Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians

Culture of Medicine

    Perspective: A Culture of Respect, Part 1: The
    Nature and Causes of Disrespectful Behavior
    by Physicians
    Lucian L. Leape, MD, Miles F. Shore, MD, Jules L. Dienstag, MD, Robert J. Mayer, MD,
    Susan Edgman-Levitan, PA, Gregg S. Meyer, MD, MSc, and Gerald B. Healy, MD

    A substantial barrier to progress in                 common are everyday humiliations of            is also devastating for patients.
    patient safety is a dysfunctional culture            nurses and physicians in training, as well     Disrespect underlies the tensions and
    rooted in widespread disrespect. The                 as passive resistance to collaboration and     dissatisfactions that diminish joy and
    authors identify a broad range of                    change. Even more common are lesser            fulfillment in work for all health
    disrespectful conduct, suggesting six                degrees of disrespectful conduct toward        care workers and contributes to
    categories for classifying disrespectful             patients that are taken for granted and        turnover of highly qualified staff.
    behavior in the health care setting:                 not recognized by health workers as            Disrespectful behavior is rooted, in part,
    disruptive behavior; humiliating,                    disrespectful.                                 in characteristics of the individual, such
    demeaning treatment of nurses,                                                                      as insecurity or aggressiveness, but it
    residents, and students; passive-                    Disrespect is a threat to patient safety       is also learned, tolerated, and reinforced
    aggressive behavior; passive disrespect;             because it inhibits collegiality and           in the hierarchical hospital culture.
    dismissive treatment of patients; and                cooperation essential to teamwork,             A major contributor to disrespectful
    systemic disrespect.                                 cuts off communication, undermines             behavior is the stressful health care
                                                         morale, and inhibits compliance with           environment, particularly the presence
    At one end of the spectrum, a single                 and implementation of new practices.           of “production pressure,” such as the
    disruptive physician can poison the                  Nurses and students are particularly           requirement to see a high volume of
    atmosphere of an entire unit. More                   at risk, but disrespectful treatment           patients.

    T  he slow pace of improvement in                    every year.6 Other reasons include our         undermines the teamwork needed to
    patient safety has been a source of                  lack of knowledge of how to prevent most       improve practice. Dismissive treatment
    widespread dissatisfaction for policy                complications of treatment, inadequate         of patients impairs communication and
    makers and the public, but even more                 government investment in patient safety        their engagement as partners in safe care.
    to the health professions. Despite                   initiatives, and insufficient preventive and
    extensive efforts by many institutions               remedial measures.7                            In addition to its toxic impact on patient
    and individuals, recent studies show little                                                         safety, disrespectful behavior affects many
    improvement in the rate of preventable               We believe, however, that the funda­           other aspects of health care. Quality suffers
    patient harm since the Institute of                  mental cause of our slow progress is not       when caregivers do not work in teams.
    Medicine’s (IOM’s) “To Err Is Human”1                lack of know-how or resources but a            Disrespect saps meaning and satisfaction
    sounded the alarm and issued its call for            dysfunctional culture that resists change.     from daily work and is one reason nurses
    a nationwide safety improvement effort               Central to this culture is a physician         experience burnout, resign from hospitals,
    12 years ago.1–4                                     ethos that favors individual privilege         or leave nursing altogether.8 Lack of
                                                         and autonomy—values that can lead              respect poisons the well of collegiality and
    One explanation for this poor record is              to disrespectful behavior. We propose          cooperation, undermines morale, and
    that the problem is so large and its causes          that disrespectful behavior is the “root       inhibits transparency and feedback. It is a
    are so varied. For example, the Centers              cause” of the dysfunctional culture            major barrier to health care organizations
    for Disease Control and Prevention                   that permeates health care and stymies         becoming collaborative, integrated,
    estimates that 5,000 people acquire an               progress in safety and that it is also a       supportive centers of patient-centered
    infection in our hospitals every day,5               product of that culture.                       care.
    and the IOM estimates that 1.5 million
    patients are injured by medication errors            Disrespectful behavior threatens               Students and residents suffer from
                                                         organizational culture and patient safety      disrespectful treatment. “Education by
    Please see the end of this article for information
                                                         in multiple ways. A sense of privilege and     humiliation” has long been a tradition
    about the authors.
                                                         status can lead physicians to treat nurses     in medical education and still persists.
    Correspondence should be addressed to Dr. Leape,
    Harvard School of Public Health, 677 Huntington
                                                         with disrespect, creating a barrier to         Patients suffer when physicians do not
    Ave., Boston, MA 02115; telephone: (617)             the open communication and feedback            listen, show disdain for their questions, or
    432-2008; e-mail:            that are essential for safe care. A sense      fail to explain alternative approaches and
                                                         of autonomy can underlie resistance            fully involve them in the decision-making
    Acad Med. 2012;87:1–8.
    First published online                               to following safe practices, resulting         process.9,10 Failure to provide full and
    doi: 10.1097/ACM.0b013e318258338d                    in patient harm. Absence of respect            honest disclosure when things go wrong

