Despite the dire need for primary health care providers in California's Central Valley, workplace discrimination and harassment can cause them to change practices or leave the region entirely. 

These insights are reported in a pilot study published today in JAMA Network Open and led by UC Davis health policy expert Michelle Ko.

Study participants' experiences with colleagues, staff and administrators ranged from negative comments to vandalism of personal property to loss of professional privileges. As a result, Ko recommends a larger assessment of U.S. workplaces for female, non-white and LGBTQ+ primary care providers in rural and agricultural areas. 

"Workplace discrimination, bias and harassment can happen in any health care setting," said Ko, a physician and researcher with the UC Davis Department of Public Health Sciences. "But they are an even bigger problem in areas where there are shortages of primary care providers. The providers I talked with believed very strongly in serving their patients, but some felt forced out because they could no longer work in abusive environments." 

The U.S. overall is facing a shortage of primary care providers, with the greatest shortages in rural and agricultural areas. UC Davis School of Medicine is bridging that gap by recruiting diverse students who are passionate about reducing health inequities and working in medically underserved communities. Based on her research, Ko believes medical educators also must help those students become aware of circumstances they could face once they begin their careers. 

A rare snapshot of diverse physicians' work experiences 

Ko's research is unique because of the racial, ethnic, gender and sexual orientation diversity of the participants. Most prior studies focused on the medical practice perspectives of white, male physicians. 

The study included 26 physicians, nurse practitioners and clinic directors working in family medicine, internal medicine or pediatrics in a variety of settings - from small community practices to large health systems. All were currently working, or had recent experience working, in the Central Valley. 

Ko conducted in-person and telephone interviews to learn more about their work-related experiences, challenges and coping strategies. The interviews were recorded, transcribed, coded and analyzed for major themes, which included: 

• Bias, harassment and hostility based on gender, race/ethnicity, sexual orientation or gender identity. One female participant said, "I have kids and a family, so I was always on a blacklist."

• Community and professional isolation due to minority status. LGBTQ+ providers, for instance, were reluctant to disclose their status due to stigma. One participant said, "Primary care providers are terrified about what it would do to their practice." One Black participant expressed fear that overall discrimination and isolation were negatively impacting his/her children.

• Hostile environments and institutional discrimination that could lead to burnout, job change or leaving the region altogether. Two LGBTQ+ participants reported that staff filed formal complaints and hospitals retracted admitting privileges after they came out about their status. One said, "They made it super clear they didn't want us there."

Non-minorities reported no career impact 

Another theme related to study participants who did not identify with a particular minority group. Generally, their personal identities had no impact on their practice experiences. They also were not likely to recognize how minority status impacted the work lives of their colleagues. 

Ko hopes to expand this research to encompass more health care providers and rural and agricultural regions. Her goal is to tell a complete story of provider experiences and see if the initial themes persist. While the current study is small, she says it raises important questions about the experiences of minority providers in underserved communities. 

"We are hoping to start a conversation throughout the health professions and medical schools about what constitutes acceptable interactions," Ko said.