Perspective: A Culture of Respect, Part 1: The Nature and Causes of Disrespectful Behavior by Physicians
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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.
T he 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,
12 years ago.1–4 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 progress in safety and that it is also a supportive centers of patient-centered
infection in our hospitals every day,5 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,
Harvard School of Public Health, 677 Huntington
with disrespect, creating a barrier to Patients suffer when physicians do not
Ave., Boston, MA 02115; telephone: (617) the open communication and feedback listen, show disdain for their questions, or
432-2008; e-mail: leape@hsph.harvard.edu. 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;87:1–8.
First published online to following safe practices, resulting process.9,10 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 1
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibitedCulture 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
is also a foundational element of Disruptive behavior
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
specialties.12 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 reported knowing a nurse who had
that only 5% or 6% of physicians fall into
professionalism. left the hospital because of disruptive
this category,16 the detrimental influence
of this small minority far outweighs their physician behavior.19
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 patient care team hierarchy, are very
Disruptive actions include angry
national survey, two out of three vulnerable to disrespect from faculty,
outbursts, verbal threats, shouting,
physicians reported witnessing other house staff, nurses, and others through
swearing, and the threat or actual
physicians disrupting patient care or verbal or physical abuse, belittlement,
infliction of unwarranted physical force
collegial relationships at least once a humiliation, harassment, intimidation
that legally would be considered battery.
month. One in nine physicians reported and exploitation, or simply by being
Having a temper tantrum, throwing
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.”
A culture of disrespect is harmful for forms of disruptive behavior, as is any
Annual surveys by the Association of
many reasons, but it is its effect on the unwanted physical contact of a sexual
American Medical Colleges show that
safety and well-being of our patients nature. Disruptive conduct may be
14% to 17% of graduating students
that makes it a matter of urgency. In directed at anyone—nurses, colleagues,
report having been subjected to or
simple terms, we believe that a health residents, medical students, ward staff,
witnessing some form of mistreatment.20
care organization that supports and hospital administrators, and even patients
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
2 Academic Medicine, Vol. 87, No. 7 / July 2012
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibitedCulture 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 treatment in a number of ways: “He treats
behavior is tolerated, if not celebrated.
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
adequate performance.25 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 3
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibitedCulture 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
4 Academic Medicine, Vol. 87, No. 7 / July 2012
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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.
detrimental to teamwork.43 Teamwork is clinical years. Although some students
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
improving safety. The major safety efforts honest, and understanding in these
in some individuals may accentuate
have focused on implementing new safe situations. Dismissive or dissembling
narcissistic character traits. Highly
practices. Both implementing standard treatment undermines the trust that is
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
Students are especially vulnerable to Disrespectful behavior results from of other people. Banja48 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.
Academic Medicine, Vol. 87, No. 7 / July 2012 5
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibitedCulture of Medicine
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
6 Academic Medicine, Vol. 87, No. 7 / July 2012
Copyright © by the Association of American Medical Colleges. Unauthorized reproduction of this article is prohibitedCulture 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.
Brigham and Women’s Hospital. The authors
60%.58 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
Summary ened the manuscript.
1):1–5.
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,
behavior has drawn increasing attention Massachusetts.
12 Accreditation Council for Graduate Medical
in recent years, other types of disrespect Education. Core competencies. http://
Dr. Shore is Bullard Professor of Psychiatry, www.acgme.org/acWebsite/RRC_280/280_
are far more common and potentially coreComp.asp. Accessed March 29, 2012.
Emeritus, and chair, Promotions and Review Board,
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 2012.
Dr. Mayer is Stephen B. Kay Family Professor of
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.
Massachusetts General Hospital, Boston,
part, disrespect is learned behavior 15 Hickson G, Pichert J. One step in promoting
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Dr. Meyer is lecturer in medicine, Harvard Medical behavior. Physician Insurer. Fourth quarter
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