    Academic Medicine, Vol. 87, No. 7 / July 2012                                                                                                  1

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Culture of Medicine

    is the epitome of disrespect and is a major     collective personal experience, we suggest      Humiliating, demeaning treatment of
    reason patients file malpractice suits.11       the following as a useful classification of     nurses, residents, and students
                                                    disrespectful behaviors in the health care      Much more common than egregious
    Respectful behavior is a moral value            setting.                                        forms of disruptive behavior are patterns
    esteemed in its own right. Respect                                                              of demeaning or humiliating treatment
    is also a foundational element of               Disruptive behavior
                                                                                                    of subordinates, particularly nurses,
    professionalism that forms the core             At one end of the spectrum of disrespect        residents, and medical students.
    of the self-image of most physicians.           are physicians whose behavior has been
    Professionalism is a critical element           characterized as disruptive, defined by         Abuse of nurses by physicians has a
    of the six competencies that form the           the Ontario College of Physicians and           long history. Twenty years ago, Cox17,18
    foundation of medical education and             Surgeons as “inappropriate conduct,             reported on the high rate of verbal
    practice espoused by the Accreditation          whether in words or action, that                abuse of nurses and its negative effects.
    Council on Graduate Medical Education,          interferes with, or has the potential           A recent review of the literature yielded
    the standard-setter for graduate medical        to interfere with, quality health care          10 U.S. studies since 2000 of abusive
    education, and by the American                  delivery.”14 Hickson and Pichert15 define       treatment of nurses.19 A large percentage
    Board of Medical Specialties (ABMS),            disruptive behavior as “any behavior            of nurses reported being subjected to
    the standard-setter for all medical             that impairs the medical team’s ability to      abuse or disruptive behavior, and in four
    specialties.12 Although professionalism         achieve intended outcomes.” Disruptive          of the studies, more than 90% of nurses
    embraces a number of other behaviors            physicians are found in almost all              reported that they had experienced such
    and attitudes, showing respect for              hospitals. Although most observers agree        abuse. In one large study, 31% of nurses
    others is central to all aspects of                                                             reported knowing a nurse who had
                                                    that only 5% or 6% of physicians fall into
    professionalism.                                                                                left the hospital because of disruptive
                                                    this category,16 the detrimental influence
                                                    of this small minority far outweighs their      physician behavior.19
    The vast majority of physicians treat
    others respectfully most of the time;                                                           Medical students, at the bottom of the
    however, some do not. In a recent                                                               patient care team hierarchy, are very
                                                    Disruptive actions include angry
    national survey, two out of three                                                               vulnerable to disrespect from faculty,
                                                    outbursts, verbal threats, shouting,
    physicians reported witnessing other                                                            house staff, nurses, and others through
                                                    swearing, and the threat or actual
    physicians disrupting patient care or                                                           verbal or physical abuse, belittlement,
                                                    infliction of unwarranted physical force
    collegial relationships at least once a                                                         humiliation, harassment, intimidation
                                                    that legally would be considered battery.
    month. One in nine physicians reported                                                          and exploitation, or simply by being
                                                    Having a temper tantrum, throwing
    seeing disruptive behavior every day.13                                                         ignored. Nurses and residents may make
                                                    objects, and breaking things are other
                                                                                                    them feel insignificant or “in the way.”
    A culture of disrespect is harmful for          forms of disruptive behavior, as is any
                                                                                                    Annual surveys by the Association of
    many reasons, but it is its effect on the       unwanted physical contact of a sexual
                                                                                                    American Medical Colleges show that
    safety and well-being of our patients           nature. Disruptive conduct may be
                                                                                                    14% to 17% of graduating students
    that makes it a matter of urgency. In           directed at anyone—nurses, colleagues,
                                                                                                    report having been subjected to or
    simple terms, we believe that a health          residents, medical students, ward staff,
                                                                                                    witnessing some form of mistreatment.20
    care organization that supports and             hospital administrators, and even patients
                                                                                                    However, other studies and informal
    tolerates disrespectful behavior is unsafe      and their family members.                       discussions with students suggest that
    for its patients and hostile for its workers.                                                   the prevalence of student mistreatment
    Although disrespectful behavior permeates       Disruptive behavior includes profane,           is much higher.20,21 Recent reports that
    all of health care, physicians dominate the     disrespectful, insulting, or abusive            53% of medical students experience
    culture and set the tone; therefore, in this    language; loud or inappropriate                 “burnout”22 and that 14% suffer clinically
    discussion we focus on physicians.              arguments; demeaning comments                   significant depression23 provide further
                                                    or intimidation; shaming others for             evidence that the environment in many
    Here, we present a call to action. Our          negative outcomes; and simple rudeness.         of our academic medical centers and
    intent is to motivate individuals at all        Violations of physical boundaries and           medical schools is sometimes hostile and
    levels in health care institutions to take      sexual harassment are in this category,         quite toxic.
    action toward creating a culture of respect     as are gratuitous negative comments
    and to provide them with the evidence           about other physicians’ care and                In our experience, students indicate
    they need to support improvements in            passing severe judgment or censuring            that they seldom report disrespectful
    the cultures of their institutions.             colleagues or staff in front of patients,       acts because they are concerned about
                                                    visitors, or other staff. Also included         being seen as troublemakers and fear
                                                    are bullying; insensitive comments              reprisal or vindictive retaliation, such as
    The Scope of the Problem                        about a patient’s medical condition,            a lower grade, a critical evaluation, or
    Disrespectful behavior takes many forms,        appearance, or situation; and jokes             a poor recommendation for residency
    ranging from outbursts of outrageous,           or nonclinical comments about race,             applications. Disrespect can also occur in
    aggressive behavior to subtle patterns that     ethnicity, religion, sexual orientation, age,   the preclinical classroom or laboratory,
    are so firmly embedded in our culture           physical appearance, or socioeconomic or        but it is more common in clinical settings
    as to seem normal. On the basis of our          educational status.                             like hospital wards or clinics. Women

