Bias toward low-income patients may be unconscious

Physicians wrongly believe they're likely to sue

Low-income patients are less likely to sue physicians than patients with higher incomes, according to an analysis of litigation rates and medical malpractice claims.1

The fact that many physicians wrongly believe poor patients are more likely to sue "is a reflection of the ongoing reality of conscious and unconscious bias that impacts health care in a very pervasive way," says Augustus A. White III, MD, PhD, chair of the Culturally Competent Care Education Program at Harvard Medical School in Boston.

In Seeing Patients: Unconscious Bias in Health Care (Harvard University Press, 2011), White discusses 13 groups of people that experience disparate care simply because of the group they are in. These include disabled individuals; African-Americans; Native Americans; Asian Americans; Latinos; prisoners; women; the Appalachian poor; certain religious groups; elderly people; obese people; immigrants; and gays, lesbians, bisexual and transgendered people.

"Socioeconomic biases also exist. These can be operative in this situation, as with the myth that poor people are more likely to sue you," he says. "This can represent either unconscious bias toward poor people, or it could be partially cultural."

Physicians may rationalize their decision not to accept Medicaid patients, for instance, with the misconception that poor people are more likely to sue. "This could be an excuse for not wanting to get involved in their care," White says.

Physicians should obtain training in culturally competent care, says White, to help them provide equitable care to all patients regardless of their gender, sexual preference, or race.

"Even if they think they are not biased toward Asian patients or obese patients, maybe, in fact, they are," he says. "Physicians need suggestions for how to avoid giving disparate care."

Lack of access is issue

Arthur R. Derse, MD, JD, director of the Center for Bioethics and Medical Humanities at the Medical College of Wisconsin in Milwaukee, says that if a patient is low-income enough to be eligible for Medicaid and is unemployed, there is less likelihood that a private practice attorney will agree to take his or her case.

"This is because the attorney may be able to recover very little compensation for economic damages because the patient either wasn't earning anything or didn't have the potential to earn much," he says. "Also, low-income patients do not have as many ways to access an attorney as a middle-income or high-income person may."

Derse says that in his experience, low-income patients are often more accommodating and appreciative of the medical care they receive than high-income patients, who may have higher expectations for quickly delivered services; may be more demanding of additional testing, interventions, and sub-specialty services that may be unnecessary; and have more resources to seek redress should an untoward outcome occur.

Lack of transportation, an inability to articulate what transpired during the medical encounter, and unwillingness of low wage earners who are undocumented immigrants to go to court are other barriers, says Derse.

"If people can't get medical care anywhere else, they may be unwilling to sue the one physician who is taking care of them," he adds. "A higher income group can always see a different doctor."


  1. McClellan FM, White III AA, Jimenez RL, et al. Do poor people sue doctors more frequently? Confronting unconscious bias and the role of cultural competency. Clin Orthop Relat Res. 2012; 470(5):1393-1397.


  • Arthur R. Derse, MD, JD, Director, Center for Bioethics and Medical Humanities, Medical College of Wisconsin, Milwaukee. Phone: (414) 955-8498. Email:
  • Augustus A. White III, MD, PhD, Director, Culturally Competent Care Education Program, Harvard Medical School, Boston. Phone: (617) 998-8802. Email: