Editor’s Note:

This post was originally published in October 2021 and covered the study when it was released as a JAMA Network Open Research Letter. It has been updated to reflect additional research also published in JAMA Network Open.

How do health care consumers experience and report on racism in hospital settings? In the Diversity, Equity, and Inclusion issue of JAMA Network Open, my co-authors and I analyze consumer hospital reviews on Yelp and find that racism involves a wide array of clinical and nonclinical staff, affecting both patients and hospital employees.

Inequities in care delivery and outcomes have been well established within health care. Some have pointed at structural racism and acts of interpersonal racism as potential drivers of these disparities. But interpersonal racism is hard to study, because no health care-specific metric of interpersonal racism exists. Consumer reviews, such as Yelp reviews, may be an untapped resource for examining the presence of racism within health care. Unlike other existing hospital patient surveys, consumer reviews are familiar to the lay community, widely used, and open-ended. Moreover, consumer review platforms are independent from health care institutions, allowing for consumers to report on the sensitive topic of racism anonymously, without fear of possible retribution.

We collected 90,786 online consumer reviews of U.S. acute-care hospitals published on Yelp between 2010 to 2020. We used natural language processing to identify 260 reviews explicitly citing instances of racism in 190 hospitals across 33 states. Qualitative analysis revealed that racism occurred in a variety of clinical and nonclinical spaces. Additionally, consumers experienced racism from a variety of actors, ranging from clinical staff, such as physicians and nurses, to other critical hospital personnel such as security officers and reception staff. We found that racism is bidirectional and affects both health care consumers and staff. Sample quotes from our study are included in Table 1.

Coding DomainSample Quote*
Interpersonal“He’s marginalizing me due to certain key facts and not the whole picture. He sees Hispanic Male, takes narcotics and I’ve seen him several times SO I KNOW he’s only looking for drugs… he’s clumping me in with those people and actively being a Racist, Bigot…”
Institutional“The Maternity Ward is managed/run by Hateful Racists… they honestly hate you.”
Clinical“Be careful in there Emergency room, the nurses touched me inappropriately and made me feel afraid. I will report this soon the nurses we also saying racist comments towards blacks.”
Nonclinical“I brought my husband to the ER the security was very unprofessional and rude… made me feel very disrespected and he seem very racist…”
Internalized“I did not know this is a completely Black institution… I’d rather die than go back to that place! LAZY…employees rampant.”

Table 1. Sample Quotes of Racist Experiences and Associated Coded Themes. Source: Tong et al., JAMA Network Open, 2021.
*Quotes are de-identified and unedited and may contain spelling or grammatical errors.

Our findings suggest that consumers are highly attuned to acts of interpersonal racism during health care encounters and its impact on the quality of their experience and care. By listening to the health care consumer and identifying the recurring themes within narratives, health care institutions may be able to better target quality improvement initiatives to combat racism. Additionally, the presence of bidirectional racism suggests that the health care workforce needs better tools to not only manage their own implicit biases, but also acts of racism directed at them.

Using this pilot study’s findings, we expanded our work to further examine how consumers perceive and report on a broader variety of forms of discrimination including race, ethnicity, sex, religion, age, and environments lacking in diversity, equity, or inclusion. In our recently published work in JAMA Network Open, we first collected 10,535 reviews associated with 100 randomly selected hospitals in the U.S. published between 2011 to 2020. Then, we created a keyword filter by applying modified grounded theory to the Everyday Discrimination Scale to help identify reviews most likely to contain information on discrimination. Using this filter, we identified 2,986 reviews for further manual qualitative content analysis. We found 182 reviews describing instances of discrimination which were further categorized by the actors, setting, and directionality of discrimination. Additional review and coding of these experiences identified six recurrent themes of discrimination including acts of commission, acts of omission, unprofessionalism, disrespect, stereotyping, and dehumanization. We highlight that the future application of traditional quality improvement tools to this novel source of consumer-derived data may help healthcare institutions better understand and improve upon discrimination.

The study, Evaluation of Online Consumer Reviews of Hospitals and Experiences of Racism Using Qualitative Methods, was published in JAMA Network Open on September 22, 2021. Authors include Jason Tong, Anietie U. Andy, Raina M. Merchant, and Rachel R. Kelz.

The study, Reporting of Discrimination by Health Care Consumers Through Online Consumer Reviews, was published in JAMA Network Open on February 28, 2022. Authors include Jason Tong, Eda Akpek, Anusha Naik, Medha Sharma, Danielle Boateng, Anietie Andy, Raina M. Merchant, and Rachel R. Kelz.


Jason Tong

Jason Tong, MD

Resident, General Surgery, Perelman School of Medicine

More on Health Equity