    2                                                                                               Academic Medicine, Vol. 87, No. 7 / July 2012

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Culture of Medicine

    students are more vulnerable than               calls, fail to dictate charts or operating                tend to accept it as a fact of life that some
    men.21,24 Anecdotally, students report that     notes in a timely fashion, and do not                     people are “difficult.”
    barbs related to gender, race, or sexual        work collaboratively or cooperatively
    orientation are heard more commonly in          with others. They resist following safe                   Dismissive treatment of patients
    high-stress areas, such as the operating        practices, such as hand disinfection,                     Again, incidence data are lacking, but
    room and the emergency department.              checklists, and “time-outs,” even when the                anecdotal evidence abounds in the form
    Often, students relate that when such           rationale has been sufficiently described.                of patient stories regarding demeaning,
    disrespectful behavior is reported,             They may decline to participate in quality                disrespectful, and dismissive treatment
    corrective measures are not apparent,
                                                    improvement efforts, or, if they do, they                 by physicians. Patients may describe this
    sending the message that disrespectful
                                                    are indifferent or poor team players. All                 treatment in a number of ways: “He treats
    behavior is tolerated, if not celebrated.
                                                    of these behaviors are manifestations of                  me like an idiot,” “He makes me feel like
    Examples of serious disrespectful               disrespect—for others, for the institution,               I’m wasting his time,” “She won’t return my
    behavior toward medical students                and for expert opinions.                                  calls,” “They ignore me on rounds. They talk
    reported in one academic year are                                                                         about me but not to me,” or, “It was clear he
    presented in Box 1.20                           Although this type of behavior would                      doesn’t like people who ask questions.”
                                                    be included in Hickson’s definition of
    Passive-aggressive behavior                     disruptive behavior,14 it is usually not                  Not only does such behavior violate
    Passive-aggressive behavior is defined          perceived as such by colleagues, who                      the fundamental obligation of the
    as a pattern of negativistic attitudes
    and passive resistance to demands for           Box 1
    adequate performance.25 Unable to               Examples of Disrespectful or Abusive Behavior Experienced by Medical Students
    express anger in a healthy way, passive-
    aggressive individuals harm others              1.	Two second-year medical students spent an afternoon observing surgery in the operating room
                                                        (OR) as part of a medical school course. The chief surgical resident assigned the students to a
    through actions that seem normal on the             corner of the room with instructions to be quiet and not touch anything. After the students
    surface. They tend to be unreasonably               washed their hands and moved to their assigned place, the attending surgeon noticed the
    critical of authority and blame others for          students and yelled, “Who are you? What are you doing in this OR? When you come into an
    their failures. They frequently complain of         OR you introduce yourself to the surgeon. And why are you standing there? Go stand in that
                                                        [pointing to a different] corner.”*
    being misunderstood and treated unfairly.
                                                    2.	One third-year medical student was scrubbed-in for a case, observing and occasionally assisting
    Passive-aggressive behavior includes                the surgeon. At one point, she noticed the surgeon pulling a retractor in a way that seemed
                                                        to indicate that the surgeon wanted her to take over retracting. As she reached to grab the
    refusing to do tasks or doing them                  retractor, the surgeon, who apparently did not want her assistance, slapped her hand out of
    in a way intended to annoy others.                  the field instead of verbally instructing her to remove her hand.*
