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Special Report: The Cost of Incivility in Medicine

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000524786.51809.71
Special Report

Famed Dutch novelist and playwright Jan de Hartog's eloquent and anguished description of Jefferson Davis Hospital's emergency room tells the story of a young African-American woman bleeding from a miscarriage and sitting passively in a wheelchair as she hemorrhaged.

“Underneath her chair lay what looked like a pool of blood,” wrote de Hartog in his landmark non-fiction book The Hospital, published in 1964. When a nurse asked the two women at the registration desk, “Who is the patient who is in that chair, who is hemorrhaging?” one of them replied without looking up, “I wouldn't know. She hasn't registered.”

“Has anyone seen her?” the nurse asked. “Not if she hasn't registered,” the woman replied.

“Why has she not been registered?”

“Because she hasn't come to the desk,” the woman replied unhurriedly.

That scene, recorded more than 50 years ago, represents the height of incivility, which remains a major issue in hospitals around the world. Arik Riskin, MD, MHA, and his colleagues at Bnai-Zion Medical Center in Haifa, Israel, set out to measure the real-life impact of rudeness on hospital operations and patient outcomes. He had experienced the issue firsthand. “A father had a preemie in the neonatal intensive care unit. The baby was not that sick, but he rushed into NICU and started shouting at us and said we were not treating the baby,” he said. Eventually, they got the father to calm down, but Dr. Riskin was shaken by the encounter.

“I found I could not do anything,” he said. “I told the nurses, ‘It's quiet now, and I'm going to take a break for about 15 minutes.’ You cannot do that most of the time.”

Clearly, Dr. Riskin and his colleagues could not test the effects of rudeness in a real-world environment. Instead, they used training simulation in which a preterm infant had become very ill because of necrotizing enterocolitis. (Pediatrics 2015;136[3]:487.) The participants were told an expert on team reflexivity in medicine was observing them. Twenty-four NICU teams took part in the study, and they were randomly assigned to the “rude” group, which was exposed to mildly rude statements by the expert unrelated to the team's performance, or to the control group, which was exposed to neutral statements. Three independent judges blinded to the teams' exposure evaluated the videotaped sessions, using questionnaires to assess the teams' performance.

The differences split along the lines between those exposed to rudeness and those who were not. Composite diagnostic and procedural performance scores were lower for the “rudeness” teams compared with the control group's scores. The authors wrote, “Our results highlight the potential role of human interaction in iatrogenic events, indicating that occurrence of even mild rudeness can have adverse consequences on the diagnostic and procedural performance of NICU team members. Indeed, many of the ratings received by members of the rudeness group were between 2 (poor) and 3 (moderate), suggesting that the judges saw evidence of potentially harmful practice. Moreover, they showed that even the mild incivility common in medical practice can have profound, if not devastating, effects on patient care.”

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Deleterious Effects

Dr. Riskin and his colleagues used similar methods to study what happened when NICU teams were exposed to rude statements from a patient's mother compared with teams that did not experience such statements in another study. (Pediatrics 2017;139[2]; doi: 10.1542/peds.2016-2305.) They found that “rudeness has robust, deleterious effects on the performance of medical teams. Moreover, exposure to rudeness debilitated the very collaborative mechanisms recognized as essential for patient care and safety.”

Dr. Riskin said the second study also showed what can make a team better. “Communication, information-sharing, and workload share can be mediators of rudeness on the performance of the team,” he said. “It was striking to us that the effect was so big. There was a 12 percent variance in diagnostic and procedural performance that could be explained by rudeness.”

Rudeness is not a rare occurrence in the workplace. Dr. Riskin's study cited others that estimate 98 percent of employees experience incivility, with 50 percent experiencing it at least weekly from customers, clients, and patients, particularly in service-oriented organizations such as hospitals. (Harv Bus Rev 2013;91[1-2]:114; J Organ Behav 2004;25[3]:397.)

Other things can mitigate the issue, like narrative or describing how they thought the mother was feeling to be that rude, said Dr. Riskin. “We found [from their narratives] that they were more sensitive to the mother's feelings, but that didn't improve performance.”

Another method used before the exposure was cognitive bias modification, which looks and moves quickly like a computer game and asks people to indicate whether they were angry, he said. It is normally used to treat post-traumatic stress disorder. Dr. Riskin and his colleagues found that 15 to 20 minutes “immunized” the doctors against rudeness, but they don't know if it would be effective on a daily basis.

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Doctor to Doctor

One question that these studies did not address and that is just as important as patients' rudeness was when members of the teams were rude to one another. Benjamin C. Whitelaw, MBBS, and his colleagues in the United Kingdom conducted a study on how frequently rude, dismissive, and aggressive communication among doctors occurs and is a potentially damaging behavior. The study from King's College Hospital and the National Health Service used a survey and focus groups to find out how often and among whom such behavior occurs. (Clin Med [Lond] 2015;15[6]:541.)

