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© Royal College of Physicians 2015. All rights reserved. 541
Clinical Medicine 2015 Vol 15, No 6: 541–5 ORIGINAL RESEARCH
Sticks and stones: investigating rude, dismissive and
aggressive communication between doctors
Destructive communication is a problem within the NHS;
however previous research has focused on bullying. Rude,
dismissive and aggressive (RDA) communication between
doctors is a more widespread problem and underinvestigated.
We conducted a mixed method study combining a survey and
focus groups to describe the extent of RDA communication
between doctors, its context and subsequent impact. In total,
606 doctors were surveyed across three teaching hospitals in
England. Two structured focus groups were held with doctors
at one teaching hospital. 31% of doctors described being
subject to RDA communication multiple times per week or
more often, with junior and registrar doctors affected twice
as often as consultants. Rudeness was more commonly
experienced from specific specialties: radiology, general
surgery, neurosurgery and cardiology. 40% of respondents
described that RDA moderately or severely affected their
working day. The context for RDA communication was
described in five themes: workload, lack of support, patient
safety, hierarchy and culture. Impact of RDA communication
was described as personal, including emotional distress and
substance abuse, and professional, including demotivation.
RDA communication between doctors is a widespread
and damaging behaviour, occurring in contexts common
in healthcare. Recognition of the impact on doctors and
potentially patients is key to change.
KEYWORDS: Medical education, rudeness, communication,
incivility
ABSTRACT
Introduction
Destructive or negative workplace communication is recognised
to be a problem both in the NHS and other organisations1–4 and
has attracted concern following recent care scandals such as
Mid Staffordshire and Morecombe Bay.5,6
Negative workplace behaviours encompass a broad spectrum
and most of the research on negative communication between
doctors has analysed bullying or undermining as a discrete
subset.7–10 However, relatively little work has been done to
describe more widespread rude, dismissive and aggressive
(RDA) communication between doctors that can also be
defined as workplace incivility.11 RDA communication is
distinct from bullying which is a more persistent and power-
based form of abuse most commonly occurring within a
department.2,12
Doctors who are recipients of bullying and negative
communication have increased levels of stress and depression,
and an increased desire to leave medicine.9 There is increasing
recognition that this kind of adverse staff interaction leads
to worse patient outcomes and can represent a patient safety
threat.13–15
In order to find out the scale of RDA communication in
hospitals, and the impact it has on doctors, we conducted a
mixed methods study at three teaching hospitals. The study
involved surveying doctors to report their experiences of
negative communication and conducting focus groups.
Methods
Survey
An online-hosted questionnaire combined multiple choice
questions and free text boxes to gather information on:
1. Frequency of RDA.
2. Context of RDA – who perpetrates rude behaviour?
3. Impact of RDA.
The cohort of doctors to whom the questionnaire was
circulated was defined by lists of current employed doctors
obtained by the postgraduate medical department and the
office of the medical director in each trust. It was distributed
to three core groups – junior doctors (defined as all in posts
<specialty training year 3 (ST3)), registrars (defined as training
posts ≥ST3) and consultants.
Authors: Victoria Bradley,A Samuel Liddle,B Robert Shaw,C Emily Savage,D Roberta Rabbitts,E Corinne Trim,F
Tunji A LasoyeG and Benjamin C WhitelawH
Authors: Amedical education fellow, PGMDE, King’s College
Hospital NHS Foundation Trust, London, UK; Bmedical education
fellow, PGMDE, King’s College Hospital NHS Foundation Trust,
London, UK; Ccore medical trainee, Oxford Deanery, Oxford, UK;
Dcore medical trainee, South West London Deanery, London,
UK; Ecore medical trainee, South West London Deanery, London,
UK; Fmedical education manager, King’s College Hospital NHS
Foundation Trust, London, UK; Gdirector of medical education,
King’s College Hospital NHS Foundation Trust, London, UK;
Hconsultant endocrinologist, King’s College Hospital NHS
Foundation Trust, London, UK
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Victoria Bradley, Samuel Liddle, Robert Shaw et al
542 © Royal College of Physicians 2015. All rights reserved.
Doctors received an email invitation to complete the survey
and then up to two email reminders.
The questionnaire was circulated at three large teaching
hospitals, two in London and one outside London over a period
between November 2013 and February 2015, henceforth known
as hospitals A, B and C.
Results were analysed by one of the investigators using
Microsoft Excel.