    Passive-aggressive individuals go out
                                                    3.	S.N., a third-year student, was distressed with the behavior of the young attending physician
    of their way to make others look bad                and the senior resident on the last month of her medical clerkship. Constant references to “the
    while pretending innocence, fail to                 yellow fat whale in Room 506” or that “dumb drunk” by the attending shocked S.N., and
    follow through on agreements, and                   when she spoke to both the attending and resident about their constant disparagement of
    deliberately delay responding to calls,             patients, she was told, “When you grow up you’ll do the same thing.” S.N. was heartbroken to
                                                        hear these comments from physicians she had respected.
    covering the delays with excuses. They
    often make negative comments about              4.	A third-year medical student on an OB/GYN rotation related the following: I was instructed to
    their institution, hospital, group, or              observe a hysterectomy, but when I arrived to the OR, the doctor looked at me with disdain
                                                        and told me to stand in the far corner and not mess anything up. So, I perched myself atop a
    colleagues. The defining characteristics            small stepstool in the back corner of the room, and I spent the next three hours squinting from
    of passive aggression are concealed                 across the room, completely unable to see anything except for blue-gowned backs. Suddenly,
    anger, negativism, and intent to cause              the doctor called out, “You, over there!” I looked over in surprise—me? Apparently, there was
    psychological harm.                                 no one available to pull out the catheter, and they beckoned for me to approach the table. I
                                                        cautiously approached, and before I could even begin, the doctor sharply barked, “DON’T mess
                                                        this up for me!” Shaking, I followed her instructions, and managed to remove the catheter
    We know of no studies undertaken to                 without contaminating the sterile field. “Now, GET OUT of the way!” she yelled. I couldn’t
    quantify these types of behaviors, but we           see behind me, and in a small tremulous voice, I asked, “Is it ok to move backwards, I can’t see
    have encountered widespread agreement               anything behind me...?” Raising her voice up a notch, she yelled, “Just GET OUT!” I took several
                                                        hasty steps backwards, and my arm grazed lightly against the side of a table holding sterile
    among clinicians that such behaviors are            instruments—mind you, nowhere NEAR the table-top, where the instruments lay, but just on the
    not rare.                                           side curtain—and a nurse shrieked, “She contaminated the whole sterile field!” With fury, the
                                                        doctor looked up and spat, “F___ you!” I blinked and stared right back at her—really, did she just
    Passive disrespect                                  actually say that? Although I didn’t feel sad at all—only mad as hell—tears rushed to my eyes in a
                                                        visceral response to all of the shouting. The instant that the curse left her lips, I could tell that she
    By contrast, passive disrespect is common;          regretted it, but you can’t take back something like that, so the words hung awkwardly in the air,
    it consists of a range of uncooperative             hovering over all of our heads for the rest of the procedure. She tried to make up for it, sending
    behaviors that are not malevolent or                arbitrary, irrelevant compliments in my direction, and the nurse patted me on the shoulder several
    rooted in suppressed anger. Whether                 times and tried to appear motherly and compassionate. But, what I remember most strongly
                                                        from the experience—what I STILL cannot believe—is the fact, despite their palpable remorse, no
    because of apathy, burnout, situational             one ever said, “I’m sorry.”*
    frustration, or other reasons, passively
    disrespectful individuals are chronically       *Source: Cases 1, 2, and 4 are reprinted with permission from Unmet Needs: Teaching Physicians to Provide Safe
    late to meetings, respond sluggishly to         Patient Care. Boston, Mass: National Patient Safety Foundation; 2008.20

