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

Department of Health Policy and Management, Harvard School of Public Health, Boston, MA 02115, USA.
Academic medicine: journal of the Association of American Medical Colleges (Impact Factor: 2.93). 05/2012; 87(7):845-52. DOI: 10.1097/ACM.0b013e318258338d
Source: PubMed


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

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    • "hostility, apathy, and distrust), and behavioral problems (e.g. aggressiveness, irritability, and feelings of isolation) among others (Jansson-Frojmark & Lindblom, 2010; Leape et al., 2012). At the organizational level, problems can also arise that make it impossible to achieve the objectives for healthcare personnel. "
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    • "Reduced rates of substance disorder diagnoses in our population may reflect a combination of improved recognition, diagnosis and treatment as well as decreasing stigmatization of addicted physicians. Physician behavior that interferes with the optimal functioning of healthcare teams [30] [31] can be detrimental to the culture of (clinical) safety [32]. Actions or speech by a physician that demeans, upsets or disrespects others decreases the ability of the clinical team to achieve its intended outcomes [33]. "
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    ABSTRACT: We compare findings from 10 years of experience evaluating physicians referred for fitness-to-practice assessment to determine whether those referred for disruptive behavior are more or less likely to be declared fit for duty than those referred for mental health, substance abuse or sexual misconduct. Deidentified data from 381 physicians evaluated by the Vanderbilt Comprehensive Assessment Program (2001-2012) were analyzed and compared to general physician population data and also to previous reports of physician psychiatric diagnosis found by MEDLINE search. Compared to the physicians referred for disruptive behavior (37.5% of evaluations), each of the other groups was statistically significantly less likely to be assessed as fit for practice [substance use, %: odds ratio (OR)=0.22, 95% confidence interval (CI)=0.10-0.47, P<.001; mental health, %: OR=0.14, 95% CI=0.06-0.31, P<.001; sexual boundaries, %: OR=0.27, 95% CI=0.13-0.58, P=.001]. The number of referrals to evaluate physicians presenting with behavior alleged to be disruptive to clinical care increased following the 2008 Joint Commission guidelines that extended responsibility for professional conduct outside the profession itself to the institutions wherein physicians work. Better strategies to identify and manage disruptive physician behavior may allow those physicians to return to practice safely in the workplace.
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