Focus group
The focus groups were held in the early evening on a
weekday and the groups were run by a trained facilitator.
Two focus groups were held: one for trainee doctors, with six
participants; another for consultants, with four participants.
The participants were recruited by email from one of the three
hospitals. Questioning was semi-structured based on the data
gathered from the survey to explore a greater depth of data in
key areas:
1. Experiences of rudeness.
2. Context of rudeness – what is seen as triggering rude
behaviour?
3. Impact of rudeness.
Other topics or themes which arose were explored as far
as useful and relevant. Questioning was open and non-
judgemental to minimise bias from the facilitator’s own
opinions and perceptions. The focus groups were recorded
and transcribed verbatim. Two investigators independently
coded for themes, and met to resolve disparities and achieve
consensus, and a third investigator agreed the final analysis.
Quotes were tagged with T or C for trainee or consultant
respectively, followed by a numerical identifier.
Approval for the project was granted as service evaluation by
the trust research and development department. Focus group
participants gave written consent to be recorded and their
discussion analysed and published verbatim.
Results: survey
We received 606 responses in total (see Table 1). RDA behaviour
was reported to be common. 31% of doctors describe being
personally subject to this behaviour multiple times per week
or more often (Fig 1). The rates are similar across the three
hospitals studied. All grades of doctor are affected but junior
and registrar doctors are affected more than twice as much as
consultants, with 43% of junior doctors and 38% of registrars
experiencing RDA a few times per week or more, compared to
18% of consultants (Fig 1).
The behaviour is experienced from a wide range of sources
within the hospital. A minority of rudeness, dismissiveness
or aggression originates from within the individuals’ own
department (16%) and a larger proportion comes from
interaction with other departments and specialities (49%).
Certain specialties were repeatedly and consistently named
as more likely to engage in this behaviour and these were:
radiology, general surgery, neurosurgery and cardiology
(Fig 2).
Despite negative behaviour being common and widespread
in the survey, respondents were very unlikely to recognise
themselves as perpetrators of this behaviour with 86% of
respondents saying they either never communicated in this way
or only did so a few times per year.
Table 1. Response numbers and rates for each hospital and grade of doctor surveyed.
Hospital Junior respondents Registrar respondents Consultant respondents Total respondents Response rate (%)
A 90 47 113 250 21
B 28 29 70 127 15
C 76 60 93 229 12
Total 194 136 276 606 15
Fig 1. Combined data from three hospitals in answer to the question:
How often do you personally experience rude, aggressive or dismissive
communication in interactions with other members of staff? Visually
represente d are (a) all respondents’, (b) junior doctors’ and (c) consultants’
answers expressed as a percentage. DN A = did not answer.
60
50
%
%
%
40
30
20
10
0
9
Daily
22
Few mes
per week
Few mes
per month
Few mes
per year
Never
DNA
28 34
7
0
60
(a)
(b)
(c)
50
40
30
20
10
0
Daily
Few mes
per week
Few mes
per month
Few mes
per year
Never
DNA
34
17
61
11
32
60
50
40
30
20
10
0
Daily
Few mes
per week
Few mes
per month
Few mes
per year
Never
DNA
21
51
11
0
4
14
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Sticks and stones
© Royal College of Physicians 2015. All rights reserved. 543
RDA behaviour had a marked adverse effect on those subject
to it, with 40% of respondents saying that this behaviour
moderately or severely affected their working day (Fig 3).
Feeling sad, angry or demotivated was widely described, and
7% report that this behaviour had led them to make a mistake
at work.
Results: focus group
‘What is rudeness?’
A spectrum of behaviours was described. Overt aggression,
such as raised voices and swearing was clearly described:
One of my registrars rang…to get a [specialty] opinion at 4
o’clock in the morning and spent 10 minutes listening to the
[specialty] registrar telling her that she was, um, sorry excuse
my language : ‘ f***ing useless, and was a f***ing waste of
space. What are you doing ringing me at this f ***ing time in
the morning?’ – C2
Other more insidious examples of rudeness included
undermining, unwillingness to help, sexism and racism:
I’ve had situations where people…haven’t listened to me
because I’m a woman. Other colleagues who’ve not been
listened to because their particular ethnicity – T6
Concerns were raised that legitimate negative feedback could be
confused with rudeness:
I got accused of bullying and harassment by one of the F1s, um,
because I said, very politely, on the consultant ward round...I
don’t think you did that right…next time you ought to try this
and I’m sure it will be fine. – C2
‘Why does rudeness happen?’