    Academic Medicine, Vol. 87, No. 7 / July 2012                                                                                                                3

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Culture of Medicine

    physician to provide support and healing,    apologizing for waiting demonstrates           names without seeking permission for
    it can be devastating for the already-       respect.                                       this level of familiarity may be interpreted
    apprehensive patient. Patients seldom file                                                  as disrespect. Calling a patient by terms of
    formal complaints to the hospital about      A more serious example of systemic             endearment, such as “honey” or “dear,”
    dismissive behavior, but as more hospitals   disrespect is the hostile working              infantilizes the patient and enforces a
    implement the Consumer Assessment of         conditions that are so universally             power differential with the clinician.
    Health Plans Survey as part of Center for    ingrained that we take them for granted
    Medicare and Medicaid Services Hospital      as “normal.” Unduly long hours, sleep          Perhaps the most serious form of
    Compare reporting,26 these sentiments        deprivation, and excessive workloads are       systemic patient disrespect is the failure
    are now beginning to be captured in a        well-known causes of errors and patient        to admit and explain fully what happened
    systematic fashion.                          harm.30–36 Requiring residents or nurses       when things go wrong and to apologize
                                                 to work under these conditions not only        when we or our system has failed.
    Dismissive treatment and put-downs are       is disrespectful of their well-being and       Honoring the patient’s right and need
    not limited to patients. Some physicians     potentially harmful for them (residents        to know everything that is relevant to
    treat nurses, students, residents, and       who have been on continuous duty for           his or her well-being is fundamental to
    even peers with disdain, making easy         24 hours or more are more likely to            doctoring and reflects respect for the
    communication and collaboration              have a fatal automobile accident when          “doctored.”
    impossible. However, because they are so     driving home)35 but also violates their
    dependent on the doctor for their well-      right to work under conditions that do
    being, patients are especially vulnerable    not increase the likelihood that they will     The Effects of Disrespectful
    to dismissive treatment.                     harm their patients. And, of course, it is     Behavior: Why Is It a Concern?
                                                 disrespectful to patients to knowingly put     Humiliating, degrading, or shaming
    Systemic disrespect                          them at increased risk of injury.              behavior is a threat to patient safety
    Many features of our health care system                                                     because it can have both immediate
    are so firmly entrenched that they are       Hospitals also demonstrate lack of             and long-term negative effects on the
    taken as givens and not recognized           respect for nurses and other workers           recipient. In the immediate aftermath of
    for the disrespect they represent. A         when they fail to ensure their physical        an episode of humiliation, the recipient
    classic example is waiting. Everyone—        safety by taking appropriate measures          experiences a mixture of intense
    patients, doctors, nurses, clerks, and       to prevent injury, such as needlesticks        feelings: fear, anger, shame, confusion,
    administrators—seems to accept the fact      and back strain. The fact that these           uncertainty, isolation, self-doubt,
    that patients should wait for services.      are often accepted as risks of the job         frustration, and depression. These feelings
    There is a reason we label our reception     illustrates the extent to which disrespect     affect significantly a person’s ability to
    areas as “waiting rooms”! Making             is institutionalized in hospitals.             think clearly, making an error in decision
    a person wait, however, sends the                                                           making or performance more likely. In
    unambiguous message that the physician       At the patient level, a serious form of        addition, intimidation may stimulate a
    considers his or her time more valuable      covert systemic disrespect is the failure to   person to commit an unsafe act.37
    than the patient’s.                          engage and inform patients fully about
                                                 their care. Failure to provide the reasons     Long-term consequences of humiliating
    Physicians are also victimized by a          for tests, the meaning of test results,        and intimidating behavior stem from
    scheduling system that doesn’t respect       the options for diagnosis and treatment        the recipient’s very rational response:
    their time. The productivity demands         choices, and, most important, thorough         Avoid the person inflicting the hurtful
    of the short appointment times               explanations of the risks and benefits of      behavior. For a nurse or resident, this
    characteristic of present-day ambulatory     each option, are failures of respect of the    may be expressed by reluctance to call
    medicine mean that to have necessary         patient’s right to information and of his      a disrespectful attending physician with
    additional time with one patient requires    or her ability to understand and make          questions for clarification of an order,
    the physician to make the next (and all      decisions. Shared decision making is not       or for clinical concerns that are not
    subsequent) patients wait. This type of      just a good idea, it is showing respect.       clear-cut. In such cases, caregivers may
    scheduling is institutional disrespect                                                      divert their attention from the patient to
    of both the physician and the patient,       Minor forms of systemic disrespect of          self-protection. When communication
    ignoring the physician’s need to have        patients abound. One is the ubiquitous         on the health care team is limited to that
    enough time to do a professional job.        clipboard questionnaire about                  which is absolutely necessary, the loser is
                                                 demographic and medical history                the patient, who may suffer from delayed
    The unnecessary nature of waiting is         information that patients fill out for every   or erroneous diagnoses or treatment.
    apparent from the success that increasing    doctor, even when the physicians are
    numbers of institutions—offices,             in the same institution and have access        Everyone suffers in an atmosphere
    clinics, hospitals, operating rooms,         to a common electronic medical record          of intimidation. A hostile work
    and even emergency rooms—have                that already contains this information.        environment lowers morale, creates
    had in streamlining flow, with marked        Another is the simple failure of health        self-doubt, and is a cause of burnout.38–40
    reductions in and sometimes elimination      care workers to greet patients, introduce      Not surprisingly, some health care
    of waiting.27–29 But even when systems       themselves, and say “please” and “thank        professionals choose to leave rather
    fail and emergencies create delays,          you.” Addressing patients by their first       than endure such an environment.41

    4                                                                                           Academic Medicine, Vol. 87, No. 7 / July 2012

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Culture of Medicine

    Malpractice suits are more common               to be a physician. Students are also          important to physicians. It is closely
    against physicians who intimidate or            vulnerable because they are subject to        linked to their perception of their own
    insult patients.42                              faculty evaluation. A negative assessment     competence and reputation. Because
                                                    can make a student less competitive for       they invest a substantial amount of time
    Teamwork is another casualty of                 residency positions.                          and energy to achieve competence and
    disrespect because it requires mutual                                                         professional success, doctors may be
    trust and respect among all its members.        But the most serious effect on students       sensitive to any threats to self-esteem.
    Even less severe forms of disrespect,           comes from within. Disrespect is learned      When their self-esteem is threatened,
    such as not learning individuals’ names,        behavior, and students learn it from their    physicians may react with destructive
    habitual tardiness for meetings, and            role models, the faculty. The power of        interpersonal behavior as a way of
    expecting deferential treatment, are            role models is strong, particularly in the    reestablishing professional dominance.
    detrimental to teamwork.43 Teamwork is          clinical years. Although some students
                                                                                                  These reactions may be manifest in
    essential for the management of patients        will encounter disrespectful behavior
                                                                                                  several ways.
    with multiple or complicated diseases. It       and draw the opposite lesson, many
    is also the cornerstone of safe practice.       students will emulate the behavior they
                                                                                                  Insecurity and anxiety. Some physicians
    The most effective safe practices, such as      see, ensuring a never-ending cycle of
                                                                                                  are particularly prone to insecurity and
    prevention of central line infections by        disrespect.
                                                                                                  anxiety stemming from concern about
    adherence to proper insertion technique
    and prevention of surgical complications        Disrespectful behavior can also be very       whether they are up to the challenges of
    through “time-outs” and checklists,             harmful to patients. Insulting and stifling   practicing medicine. Especially when they
    require smoothly functioning teams              comments from physicians render               are overworked or stressed, doctors who
    to succeed.44,45 If the physician is not a      patients reluctant to be forthcoming          are not confident about their skills may
    constructive team player, team efforts          and volunteer information, cutting the        react to stress by blaming others when
    fail, and patients suffer the consequences.     physician off from important information      things go wrong or by making demeaning
    For these reasons, teamwork has                 that only the patient can provide about       or hypercritical comments.
    been identified as a critical element of        symptoms or complications of therapy
    systems-based practice, one of the six          and observed failures of the care system.     Depression. Surveys show that physicians
    competencies deemed essential for all           Even when they have minor ailments,           have higher levels of depression—and
    physicians by the ABMS.46                       virtually all patients have some fear and     higher suicide rates—than the public
                                                    anxiety when interacting with the health      at large.47 These individuals become
    As noted, disrespect underlies failure of       care system. Doctors and nurses have the      depressed by threats to their professional
    physician compliance with safe practices.       power to reduce this distress substantially   competence, blaming themselves for
    Lack of respect for the organization            by being sympathetic and understanding.       real or fancied inadequacy. In addition
    and the expert opinions of others leads         Conversely, they have the power to            to being hypercritical of themselves,
    some physicians to disobey rules with           increase distress substantially by ignoring   depressed individuals may cope by being
    which they do not agree, such as the            patients’ concerns or treating them with      hypercritical of others.
    requirement to disinfect hands before           scorn or indifference. Such fears are
    touching a patient or to perform a “time-       magnified many-fold in the aftermath          Narcissism. The investment of time
    out” before surgery.                            of a medical complication, whether or         and energy necessary to succeed
                                                    not it is caused by an error. Patients can    professionally in medicine requires a
    Disrespectful behavior is also a barrier to     be devastated if caregivers are not open,     high degree of self-involvement, which
    improving safety. The major safety efforts      honest, and understanding in these
                                                                                                  in some individuals may accentuate
    have focused on implementing new safe           situations. Dismissive or dissembling
                                                                                                  narcissistic character traits. Highly
    practices. Both implementing standard           treatment undermines the trust that is
                                                                                                  narcissistic individuals believe that they
    practices and developing new practices          the cornerstone of the doctor–patient
                                                                                                  and their ideas are special. They have
    require collaboration among all members         relationship.
                                                                                                  difficulty tolerating people they view as
    of the care team. If the physician fails to
                                                                                                  ordinary, have a sense of entitlement
    participate constructively in such efforts,
                                                    The Causes of Disrespectful                   to favorable treatment by others, and
    progress is virtually impossible.
                                                    Behavior                                      are insensitive to the feelings and needs
    Students are especially vulnerable to           Disrespectful behavior results from           of other people. Banja48 has coined the
    degrading or humiliating treatment by           multiple factors related both to the          term “medical narcissism” to reflect
    their teachers. In addition to the anger,       individual (endogenous) and to the            the observation that some aspects of
    humiliation, shame, and frustration that        environment in which he or she works          narcissism, such as high self-esteem
    anyone feels as a result of humiliating         (exogenous).                                  and feelings of superiority, authority,
    treatment, students may experience                                                            perfectionism, and self-absorption, are
    feelings of self-doubt and loss of self-        Endogenous factors                            often found in physicians. For some,
    esteem. A harshly negative judgment             Certain personality characteristics are       these characteristics may be essential to
    from a respected senior physician carries       associated with disrespectful behavior.       mastering the highly complex demands of
    great weight and sometimes leads a              Many are associated with threats to           practice and achieving self-preservation
    student to question his or her fitness          self-esteem. Self-esteem is especially        in a stressful environment.

    Academic Medicine, Vol. 87, No. 7 / July 2012                                                                                            5

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Culture of Medicine

    Although few physicians exhibit these           on few ears. Not unexpectedly, some of        physicians to increase output; income
    characteristics to the degree that would        this society-wide tolerance for disrespect    for both the group and the individual
    be classified as pathological narcissism,       spills over into health care.                 depends on the number of patients
    Banja48 notes that                                                                            treated. Short outpatient appointments,
                                                    In addition to this societal acceptance       shortened hospital stays, and increasingly
        many physicians and other health            of disrespect, contemporary health            complicated, sometimes dangerous
        professionals nevertheless demonstrate
        a kind of muted or closeted narcissism
                                                    care culture is characterized by features     procedures mean that pressured staff
        whose associated behaviors serve as         that foster disrespectful behavior. One       are often performing at the edge of their
        a form of self-protection when their        such feature is its hierarchical nature.      comfort and competence. As a result,
        feelings of adequacy, control, or           Disrespect, which is closely tied to          there can be loss of continuity of care,
        competency are threatened.                  status, usually flows down, not up.           and too little time is left for the courtesy
                                                    Medical students rarely are outwardly         and respect that are essential for good
    He believes that these feelings are a           disrespectful toward their professors,        patient care and a work environment that
    common cause of the difficulty many             house officers toward their seniors or        is comfortable and humane.
    physicians have in disclosing and               their attending physicians, or nurses
    apologizing after adverse events.               to their supervisors because of the           In addition to production pressure,
                                                    likelihood of repercussions. On the other     physicians face complex documentation
    Aggressiveness. Highly aggressive people        hand, students and residents often make       requirements and increasing demands
    enjoy combat and confrontation, have            disrespectful and derogatory comments         to improve quality and safety—with no
    hair-trigger tempers, and find reassurance      about their superiors when out of             increase in time or compensation—as
    in being able to bully others as a defense      earshot.                                      well as the frustrations that come from
    against helplessness. Professional setbacks                                                   trying to make a clumsy system work to
    may be experienced as helplessness,             Disrespectful behavior may actually           meet patients’ needs. This situation is a
    triggering an aggressive response. Highly       affirm status by rewarding the person         prescription for anger and exasperation
    aggressive people may find that their           behaving disrespectfully, who is typically    that, not surprisingly, results sometimes
    behavior is better tolerated in the health      highly sensitive to the hierarchy and         in outbursts or disrespectful behavior.
    care environment than in others and that,       keenly aware of the consequences of
    in some hospitals, it is even rewarded.49       disrespect directed up the status gradient.   Many other industries, however, have
                                                    In a hierarchical environment, the ability    succeeded in creating supportive
    Prior victimization. Doctors who                to disrespect others with impunity is         and satisfying work environments
    have suffered bad experiences, such as          a measure of status. The department           in spite of production pressures and
    bullying, during their formative years          chair or world-class cardiac surgeon can      complex regulatory and documentation
    may be so traumatized that imitative            often “get away with” conduct that is not     requirements. For example, commercial
    behavior becomes engrained in their             tolerated among those lower down the          aviation firms pay substantial attention
    unconscious. Their reaction to stress is to     ladder.                                       to duty hours and workloads. Former
    bully, reflecting their earlier experiences.                                                  Alcoa CEO Paul O’Neill57 emphasizes the
                                                    But the major exogenous factor leading        importance of treating employees with
    Exogenous factors                               to disrespectful behavior is the stressful    respect and dignity, of providing them
    Exogenous factors are characteristics of        environment of modern hospitals,              with the resources necessary to carry out
    the workplace that facilitate disrespectful     in particular large academic teaching         their work, and of showing appreciation
    behavior. The culture of an institution—        centers, where many people work unduly        for their contributions. A first principle
    “the way we do things here”—defines             long hours, have unreasonably heavy           is to guarantee the workers’ physical
    acceptable and unacceptable behavior.           work loads, and experience multiple           safety and psychological safety. Such
    That culture, in turn, is influenced            conflicting demands on their time and         focus on and concern for the workforce
    heavily by the customs and mores of             psyche. Burnout is common not only            are conspicuously absent at all levels
    society at large. In the United States, a       among staff doctors and nurses but even       in many, perhaps most, health care
    culture of aggressive crudity has taken         among medical students and residents.22,56    organizations.
    hold in the past 10 to 20 years, sparked        Workplace stress creates anxiety and
    originally by the “let it all hang out” and     depression and leads individuals to focus     For example, physical safety in health
    assertiveness-training era.50–52 The result     inwardly, accentuating self-absorption        care settings lags far behind safety in
    is that civility is regarded as weakness        and decreasing empathy and the                industry. The average number of days lost
    and as an invitation to exploitation.           willingness to cooperate. A person looks      because of injury per worker per year in
    This trend is obvious in the media,             naturally for others to blame for what        health care is 2.8; for Alcoa, the number
    in literature, and in conversation; a           appears to be an unsolvable situation.        is 0.15.57 Psychological safety, which
    certain degree of demeaning disrespect                                                        includes feeling safe about reporting an
    has been elevated to a normal style of          The stressful environment of health           error and being supported when things
    communication that is tolerated and             care organizations has multiple causes,       go wrong, is also often lacking. A recent
    that elicits little comment.53–55 The rise of   but primary among them is production          report by the Agency for Healthcare
    “social media” has greatly expanded the         pressure. The U.S. business model of          Research and Quality on culture surveys
    reach of insulting and derogatory speech        health care places enormous pressure          conducted in 1,052 hospitals showed that
    that, in earlier times, would have fallen       on health care organizations and              more than half (56%) of responders did

