Share this article on:

Perspective: A Culture of Respect, Part 1 The Nature and Causes of Disrespectful Behavior by Physicians

Leape, Lucian L. MD; Shore, Miles F. MD; Dienstag, Jules L. MD; Mayer, Robert J. MD; Edgman-Levitan, Susan PA; Meyer, Gregg S. MD, MSc; Healy, Gerald B. MD

doi: 10.1097/ACM.0b013e318258338d
Culture of Medicine

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.

Dr. Leape is adjunct professor of health policy, Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts.

Dr. Shore is Bullard Professor of Psychiatry, Emeritus, and chair, Promotions and Review Board, Harvard Medical School, Boston, Massachusetts.

Dr. Dienstag is Carl W. Walter Professor of Medicine and dean for medical education, Harvard Medical School, Boston, Massachusetts.

Dr. Mayer is Stephen B. Kay Family Professor of Medicine, Department of Medicine, and faculty associate dean for admission, Harvard Medical School, Boston, Massachusetts.

Ms. Edgman-Levitan is executive director, Stoeckle Center for Primary Care Innovation, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Meyer is lecturer in medicine, Harvard Medical School, and senior vice president for quality and safety, Massachusetts General Hospital, Boston, Massachusetts.

Dr. Healy is professor of otology and laryngology, Harvard Medical School, Boston, Massachusetts, and senior fellow, Institute for Healthcare Improvement, Cambridge, Massachusetts.

Correspondence should be addressed to Dr. Leape, Harvard School of Public Health, 677 Huntington Ave., Boston, MA 02115; telephone: (617) 432-2008; e-mail:

© 2012 Association of American Medical Colleges