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

Abstract

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.

The 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, 1–4 12 years ago. 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 5 progress in safety and that it is also a supportive centers of patient-centered infection in our hospitals every day, 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, with disrespect, creating a barrier to Patients suffer when physicians do not Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115; telephone: (617) the open communication and feedback listen, show disdain for their questions, or 432-2008; e-mail: [email protected]. 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;87:845–852. 9,10 First published online May 22, 2012 to following safe practices, resulting process. 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 845 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 Disruptive behavior is also a foundational element of 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 12 specialties. 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 that only 5% or 6% of physicians fall into reported knowing a nurse who had professionalism. this category,16 the detrimental influence left the hospital because of disruptive 19 of this small minority far outweighs their physician behavior. The vast majority of physicians treat numbers. others respectfully most of the time; Medical students, at the bottom of the however, some do not. In a recent Disruptive actions include angry patient care team hierarchy, are very national survey, two out of three outbursts, verbal threats, shouting, vulnerable to disrespect from faculty, physicians reported witnessing other swearing, and the threat or actual house staff, nurses, and others through physicians disrupting patient care or infliction of unwarranted physical force verbal or physical abuse, belittlement, collegial relationships at least once a that legally would be considered battery. humiliation, harassment, intimidation month. One in nine physicians reported Having a temper tantrum, throwing and exploitation, or simply by being 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.” forms of disruptive behavior, as is any A culture of disrespect is harmful for Annual surveys by the Association of unwanted physical contact of a sexual many reasons, but it is its effect on the American Medical Colleges show that nature. Disruptive conduct may be safety and well-being of our patients 14% to 17% of graduating students directed at anyone—nurses, colleagues, that makes it a matter of urgency. In report having been subjected to or residents, medical students, ward staff, simple terms, we believe that a health witnessing some form of mistreatment.20 hospital administrators, and even patients care organization that supports and 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

846 Academic Medicine, Vol. 87, No. 7 / July 2012 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 behavior is tolerated, if not celebrated. treatment in a number of ways: “He treats 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 25 adequate performance. 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 847 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

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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. 43 clinical years. Although some students detrimental to teamwork. Teamwork is 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 honest, and understanding in these improving safety. The major safety efforts in some individuals may accentuate situations. Dismissive or dissembling have focused on implementing new safe narcissistic character traits. Highly treatment undermines the trust that is practices. Both implementing standard 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 48 Students are especially vulnerable to Disrespectful behavior results from of other people. Banja 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.

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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

850 Academic Medicine, Vol. 87, No. 7 / July 2012 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. 58 Brigham and Women’s Hospital. The authors 60%. 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 1):1–5. 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 Events. http://www.macoalition.org/ the safety and well-being of patients and Dr. Leape is adjunct professor of health policy, documents/respondingToAdverseEvents.pdf. health care workers. Although disruptive Department of Health Policy and Management, Accessed March 30, 2012. Harvard School of Public Health, Boston, 12 Accreditation Council for Graduate Medical behavior has drawn increasing attention Massachusetts. in recent years, other types of disrespect Education. Core competencies. http:// are far more common and potentially Dr. Shore is Bullard Professor of Psychiatry, www.acgme.org/acWebsite/RRC_280/280_ Emeritus, and chair, Promotions and Review Board, coreComp.asp. Accessed March 29, 2012. 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 Dr. Mayer is Stephen B. Kay Family Professor of 2012. 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. part, disrespect is learned behavior Massachusetts General Hospital, Boston, 15 Hickson G, Pichert J. One step in promoting Massachusetts. that is supported and reinforced by patient safety: Addressing disruptive the authoritarian, status-based culture Dr. Meyer is lecturer in medicine, Harvard Medical behavior. Physician Insurer. Fourth quarter School, and senior vice president for quality and 2010:40–43. found in most hospitals. 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