    6                                                                                             Academic Medicine, Vol. 87, No. 7 / July 2012

Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibited
Culture of Medicine

    not feel safe to report an error.58 In large        Center, Harvard Medical School; and Anthony D.          8 Rosenstein AH. Original research: Nurse–
    hospitals (which include most teaching              Whittemore, professor of surgery, Harvard Medi­           physician relationships: Impact on nurse
                                                        cal School, and chief medical officer, emeritus,          satisfaction and retention. Am J Nurs.
    hospitals), the rate was even higher:                                                                         2002;102:26–34.
                                                        Brigham and Women’s Hospital. The authors
    60%.58                                              also gratefully acknowledge two anonymous               9 Barry M, Levin C, MacCuaig M, Mulley A,
                                                        reviewers and an editor of Academic Medicine for          Sepucha K. Shared decision making: Vision
                                                        valuable suggestions that considerably strength­          to reality. Health Expect. 2011;14(suppl
    Summary                                             ened the manuscript.
                                                                                                               10 Barry MJ. Health decision aids to facilitate
    Disrespectful behavior is pervasive in              Funding/Support: None.                                    shared decision making in office practice.
    health care and takes many forms. The                                                                         Ann Intern Med. 2002;136:127–135.
                                                        Other disclosures: None.
    six types we identify are associated with                                                                  11 Leape L, Barnes J, Connor M, et al. When
    different, sometimes unique, threats to             Ethical approval: Not applicable.                         Things Go Wrong: Responding to Adverse
    the safety and well-being of patients and           Dr. Leape is adjunct professor of health policy,
    health care workers. Although disruptive            Department of Health Policy and Management,
                                                                                                                  Accessed March 30, 2012.
                                                        Harvard School of Public Health, Boston,
    behavior has drawn increasing attention             Massachusetts.
                                                                                                               12 Accreditation Council for Graduate Medical
    in recent years, other types of disrespect                                                                    Education. Core competencies. http://
                                                        Dr. Shore is Bullard Professor of Psychiatry,   
    are far more common and potentially                                                                           coreComp.asp. Accessed March 29, 2012.
                                                        Emeritus, and chair, Promotions and Review Board,
    more harmful overall. “Institutionalized”           Harvard Medical School, Boston, Massachusetts.         13 MacDonald O. Disruptive Physician
    disrespect, such as unduly long work                                                                          Behavior. Waltham, Mass: QuantiaMD;
                                                        Dr. Dienstag is Carl W. Walter Professor of               2011. http://www.quantiamd.
    hours, burdensome high work loads,                  Medicine and dean for medical education, Harvard
    physical hazards, and psychological                                                                           com/q-qcp/QuantiaMD_Whitepaper_
                                                        Medical School, Boston, Massachusetts.
                                                                                                                  ACPE_15May2011.pdf. Accessed March 29,
    intimidation, is so common in health                                                                          2012.
                                                        Dr. Mayer is Stephen B. Kay Family Professor of
    care that it is often accepted as normal.           Medicine, Department of Medicine, and faculty          14 College of Physicians and Surgeons of
                                                        associate dean for admission, Harvard Medical             Ontario, Ontario Hospital Association.
    Although personality characteristics                School, Boston, Massachusetts.                            Guidebook for Managing Disruptive
                                                                                                                  Physician Behavior. Toronto, Ontario,
    predispose some individuals to                      Ms. Edgman-Levitan is executive director,                 Canada: College of Physicians and Surgeons
    disrespectful behavior, for the most                Stoeckle Center for Primary Care Innovation,              of Ontario; 2008.
                                                        Massachusetts General Hospital, Boston,
    part, disrespect is learned behavior                                                                       15 Hickson G, Pichert J. One step in promoting
    that is supported and reinforced by                                                                           patient safety: Addressing disruptive
                                                        Dr. Meyer is lecturer in medicine, Harvard Medical        behavior. Physician Insurer. Fourth quarter
    the authoritarian, status-based culture
                                                        School, and senior vice president for quality and         2010:40–43.
    found in most hospitals. We address                 safety, Massachusetts General Hospital, Boston,        16 Rosenstein A, O’Daniel M. Disruptive
    these cultural and educational issues               Massachusetts.                                            behavior and clinical outcomes: Perceptions
    elsewhere,59 but we hope the definitions            Dr. Healy is professor of otology and laryngology,
                                                                                                                  of nurses and physicians. Am J Nurs.
    and discussion of disrespectful behavior                                                                      2005;105:54–64.
                                                        Harvard Medical School, Boston, Massachusetts, and
                                                                                                               17 Cox H. Verbal abuse nationwide, Part I:
    we have provided in this article will               senior fellow, Institute for Healthcare Improvement,
                                                                                                                  Oppressed group behavior. Nurse Manage.
    enhance awareness and understanding of              Cambridge, Massachusetts.
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