Workload
There was widespread recognition that doctors who were busy
or overworked were more likely to be rude:
…you’re trying to do 15 things at once…my bleep’s going
crazy…everyone’s bleeding [and colleagues] want blood
products…the lab’s phoning me [about] blasts on the [blood]
film, Mr So-and-so is febrile, some external bone marrow
transplant patient is c****ing out in St Elsewheres . And that’s
when I’m rude. – T6
Lack of support
Rudeness was often described in the context of being
unsupported or attempting to support others, outside of
conventional supervisory roles:
It’s just a horrible feeling and…I just felt like I was making
myself vulnerable because I’m having to do two people’s jobs.
I’ve got no support…I didn’t really feel like I was being myself I
felt like I was being quite mean really because I had to be. – T2
Patient safety
In circumstances where patient safety or dignity is acutely
threatened, direct and rude communication was more likely.
This was the only context for rudeness in which there was
support for its presence:
And that was rude. I was rude. But [a] woman could have
died. That woman could have died without her fluids and these
are meant to be speciality [clinicians]…Christ’s sake. Set up
a load of fluids. Whack a catheter in. Jesus wept. I was, you
know…I was cross. But I was rude. She could she could have
easily have put in a complaint about me. – T6
I found her telling off my patient...I did raise my voice and I
did have to say: please would you stop talking to my patient
like this…I felt I was being rude, but I felt it was justified – C3
Hierarchy
Consultants described rude behaviour being experienced far
less once they had become consultants:
…having worked here as a junior and then as a consultant,
it always amazed me that the attitude of people underwent a
Fig 2. Combined data from three hospitals in answer to the question:
In your experience have you noticed any particular departments and/
or types of staff who are more likely to be rude or dismissive to you or
colleagues? Visually repre sented are all respondents’ answers expre ssed as
a percentag e.
1
Mean of all other
speciales name (total 27)
20
General surgery and
surgical speciales
17Cardiology
18Neurosurgeons
27Radiology
0 5 10 15
%
20 25 30
Fig 3. Combined data from three hospitals in answer to the question:
How much does this behaviour affect your experience of the working
day at the hospital? Visually represented are all respondents’ answers
expressed as a percentage. DN A = did not answer.
50
40
30
20
10
0
16
Not at all
43
Minimally
32
Moderately
8
Severely
2
DNA
%
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Victoria Bradley, Samuel Liddle, Robert Shaw et al
544 © Royal College of Physicians 2015. All rights reserved.
miraculous transformation once you announced that you were
consultant…on the telephone or in person. – C2
Trainees frequently described a power imbalance in interactions
where rude behaviour occurred.
Culture
Some individuals and departments were described as habitually
rude, with a permissive and low threshold attitude to this
behaviour. They could be regarded as having a culture which
perpetuates rude behaviour:
…the [specialty] registrar…absolutely blew my SHO out down
the phone. You know, told her she was useless…I rang up the
consultant [specialist] who was on call for the day, and his
response was ‘well what do you expect? If people roll over and
show me their belly, I will encourage people to put their claws
in.’ – C2
I do think some of it is a culture…for example, the [specialty]
unit…There is a culture of being aggressive and abrasive…and
that is accepted…that’s how you are in the [specialty] unit. – C2
‘What effect does rudeness have?’
There were broadly two areas of impact discussed: personal and
professional.
Personal impact
The significant emotional impact of rude and dismissive
communication:
…if you have had a day where you’ve had people be rude to
you or you’ve had like a load of referrals to do and they’ve been
really tough you just go home miserable basically…And then
you just can’t be bothered to do anything. Like I might not be
sitting there thinking about it but clearly like subconsciously
maybe I am, cos I just go home and I don’t want to do any
exercise, I don’t really want to eat any dinner, I’m just like,
I’m just gonna sit here and can’t even be bothered to watch
TV. – T1
Potentially harmful behaviours were also described:
…we don’t steal diamorphine but definitely there’s a direct
correlation to…if someone’s had a rubbish day the amount of
times we’ll be like [let’s drink] wine? – T5
Professional impact
Rudeness could contribute to demotivation with examples of
individuals leaving a specialty, or the profession altogether in
response to this behaviour:
…now [name removed] is leaving and going to [another
hospital] and he’s got very disheartened and feels like the whole
thing has been quite an unpleasant experience for him because
of the interactions [with] his own colleagues who…should be
supporting him. – T6
Inefficient working practice and avoidant behaviours were
described:
The referral process to…another big specialty, perhaps with
a culture of aggressiveness, is like [a junior doctors] biggest
nightmare. They’re putting it off. They don’t want to do it.
