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IMPORTANCE As the clinical workforce becomes more diverse, physicians encounter patients who demean them based on social characteristics. Little is known about physicians' perspectives on these encounters and their effects. This knowledge would help develop policies and best practices for institutions and training programs. OBJECTIVE To describe the range and importance of encounters with biased patients and the barriers and facilitators to effective responses. DESIGN, SETTING, AND PARTICIPANTS This qualitative study recruited convenience samples of hospitalist attending physicians, internal medicine residents, and medical students from 3 campuses affiliated with 1 academic medical center. Data were collected from 50 individuals within 13 focus groups from May 9 through October 15, 2018. Focus groups were conducted using open-ended probes, audiotaped, and transcribed. Participants used their own definition of biased patient behavior. Each transcript was independently coded by at least 2 investigators. Data were analyzed from May 2018 through February 2019. MAIN OUTCOMES AND MEASURES Major themes associated with types of encounter, importance to the participant, and barriers and facilitators to effective responses were abstracted through the constant comparative approach. RESULTS Overall, 50 individuals (11 hospitalists, 26 residents, and 13 students) participated; 24 (48%) were nonwhite. At total of 26 participants (52%) identified as women; 22 (44%), as men; and 2 (4%), as gender nonconforming. Reports of biased behavior ranged from patient refusal of care and explicit racist, sexist, or homophobic remarks to belittling compliments or jokes. Targeted physicians reported an emotional toll that included exhaustion, self-doubt, and cynicism. Nontargeted bystanders reported moral distress and uncertainty about how to respond. Participant responses ranged from withdrawal from clinical role to a heightened determination to provide standard of care. Barriers to effective responses included lack of skills, insufficient support from senior colleagues and the institution, and perception of lack of utility associated with responding. Participants expressed a need for training on dealing with biased patients and for clear institutional policies to guide responses. CONCLUSIONS AND RELEVANCE In this qualitative study of physicians and medical students, encounters with demeaning patients ranged from refusal of care to belittling jokes and were highly challenging and painful. Addressing biased patient behavior will require a concerted effort from medical schools and hospitals to create policies and trainings conducive to a clinical environment that respects the diversity of patients and physicians alike.

Analyses of the breadth and specificity of virus-specific CD8؉ T cell responses associated with control of HIV have largely relied on measurement of cytokine secretion by effector T cells. These have resulted in the identification of HIV elite controllers with low or absent responses in which non-T-cell mechanisms of control have been suggested. However, successful control of HIV infection may be associated with central memory T cells, which have not been consistently examined in these individuals. Gagspecific T cells were characterized using a peptide-based cultured enzyme-linked immunosorbent spot assay (ELISpot). Peripheral blood mononuclear cells from HIV elite controllers (n ‫؍‬ 10), progressors (n ‫؍‬ 12), and antiretroviral-treated individuals (n ‫؍‬ 9) were cultured with overlapping peptides for 12 days. Specificity was assessed by tetramer staining, functional features of expanded cells were assessed by cytokine secretion, and virus inhibition and phenotypic characteristics were assessed by cell sorting and coculture assays. After peptide stimulation, elite controllers showed a greater number of previously undetectable (new) responses compared to progressors (P ‫؍‬ 0.0008). These responses were highly polyfunctional, with 64.5% of responses having 3 to 5 functions. Expandable epitope-specific CD8 ؉ T cells from elite controllers had strong virus inhibitory capacity and predominantly displayed a central memory phenotype. These data indicate that elite controllers with minimal T cell responses harbor a highly functional, broadly directed central memory T cell population that is capable of suppressing HIV in vitro. Comprehensive examination of this cell population could provide insight into the immune responses associated with successful containment of viremia.

• Immune monitoring models integrating multiple functions of HIV-1-specific CD8 T cells distinguish controllers from subjects with progressive HIV-1 infection.• This strategy may have important applications in predictive model development and immune monitoring of HIV-1 vaccine trials.