Physician disrespect impedes patient safety

“I just love working here!” my nurse told me. “We have great supervision, I have wonderful colleagues – we all help each other in an emergency. The doctors are really responsive and I feel like I am doing important work. I thought I would only stay for a year because oncology is so hard, but I’ve been here ten and I still love it.”

This is what we want to hear from the people who are taking care of us.

But sometimes we don’t.  In two articles by patient safety leader Lucien Leape and his colleagues recently published in AcademicMedicine, we learn that physician disrespect of their co-workers and patients is fairly common and that it stymies efforts to improve patient safety. The two papers describe this phenomenon in detail and suggest what hospitals and health systems can do to build a “culture of respect.”

While the audience for these articles is medical educators, clinicians and hospital administrators, those of us who are interested in people’s engagement in their health care should take a look.  The authors:

— Recognize the existence of what we have long suspected: that health care is organized around a physician ethos that favors their “individual privilege and autonomy” – as opposed to collaboration, teamwork and our inclusion in decisions about our treatment.

— Validate our experience of being disrespected by some of our clinicians, for example, when our questions are met with disdain, when we are excluded from decisions about our preferences for care, or when we are not provided an honest explanation when things go wrong.

— Note that disrespect is reflected in the organization of health care, through such common occurrences as the disregard of the value of our time manifested by long hours spent in waiting rooms and requests that we fill out that questionnaire on our medical history for each clinician for each visit.

Most of us have had some experience with all these varieties of disrespect.  But reading the details about the effects of physician disrespect on the operation of hospitals and practices and the functioning of colleagues and staff is chilling. This behavior distorts relationships. It contributes to an atmosphere of intimidation and damages their willingness to be accountable, undermines cooperation, and ultimately distracts them from delivering good care leading to errors, apathy and burn-out.

It’s difficult to imagine that professionals working in a practice or department or unit where they are constrained by their own colleagues’ misbehavior are going to have the energy to invite us to learn about and share in decisions about our treatment; where preoccupation with hurt feelings and temper outbursts among staff will allow them to imagine what we must know and do to care for ourselves when we leave the hospital – and then help us plan how we will do it.

We patients are insignificant bit players in an intense ongoing interpersonal drama among those who provide our care. We come and go, but the squabbles and turf battles and grudges among them spool out over years.  Meanwhile, we can object directly, complain to administrators, change clinicians or institutions to protect ourselves.   And we can express our dissatisfaction in surveys and go public with our concerns on various rating sites, although our individual efforts will have little impact on a culture where disrespectful behavior by professionals is tolerated.

Assessment of our experience of care through HCAHPS and satisfaction surveys can provide a general whack to a hospital or a department by indicating that we notice just how bad things are. And theoretically, since payment is increasingly tied to such measures, there is an incentive to tackle these problems.

But I’m not holding my breath … there are many factors that might make me rate as poor my experience of care, and while the attribute of “disrespect” may be behind many of them, it is easier to offer free coffee and wireless in the waiting rooms than it is to fix the personal and systemic problems that the disrespect causes.

Dr. Leape and his colleagues suggest specific and direct remedies that are certain to meet with stiff resistance from the physician champions of the ethos of individual privilege and autonomy. Take a look here: How have hospitals run all this time without these basic controls?

Contemplate all this and then recall the clinicians who have listened to you and cared for you over the years.  The ones who, like my nurse, love their work and are committed to doing the best they can for each of us; the ones who work in settings where they are valued and respected and who bring energy and focus to their efforts to help us.  A culture of respect in health care may be a heavy lift in some places, but it already exists in practices and hospitals and clinics all over the country.

Patients and families can’t fix the problem of disrespectful physicians. But it needs to be addressed, and the first step in addressing it is identifying it.  These two papers are a good start.

Jessie Gruman is the founder and president of the Washington, DC based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. She blogs regularly on the Prepared Patient Forum.

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  • Tom Bouthillet

    Civilian and military aviation has known for a long time that the “infallibility of the captain” leads to plane crashes. Health care has been slow to adopt crew resource management and other techniques (like checklists) from aviation and has paid the price. It ultimately harms both the decision maker (physician) and the patient. The author is spot-on with regard to the reason. Individual privilege and autonomy is just another way to say power or dominion.

    • Ajoy Kumar, MD

      When you get around to it, read my opinion.

  • itsonlypalliative

    Thank you for writing this. It is about time that someone addresses this issue. Trying to ‘fight’ a providers ego is too hard and many just take things AS IS.

    • Ajoy Kumar, MD

      It’s not about ego. Remember, they do this 24 hours a day for years. If you were an “expert” in a field, and I read an article for 10 minutes, and then I come to you and tell you how it should be done and how you are not doing it right as per my reference and my 10 solid minute read versus your thousands of hours, would you not feel at the least bit chaffed? I know just enough to get myself in trouble. Instead, I might consider saying, “I came across this article and I want to get your professional opinion on it.” I’ve had plenty of patient do that and I appreciate their efforts at taking charge of their healthcare. I now give everyone some “homework” to read up on a website for further education and discussion. I really enjoy those visits. An educated patient is a healthier patient. I’ld rather have a patient hang out with their family than with me in my office. If they are in my office often, something’s up.

  • themedstudent

    Everyone espouses the virtues of teamwork, shared decision making, and collaboration until something goes wrong and lawsuits heat up. Then it’s obviously not the team or collaborators’ fault… all the blame is on the physician.

    So it’s all “group think” until the stuff hits the fan, then all those collaborators and teammates can be seen pointing the finger at the rich, greedy, selfish doctor who obviously made all the mistakes (because teams don’t make mistakes, only doctors).

    • ninguem

       ^^^  what themedstudent said  ^^^

      (One question though  -  your take is spot-on, so why did you sign up for this?)

    • Jan

      Do physicians try to justify anything and everything with the word “malpractice”? Some serious issues are raised in this post, and to dismiss them by citing malpractices is, in my opinion, just another form of disrespect. Actually, I think “disrespect” is a fairly mild adjective; abuse would be more accurate. A culture of abuse is pervasive, and will be persistent as long as even up and coming doctors continue to dismiss the reality of problem.

    • kathleen

      It’s obvious you’re in medical school, and, in fact, have no true idea of what actually happens.  As someone who has represented health care providers, mostly nurses, in disciplinary actions, I can assure you that the blame is usually sent down the chain of command and not up.  As a former nurse and very experienced medical malpractice lawyer I can also assure you that it’s a failure to act in accordance with minimal standards of practice and not who failed to do so that counts. So get your paranoia out of your head and spend your time becoming the best doctor you can be and understand that you have an obligation to work collaboratively with the people, particularly in the hospital setting, who care for the patient the 23.45 hours you are not present.  

      • themedstudent

        Straw man argument… I would have expected more from a “very experienced medical malpractice lawyer.”

        But thanks for setting me straight. With your words of wisdom I’ll grow up to be perfect team-playing doctor (read: scapegoat). 

      • Ajoy Kumar, MD

        It is important to communicate pro-actively in a professional manner. It is also important that physicians take the input from as many members of the team before rendering a decision. I have had my butt saved many a time as a medical student and a Resident by a very seasoned Nurse, and I respect them for everything they do and all they have taught me along the way. However, I do know their weaknesses as well. I certainly do not exploit them as I respect them as an individual and as a professional, however I do know when they too can be wrong. Throughout the years we have built up a very good relationship and I now I provide care for many of them. I am honored to do that. As such there is an unspoken understanding that they know when it’s time for me to call the shot, and even when they disagree. However, they do know I do go back and speak with them and explain why. Certain decision I do not want them to make as it may break professional statutes and laws, and now I protect them as they did me. I hope every physician is fortunate enough to develop such relationships. I will truly be sadden if anything were to happen to them.

    • MightyCasey

      Not so fast, MedStudent. Sounds like you’re headed down the “because I’m the DOCTOR and I SAID SO” path. Pull up before you auger in to the flight deck …

      • Ajoy Kumar, MD

        Teach, don’t preach. Guide them without guiding them.

    • Ajoy Kumar, MD

      Your comments are for the most part accurate, however always remember to step back and look at the issue from your patient’s point of view. In the heat of the moment, it is very difficult as I know you cannot understand how they “don’t get it” however remember, everyone has a vision, and although it may not be accurate, and may not be the same as yours, try to explain the situation to them. If they still don’t “get it” have somebody else try to explain while you decompress if you can.

      Also, make sure you are getting some down time far away from your clinicals. There is a high rate of burn-out in medical students entering Residency, and higher rate of Residents buring out before graduation, and you know the rest. Not saying you are getting burned out, but do take care of yourself. We need you out there with us helping these folks. We certainly cannot do it by ourselves.

  • MightyCasey

    Healthcare still operates from within a paternalistic/paranoid mindset when it comes to doctor/patient relationship building. In “Blink”, Malcolm Gladwell pointed out that the risk of suit had little to do with actual medical error, that patients sued doctors they didn’t LIKE. If they actually like their docs, they were much less likely to sue, even in the presence of provable error.

    I’ve presented a talk to both patient and clinician groups titled “Dating Tips for Doctors & Patients (‘Cause it’s a RELATIONSHIP) – it includes checklists for both sides of that equation. It’s critical that medical schools start addressing both the interpersonal-communication and running-a-business parts of medical practice, and climb down out of their ivory towers. Medicine IS a collaborative science, and without patient participation … it’s toast.