You might be their consultant saying, ‘well have you made that
referral?’ And, it won’t have got done. They won’t actually
admit it…it all stems from, ‘I have just got myself so worked
up, I don’t think I can speak to this powerfully important
[specialist].’– C3
Discussion
Our survey reports a high prevalence of RDA communication
affecting 31% of doctors on a daily or weekly basis. This rate is
far higher than rates of bullying which have been estimated as
only affecting 1–3% of doctors on a daily or weekly basis.1 The
data suggests that RDA communication encompasses a wide
spectrum of behaviours, for which bullying is a subset of the
wider problem.
Exposure to RDA communication was highest among
junior doctors, whereas consultants described their seniority
as relatively protective against rudeness. This illustrates how
status and medical hierarchy are intrinsically linked to negative
communication.3
We have shown that across multiple hospital trusts a subset of
predictable specialties are more likely to be rude, dismissive or
aggressive in their communication: radiology, general surgery,
neurosurgery and cardiology. This finding partly conforms
to a survey of nurses and medical students in the USA which
identified general surgeons, neurosurgeons and obstetrics and
gynaecology as the specialties most likely to be disruptive and
unprofessional.16,17
Five key themes emerged in response to ‘Why rudeness
happens’: workload, lack of support, patient safety, hierarchy
and culture. Being overworked and undersupported are
both associated with rudeness and they are both relatively
common workplace experiences. However, not all specialties
which are acute and high intensity are reported to exhibit
rudeness and it may be that differences in departmental
culture account for this. We suggest that RDA is not an
effective or reasonable coping strategy in response to
overwork. Venting of anger has been shown to fuel aggression
rather than dissipate it and the expression of rudeness is
likely to be counterproductive.18
We have shown that RDA behaviour had a marked adverse
effect on those subject to it, with 40% of respondents saying
that this behaviour moderately or severely affected their
working day. The qualitative data describes personal misery
and professional demotivation. We know from experimental
studies that being subject to rudeness impairs cognitive skills
such as memory and attention and also harms cooperation
and the willingness to help others.19 The Joint Commission
(which accredits healthcare organisations in the United States)
issued an alert in 2008 warning that rude language and hostile
behaviour among healthcare professionals pose a serious threat
to patient safety and quality of care.14
The limitations of our study include the low response rate to
the survey and small sample size in the focus groups. There
is potential for selection bias in both because doctors affected
by negative behaviour may be more motivated to participate.
Our results were reproduced across three separate teaching
hospitals, though we have not investigated experiences at
smaller district general hospitals.
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Sticks and stones
© Royal College of Physicians 2015. All rights reserved. 545
Concern to avoid rudeness should not be interpreted as
a reason to avoid direct communication in an urgent or
emergency situation; nor should concerns about rudeness
be considered a potential reason to avoid addressing poor
standards of clinical care. Patient safety is paramount and any
programme to reduce RDA would recognise the need for direct
and assertive communication in both urgent clinical situations
and in response to poor clinical standards.
Describing a programme to change behaviour is beyond
the scope of this paper but our data do point to some key
areas. If trusts can minimise contributing factors such as
overwork and lack of support for doctors this may go some
way to ameliorating RDA communication in the workplace.
However the entanglement of rudeness with certain speciality
culture and hierarchy within medicine means that much more
overarching change is needed to address the issue.3 Increasing
awareness together with promoting a programme of culture
and attitude change would be expected to be both difficult and
potentially the most rewarding intervention.20
Conclusion
There may be a perception that rudeness is a mild word, for a
mild problem; that as it is a part of everyday life and resilience
to it should be a normal part of our reactions and behaviour.
We have shown that it is a widespread problem with a large
impact on individuals and healthcare organisations. Changing
this behaviour is likely to be challenging. The recognition
that RDA behaviour is damaging and counterproductive is an
essential initial message which needs dissemination. ■
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Address for correspondence: Dr B Whitelaw, Department of
Endocrinology, King’s College Hospital NHS Foundation Trust,
Denmark Hill, London SE5 9RS, UK.
Email: benjamin.whitelaw@nhs.net
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