Online Reviews Reveal Patterns of Discrimination in Hospital Setting

Researchers examined Yelp online reviews of 100 randomly selected acute care hospitals in the United States.

Based on an analysis of Yelp online reviews, acts of discrimination in the hospital setting can be categorized in six recurring patterns, including acts of commission, stereotyping, and intimidation, a recently published research article found.

Earlier research has shown that discrimination based on minority patients' race, sex, gender, sexual orientation, age, or disability generates worse health outcomes. The co-authors of the recently published research article found that Yelp online reviews provide insight into discrimination in the hospital setting that cannot be gleaned from traditional healthcare performance measures such as Hospital Compare.

The study, which was published by JAMA Network Open, is based on Yelp online reviews made from January 2011 to December 2020 of 100 randomly selected acute care hospitals in the United States.

The reviews were filtered with 31 keywords drawn from the Everyday Discrimination Scale such as race, racist, slur, threat, hate, and bias. A total of more than 10,000 reviews were collected and nearly 3,000 reviews were determined to be potentially related to discrimination. The research team identified 182 reviews that described at least one act of discrimination.

The study features several key data points.

• 53 reviews (29.1%) were categorized as institutional racism
   
• 72 reviews (39.6%) cited individual actors as sources of discrimination such as security guards, nurses, and physicians
   
• 89 reviews (48.9%) described acts of discrimination that occurred in clinical settings
   
• 25 reviews (13.7%) described acts of discrimination that occurred in nonclinical spaces such as lobbies
   
• 66 reviews (36.3%) included acts of discrimination by patients directed at healthcare workers

The researchers found that the acts of discrimination could be categorized in six patterns.

1. Acts of commission: "Instances in which actors showed their biases through purposeful acts of physical or verbal harassment. In extreme examples, a few reviews mentioned instances when actors violated patients' consent in carrying out abuses."

2. Acts of omission: "Acts of omission described instances in which medical care or basic needs, such as food or assistance with activities of daily living, were neglected or delayed by hospital staff. … Acts of omission frequently manifested around discussions of pain. Consumers described how a lack of attention to pain ultimately led to a missed or delayed diagnosis of an acute medical issue that was only discovered after seeking second or third opinions."

3. Dehumanizing: "Dehumanizing manifestations portrayed the consumer feeling dehumanized or devalued compared with others because of a particular personal attribute. For example, one consumer wrote, 'Why wasn't I greeted with enthusiasm, let alone greeted at all? Was it because of the color of my skin? Am I less of a person? Or was it because of age discrimination? In all my time here in the healthcare systems in [city], I’ve never once felt this invalidated.' Most frequently, consumers reported feeling dehumanized because of being ignored in a variety of settings."

4. Stereotyping: "Consumers often reported on racial and gender stereotypes that perpetuated poor health care treatment, including dismissal of symptoms and pain severity. In these scenarios, the patient came to the practitioner seeking treatment, only for their symptoms to be overlooked because of the practitioners’ prejudices and biases. These experiences occurred often among self-identified Black people and women."

5. Intimidation: "Intimidation manifested as verbal and physical tactics used by health care workers, such as threats of using specific medical protocols as punishments or intrusions into consumers' personal space, to bully and harass consumers during health care visits. Consumers reported being frightened by individual or institutional discrimination. Frequently, acts of intimidation occurred during psychiatric visits and toward self-identified women or older adults."

6. Unprofessionalism: "Discrimination described as unprofessional manifested as disrespectful or unprofessional behaviors, often including terms such as mean, rude, and condescending. In addition, several consumers noted that unprofessional individuals shared personal thoughts and opinions that expressed bias, judgment, microaggression, and macroaggression. In such instances, respondents believed that perpetrators’ negative attitude and treatment was caused by bias and in violation of the standard of care."

Interpreting the data

Institutional discrimination was present when an entire hospital or clinic was described as discriminatory, the lead author of the study told HealthLeaders.

"The reviews typically cited the hospital as the source of discrimination in these cases. A specific example was a consumer who said, 'Worst hospital ever. I went to the emergency room with my daughter, who had a non-stop running nose. Their customer service was horrible. They treated people not nice, like they were racists. I am Asian.' In that instance, the consumer cited the entire hospital. There was not just a specific nurse, receptionist, security officer, or physician. They associated the entire institution as the source of racism," said Jason Tong, MD, general surgery resident and national clinician scholar fellow, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia.

Categorizing discrimination into patterns is helpful in addressing discrimination, he said.

"Discrimination is known as a difficult concept to study and target. Oftentimes, discrimination is thought of as a very experiential concept. However, by helping to organize discrimination into a taxonomy of recurring patterns, we can think of more effective ways to approach it. For example, as we highlight in our article, acts of omission have been used to describe a variety of patient safety issues such as medication administration errors. Importantly, people have already developed tools and approaches to types of acts of omission. So, by now thinking of acts of discrimination as another type of act of omission, we can apply pre-existing tools to address and study discrimination."

The research team deemed discrimination to be a form of patient harm, Tong said. "It goes back to the recurring patterns that we identified. The way that we did our study is we first went through many reviews, then the patterns emerged out of the data. At first, when we thought about it, a lot of the patterns seemed very familiar, and we went into the literature and found that all six of the recurring patterns had been previously described within the context of patient harm and patient safety, which is why we made the link to patient harm."