Drs. Alexander, Rajput, and Katz appropriately focus on the educational environment, which is where the task of making the culture of health care more respectful must begin. We agree with and endorse all of their points and emphasize the following:
First, it is crucial for students not just to learn about respect but also to experience it, both as recipients of respectful treatment and as members of a health care team that treats everyone respectfully.
Second, we agree on the importance of those experiences being interprofessional, which helps students learn to respect nurses, pharmacists, and other members of the team from the beginning, something too few medical schools now provide. At Harvard Medical School, such early modeling of well-functioning ambulatory interprofessional teams is a priority we are pursuing.
Third, it is as role models that faculty teach respect most powerfully, because most (some say all) behavioral learning comes from imitation. As the Lucian Leape Institute report on reforming medical education advises, “Every teacher must be the kind of physician we want our students to become.”1 This must be enforced. All hospitals have policies prohibiting disruptive behavior, but when students report disrespectful behavior and nothing is done about it, that silence speaks loudly.
No one would argue with the importance of assessing ethical and professional behavior during the medical school admission process. While blaming admission committees for choosing students who demonstrate deficits in ethics and professionalism is popular, in fact, those committees are quite sophisticated in their ability to collect rich information about applicants’ character from a variety of sources.
Unfortunately, the forces during medical training that degrade empathy and professionalism—not the least of which is exposure to disrespectful and demeaning behavior by their teachers—bring out the worst in even the most altruistically inclined medical trainee. Rather than blaming admission committees for ethical lapses among students, we would do better to foster sustained modeling by respectful faculty and residents and to assess, and expect, ethical and professional behavior from students once they are admitted. Too often, students talk the talk in class but somehow feel their student status exempts them from behaving respectfully themselves. As faculty, we have a responsibility to teach, model, and require professional behavior from day one.
Lucian Leape, MD
Adjunct professor of health policy, Harvard School of Public Health, Boston, Massachusetts; firstname.lastname@example.org.
Miles Shore, MD
Bullard Professor of Psychiatry, Emeritus, and chair, Promotions and Review Board, Harvard Medical School, Boston, Massachusetts.
Jules L. Dienstag, MD
Carl W. Walter Professor of Medicine and dean for medical education, Harvard Medical School, Boston, Massachusetts.
1. Lucian Leape Institute. Unmet Needs: Teaching Physicians to Provide Safe Health Care. 2010 Boston, Mass National Patient Safety Foundation