In a Culture of Disrespect, Patients Lose Out
By DANIELLE OFRI, M.D.
I’ve always thought about respect as common decency, something we should do because it’s simply the right thing to do. In the medical world, we certainly need to strive for respectful behavior, especially given our historically rigid pecking order, our ingrained traditions of hierarchical bullying and, of course, a primary constituency — patients — who are often on uniquely vulnerable footing.
But then I stumbled across two articles in Academic Medicine that talked about respect as an issue of patient safety. The authors, a group of doctors and researchers at Harvard
Medical School, outlined the myriad acts of disrespect that we’ve come to accept as a way of life in medicine, and showed how these can lead to a final pathway of harm to our patients.
Joon Park Danielle Ofri, M.D.
This shift in perspective was a shock to the system. When we tolerate a culture of disrespect, we aren’t just being insensitive, or obtuse, or lazy, or enabling. We’re in fact violating the first commandment of medicine. How can we stand idly by when our casual acceptance of disrespect is causing the same harm to our patients as medication errors, surgical mistakes, handoff lapses and missed lab results?
At one end of the spectrum are the examples of disrespectful behavior, like the volatile doctor everyone knows to steer clear of. Then there are the sadly common abuses of hierarchy — the doctor denigrating a nurse, the medical student treated like disposable goods.
Beyond these are the even more widespread passive types of disrespect, the behaviors that don’t ever get reported and are hardly noticed because they are so ingrained in the culture of medicine. Dismissive attitudes — toward other members of the medical team, toward students, toward administrators, toward patients — are as corrosive as outward manifestations of disrespect.
“Lack of respect poisons the well of collegiality and cooperation,” the authors of the articles wrote. The poisoning-of-the-well metaphor is apt. Like pornography, we know it when we see it. Ask a nurse or an intern or a medical student, and they can tell you with pinpoint accuracy which areas of the hospital are toxic to work in, and which are not. Now think of the patients who have the misfortune to be stuck in one of those toxic areas. It’s not just unpalatable; it’s unsafe.
Doctors have to take a good deal of the blame. For better or worse, we often set the tone in a medical enterprise. When we show, or tolerate, even subtle disrespect, it works its way all along the chain.
Luckily, the reverse is true. Having had the privilege of working under some of the most humane and respectful doctors, I have witnessed how everyday acts of decency and humility generate positive cascading effects toward other staff members and toward patients. Rising tides, in this case, can indeed lift all boats.
But these articles also make the point that disrespect comes from the medical system itself. When a hospital cuts its nursing staff to the bone, for example, it’s doing much more than cutting costs. It’s sending the message that nurses are interchangeable widgets whose productivity can be dialed up or down like household appliances.
This subtle disrespect can be seen in many areas: Overbooking doctors’ schedules. Piling on paperwork. Squeezing in additional responsibilities. Requiring ceaseless “compliance courses” that must be completed on personal time. The system functions because most medical professionals generally do what’s required of them to make it all work.
Though these annoyances may seem trivial, this lack of respect “undermines morale, and inhibits transparency and feedback,” the authors write. Morale, transparency and feedback are pillars of preventing medical error. Patients ultimately bear the brunt of this unhealthy atmosphere.
The solutions to a disrespectful environment are wide-ranging, and there’s no doubt that personal example, starting from the top of the hierarchy, is a powerful agent of change.
Expectations of professional conduct need to be applied equally, without exemptions for the well-connected or the powerful. Confidential reporting systems for unprofessional behavior are crucial and need to be available to staff members as well as to patients and families.
Added to the clarion call should be patient safety. The connection between disrespectful behavior to patient safety should be made explicit in our efforts, since this is a rallying point that everyone can agree on. Medical staff members should absolutely be holding ourselves to the highest bar of professional and respectful conduct. We have no excuses for anything less. But beyond this, the medical system needs to re-evaluate itself and the way it respects — or disrespects — its own workers, and by extension, its patients.