    • Ajoy Kumar, MD

      Without a doubt, the patient-physician relationship is straining. The forces around our $2.6 Trillion dollar monstrosity are destroying the very thing it supposed to strengthen. When neither the patient nor the physician is happy, it’s not good healthcare. We must make every effort to strengthen that relationship via increasing time spent with their Primary Care Physicians, which means helping Primary Care Physicians get off the reimbursement wheel. > 55% goes toward overhead costs of a clinic (i.e. staff, supplies, etc), while reimbursements decrease, hence the wheel to keep up. Whereas procedures are paid handsomely. That needs to change. For a Primary Care Physician to make the equivalent to 1 cardiac catheterization, that Primary Care Physician has to see several hundred patients. Remember, why the focus on reimbursement? Overhead cost, malpractice costs, medical school loan cost, etc. Why do you think it’s difficult to get medical students to choose Primary Care? Yet, studies conclusively show that a strong Primary Care Physician base decreases costs of the entire system of care.

  • dsammett

    “TheMedStudent” is right. Everybody is an expert until there’s a complication. When there’s a complication, or the operation doesn’t go right, everyone runs for the hills and says “Well, he or she is the doctor” or “it’s his/her patient”. You don’t see everybody (or anybody) stepping up and saying “don’t blame Dr so-and-so, it was a collaborative decision”. The doctor certainly can’t use “collaboration” as an excuse in court. It’s the same old issue: Many people (in the hospital) want to have all the authority but none of the responsibility. You wouldn’t do it this way for your own family would you? You wouldn’t want your neighbor telling you how to run your household. If you make a mistake it’s going to be your mistake. After all you know what’s best for your family and your children, right? However there’s an aspect to the responses that, I think, completely misses the point of the article. And that is this: The disrespect that we see in the hospital (and elsewhere) nowadays, is directed towards doctors not from them. I am constantly spoken to with utter disrespect. I am cursed and have even been practically physically assaulted. Of course when I bring this up the most common response is not that “it isn’t true” or “I’m just making it up”. But rather “Well, you must have done, or said, something to deserve it” or “Oh, you just have a thin skin”. I am sure all the doctors out there reading this can relate more than one incident of being verbally abused in the hospital (usually by a nurse) often right in front of the patients. There is a total culture of disrespect towards doctors in the hospital mainly because the nurses now run the hospital. They occupy all the administrative positions and are the “directors” of all wards, intensive care units, OR’s and clinics. They have created a poisonous and vindictive atmosphere where you under consant threat of being “reported” or “written up”. This of course is code for: “If you don’t do as I say, you will be fired. If anyone doubts any of this then do a “60 Minutes” type of investigation and go into any hospital and follow arouind a doctor for several days (preferably a surgeon, since they absorb the brunt of the abuse) with a hidden videocam. I dare anyone to do this. You know it would prove me right.

    • Ajoy Kumar, MD

      Read my post when you get the chance.

  • Ajoy Kumar, MD

    Our healthcare system for lack of a better word, sucks. It sucks for patients, it sucks for physicians, it sucks for everyone around, except . . . those entities who make the overwhelming share of the $2.6 Trillion (and rising) spent every year. Somebody’s laughing all the way to the bank!
    I can certainly understand the author’s feeling of being being disrespected. However, please do understand that many who are working this “sucky” system feel just as disrespected. Ironically, those working in this system go into it to help people and want to make things better. So how did it turn out this way? In my personal opinion, it became this way when it became profitable. In order to increase profits, you increase red-tape, increase billing levels, cut back costs (services and people), and demand more from less. What do you expect? The system is burned out as are the people working in the system. What do burned out people who feel they have no control do? Lash-out. The ability to lash-out is the only thing many have control over these days. Very unfortunate who we lash out against. It’s not just physicians, I’ve seen patients and their family member lash out at physicians and nurses threatening to kill them.

