including overt and covert behaviors. Leaders must codify clear consequences for those who do not comply with nonharassment policies.

Although the interventions presented above will help, they are not enough without a culture of trust and accountability. Physicians fear retaliation for reporting incidents of mistreatment and inaction. A 2020 study3 found that almost half of the clinical faculty in a department of surgery said that they would not report an incident of harassment, believing that “nothing would be done.” Thirteen percent of these faculty members said that they would not know the process for reporting, whereas 25 percent feared reprisal for reporting.

Physicians with disabilities may also fear losing their jobs. Indeed, the literature on disabled employees, in general, suggests that fear of retaliation and fear of losing employment are significant drivers for disabled employees’ nonreporting.40 Given these concerns, institutions must recognize the necessity of creating working and learning climates, cultures, and policies supporting the reporting of mistreatment. Institutions must then take action when mistreatment is reported and provide protections against retaliation. Finally, training and reporting mechanisms should also be available for peer bystanders. Bystander training should include mechanisms for de-escalating mistreatment by patients and peers.

The highest-ranking leaders of health care institutions should endorse these training and policy implementations by stating their commitment to disability inclusion, communicating a zero-tolerance approach to disability discrimination and mistreatment, and teaching mechanisms of disability inclusion and the value of disabled physicians in the workplace.

Belonging For Physicians With Disabilities

People with disabilities report desiring a sense of belonging in the workplace and not wishing to be treated as “special” or different because they have a disability.40 As with most physicians, physicians with disabilities want to be valued for their unique contributions to medicine,25 including their increased empathy and lived experience as patients.36,46–48 Therefore, workplaces should include disability in their broader justice, equity, diversity, and inclusion efforts.

Efforts to address and eliminate mistreatment of physicians with disabilities must target both peer and patient populations.

Further, institutions should communicate their commitment to disability inclusion in policies and materials shared with patients and the public. Given our findings that disabled physicians are almost equally likely to have experienced mistreatment from coworkers and patients, efforts to address and eliminate mistreatment of physicians with disabilities must target both peer and patient populations.

Conclusion

This study offers the first comprehensive national assessment of physician mistreatment among physicians with disabilities. Our findings highlight the need for immediate systems-level intervention and training focused on the value of disabled physicians and the need to create safe, equitable, and supportive workplaces. Physicians with disabilities experience mistreatment frequently, with moral and material consequences. The continued mistreatment and subsequent attrition of physicians with disabilities in the physician workforce reduce the potential for mentoring future generations of disabled physicians.

Physicians with disabilities in our study were three times more likely than nondisabled physicians to receive negative remarks about their race or ethnicity and five times more likely to receive negative remarks about their sexual orientation. These findings suggest that there is unique and potentially exponential mistreatment occurring at these intersections, and they warrant further research.

Finally, although quantitative data provide a global view of the landscape, future efforts should be made to conduct qualitative interviews with physicians with disabilities across several employment settings and specialties to gain more detailed information about their experiences. Such additional data will help refine interventions and improve the climate for physicians with disabilities.

ACKNOWLEDGMENTS

Lisa Meeks and Sarah Conrad are co–first authors. A previous version of this work was presented at the 2022 Association of American Medical Colleges (AAMC) Health Workforce Research Conference (virtual), May 4–6, 2022. Meeks was partially supported by the Health Resources and Services Administration (Grant No. UH1HP29965). The authors are indebted to the physicians who responded to the National Sample Survey of Phyicians, without whom this article would not have been possible. This study was supported, in part, by the AAMC. The AAMC had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt, and build upon this work, for commercial use, provided the original work is properly cited. See https://creativecommons.org/licenses/by/4.0/.

NOTES

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