Thirty-one percent of the 606 responders said they had been exposed to rude, dismissive, or aggressive communication many times a week, and 40 percent of those doctors said the communication had adversely affected their working days. Junior and registrar doctors, who have less clout in the medical arena, were affected twice as often as consultants or specialists. Radiologists, general surgeons, neurosurgeons, and cardiologists were among the consultants most often involved in uncivil communications.

“This is a controversial finding, but it is probably valid,” said Dr. Whitelaw. “These specialties are high-intensity, acute specialties, and so the volume of referrals and inquiries that they receive are probably a major factor. Some have suggested that these departments have a culture of aggression (or contempt or arrogance, depending on whom you ask). With radiology, the issue may be slightly different, because they get a number of scan requests of variable quality. They are likely to emphasize poor quality referrals as their main concern and main cause of rude response.”

Dr. Whitelaw said he thinks the hierarchical nature of hospitals is the reason most of the uncivil behavior falls on junior doctors (or residents in the U.S. system). “Consultants are regarded as important,” Dr. Whitelaw said. “However busy, tired, or frustrated you are, it is uncommon to be rude or aggressive to a consultant (probably because you think there may be consequences), whereas when you are talking to a junior doctor, no such concerns apply and you can let rip.”

Dr. Whitelaw said it has less to do with training and more to do with culture and maybe imitation of others. “Most rudeness is from relatively more senior to relatively more junior, our evidence suggests,” he said. “But it may be coming more from the registrars [more senior residents]. We don't really know if registrars or consultants are the most widespread perpetrators, but anecdotally, I would suggest registrars.”

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A ‘Kick the Dog’ Culture

Dr. Whitelaw and his colleagues concluded that five factors prompt rude, dismissive, or aggressive communication most often in their study: workload, lack of support, patient safety, hierarchy, and culture. Such rudeness had negative effects on its targets, causing emotional distress and even substance abuse on a personal level and affecting motivation on a professional level.

Dr. Whitelaw said he believes it also contributes to burnout. “Our survey showed that doctors described self-reported adverse effects such as feeling sad, tearful, and demotivated. There is evidence that rude and aggressive behavior affects safety and quality,” he said, referring to Dr. Riskin's report, among others. While physicians who admit to exhibiting rude, dismissive, or aggressive behavior blame workload or poor-quality referral, Dr. Whitelaw said the claim is disingenuous. “They are not compelled to communicate in this way,” he said. “They hardly ever lose their cool with patients or shout at relatives. They let rip at junior doctors because institutions don't challenge or respond to this kind of behavior. The culture condones and supports it. It is an easy output for frustration—a ‘kick the dog’ mentality.”

Sexism or racism may also play a part in the uncivil action, but the study did not address those issues. Dr. Whitelaw hypothesized that “black or minority ethnic doctors are probably more commonly on the receiving end of this communication.”

Asked what happens when patients or outsiders witness this behavior, Dr. Whitelaw said there is not much evidence from which to draw, but his belief is that patients are upset by this kind of behavior. “There was one episode in my hospital of patient reporting a senior doctor for being rude to or bullying a more junior colleague—and this was addressed by the hospital,” he said.

Dr. Whitelaw said changing this situation and reducing burnout resulting from rudeness means addressing the factors that lead doctors to be rude. “I think that if you just take the current working arrangements and add to it a witch-hunt against doctors who are rude so that everyone is reporting one another for unprofessionalism, that of itself would not improve cooperative working relationships, and burnout may remain common,” he said. “In other words, a reorganization of workload with a change of culture could improve communication and reduce burnout, but a punitive approach in isolation could increase bad feeling and hidden conflict.”

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Talking It All Out

An alternative approach that has been proven successful is encouraging doctors to have open conversations about their stress and work. Beth A. Lown, MD, the director of faculty development at Mount Auburn Hospital and an associate professor at Harvard Medical School, is trying to rectify rude behaviors among providers through a series of interdisciplinary forums called the Schwartz Center Rounds. Attendees of these rounds discuss the social and emotional issues they face in caring for patients and families.

Dr. Lown and her colleague Colleen F. Manning, the director of the Goodman Research Group, Inc., in Cambridge, MA, conducted retrospective surveys of attendees at six sites that had offered the Schwartz Center Rounds for three years or more and prospective surveys of attendees at 10 new rounds sites that had held more than seven rounds. (Acad Med 2010;85[6]:1073.)

Most of the retrospective survey respondents said attending the rounds made it more likely that they would be more sensitive to the psychosocial and emotional aspects of care and enhanced their belief in the value of empathy. They also reported better teamwork, including heightened appreciation of the roles and contributions of their colleagues. The prospective study found that the more rounds a person attended, the greater the improvement in his insights into the psychosocial aspects of care and teamwork.

Dr. Lown said she thinks things are changing. The rounds themselves are a beginning step in dealing with the issue. Started in 1997, they are now taking place in more than 186 sites across the country. “We are far from perfect, but I see a number of positive things,” she said.

Dr. Lown said teaching medical students has shown her that a lot of “people go into health care to do good,” but they get plowed under by the constraints of the system itself.” New licensing requirements mean would-be physicians must prove their communication skills with standard patients. “That's encouraging,” she said.

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