    I’ve had patients threaten to kill me and my family because of some perceived notion that I had some decision making power over hospital billing or EMS! I had two people that were both dying at the same time and I was trying to resuscitate them the best I could with my one team, and in the middle of it another patient stopped me an demanded that I stop what I was doing so that I can treat her issue, which was not life threatening, so I told her as such, but I would get to her when I stabilized the patients who needed my attention, and you know what she said? “I have been waiting for 30 minutes, if you are not going to see me now, I am leaving and calling the administrator to report you to the State Board.” I had another patient that was a child who was having respiratory distress and I was arranging for EMS to take the child to the ER, I could not leave his side for fear of losing airway and thus death may ensue. Another patient sets out into the hallway and demands that I see them for something that was not immediately life threatening, I told them I am in the midst of helping a child, however the patient said they “didn’t care” they were there waiting for an 40 minutes. “That’s not my problem, I need you see me or I’m leaving and filing a lawsuit.” In another instance I had a patient told me “You better order that test, my Medicaid is paying your salary. I’ll report you to Medicaid.” I didn’t go into Medicine for this. Now I must say that there are just as many understanding and truly wonderful people I had the fortunate pleasure to assist, and that’s why I do what I do.
    However, if you ask many who go into medicine 15 years out whether they imagined that it would be exactly how they thought it would be going in, over 90% would say, “I didn’t expect it to be like this, this sucks.” Nurses as well. So how do you fix it? Well the Bright Idea Brigade developed “Let’s do Teams” as healthcare is a lot like the airline industry.
    In many ways, healthcare is like the airline industry, process-wise and communication-wise. Standardization in certain things as well as checklists are good. However, healthcare is personal. As a patient, I do not want the whole darn Team looking at all my goodies. Sure the other Team Members (flight crew) can handle different aspects of my care, however I came to see the Physician (the Captain), and if not his second in command (PA or ARNP), not the whole darn crew. Furthermore, I want the facility (the Plane) to look good, and I expect the office manager or Hospital Manager to ensure the facility is sanitary, has newest and best equipment, and meets my needs, and I want it in a timely manner as I am busy and need to manage my own patients. That’s how I envision my care to be, now I know that is not the reality 100% of the time. I’m a physician, I get it. At the same time, I want my physician to acknowledge certain things if they are late and at the least explain why. Again, I’m a physician, I get it if another patient took a longer time, however I don’t want my time to be cut short by it either, and I know they get it as well. As it relates to my care, if something went wrong I know who I’ll be going after, and it’s not the Team. I expect the physician to choose their Team members, and if they don’t have any input, I’ll talk to the office manager/CEO. If something went really wrong, for sure my wife and her attorney will see if it’s the physician (Captain) or the facility’s fault (Plane) or both, but rarely if at all, the Team.
    So this concept of Team works when things go good, however once lawsuits fly, guess what? It’s pilot error or plane’s malfunction or both, rarely the Team. The Team doesn’t have their hands on the controls, in fact if the Captain offered them the controls everyone would back away telling the Captain “No no, it’s ok you’re the Captain” while documenting away to CYA. The Team didn’t make the decision as the Team is not in the flight deck as they do not want to go anywhere close to that flight deck, and the Team certainly did not build and maintain the plane, no the Team doesn’t want responsibility of a busted plane either. Quite frankly, the member of the Team will be the first to say, “I don’t know, I’m not the doctor or I’m not the CEO.” “Don’t look at me, I don’t have the qualifications to make that level of decision.” The CEO’s lawyer will say, “It’s the doctor’s decision, my client was not even in the room when it occurred.” Yet each will say what they individually did, when they individually did, and when they individually notified somebody else (ie. the physician), and what that person said and did in response.
    However, at the very end, guess what? Somehow, the Team suddenly develops an unshakable clarity of the episode. If only that physician was not like this or that, and had they only listened to the Team and let the Team lead the results would’ve turned out differently.
    Thus, as you can see . . . it’s complicated. Our healthcare system sucks, however one way we can improve it is to communicate with one another better pro-actively. We’re all human, we all get crispy.
    Patients, be pro-active, sometimes your physicians are all sorts of stressed, take a breather even if they are running late and find out why (your healthcare is not fast food). You are dealing with people who want to help you, if that was not the case, they would not enter the room. Physicians, if you know you are edgy, miffed at something, take a breather for a few minutes, don’t take it out on the patient, you know this is displacement.
    The patient-physician relationship has suffered greatly over the last 50 years and it does not seem to be getting better. Too many entities that make up the $2.6 Trillion (and growing) that we spend on our sucky healthcare system are getting between the patient-physician relationship. It’s well beyond time that both the disrespected patient and their burned out physician take back their healthcare . . . together.
    Thanks for reading, and thanks for writing that article.

    • Tom Bouthillet

      Why do you fixate on the fact that you are ultimately responsible? Someone has to have the final say. That’s as it should be. I don’t sense that you are an arrogant man and it sounds like you consider input from patients, family members, nurses and other members of the health care team. That mutual respect allows you to take advantage of the information each team member possesses so that you can make a wiser decision. It really doesn’t matter if you’re the Captain, the physician, the surgeon, the team leader, or whoever. Don’t let the authority gradient get in the way of utilizing your best assets. Ignoring valuable information because you think authority equals situational awareness can be a fatal mistake. In the last analysis, it’s because you bear most of the responsibility that you cannot afford to be a jerk. If you’re unapproachable the rest of the team will let you sink and you’re not perfect, as none of us are perfect.

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