A PA rounds with an attending physician and a resident in an inpatient unit. The attending physician frequently speaks harshly to the PA and the resident, sometimes mocking them in the presence of patients. The attending sarcastically refers to the PA as “our precious Dr. Einstein” and usually starts rounds with a series of sharp questions about medical conditions, laboratory tests, etc. When the PA does not provide a satisfactory answer, the attending responds with a sarcastic comment, asking, “Are you sure you didn't attend the MA program instead of the PA program by mistake?”
In one instance, the attending asks, in the patient's presence, if the PA has examined the patient's ears. The PA states that she has not performed an ear examination. The attending physician walks to the otoscope hanging on the wall, lifts the instrument out of its holder, and says, “You see this thing? This is called an oh-toe-scope. Can you say that? Oh-toe-scope. Since you apparently don't know what it is for, let me tell you. It is to put in the patient's ears and examine them. Does that ring a bell, Dr. Einstein?” The attending then tosses the otoscope to the floor, where it shatters. The attending leaves the room, as the PA-resident team apologizes to the patient and his family and finishes the examination.
Later during rounding, the attending physician instructs the PA to order a fentanyl patch to replace long-acting morphine for a patient who has developed nausea and has difficulty taking pills. Both the resident and the PA feel that the dose of fentanyl the attending has selected is far too low and is not close to equivalent to the dose of morphine being replaced. With the attending out of earshot, the PA and resident discuss the dose. They decide to say nothing about their concerns, noting that when they have challenged the opinion of the attending in the past, he has become abusive. As the resident says, “I don't really feel like having him down my throat.”
>IMPACT OF DYSFUNCTIONAL COMMUNICATION
According to The Joint Commission, “a sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.”1 The Joint Commission's look into root causes of sentinel events points to the persistence of disordered communication in causing such harm to patients. For example, Joint Commission data show that from 2010 to 2012, approximately two-thirds of sentinel events were directly related to communication.2
Rosenstein and O'Daniel looked more closely at physician/registered nurse (RN) beliefs about the clinical impact of disruptive behavior on patient care. Their survey of 4,530 participants produced disturbing results: “71% felt that there was a linkage to medical errors, and 27% felt that there was a linkage to patient mortality. Eighteen percent of the respondents reported that they were aware of a specific adverse event that occurred because of disruptive behavior, 75% of whom felt that the adverse event could have been prevented.”3
The Joint Commission's series of “Sentinel Event Alerts” focuses on enhancing a culture of safety in medical settings. Sentinel Event Alert 40 entitled “Behaviors that undermine a culture of safety” offers further description of disrespectful communication issues that impact patient care:
Intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness and can compromise the safety of patients. All intimidating and disruptive behaviors are unprofessional and should not be tolerated.4
>DISRESPECTFUL BEHAVIOR DEFINED
Leape and colleagues describe the slow progress being made by the medical community in meeting the charges of the Institute of Medicine's “To Err is Human” publication almost 13 years ago. While noting that there are undoubtedly many factors involved in the slow pace, the group offers a more focused possible explanation:
We believe, however, that the fundamental cause of our slow progress is not lack of know-how or resources but a dysfunctional culture that resists change. Central to this culture is a physician ethos that favors individual privilege and autonomy—values that can lead to disrespectful behavior. We propose that disrespectful behavior is the “root cause” of the dysfunctional culture that permeates health care and stymies progress in safety and that it is also a product of that culture.5
“Improving communication and addressing disrespectful clinician behaviors is essential to reducing the threat of harm to patients.”
One of the challenges that medicine faces is defining what exactly constitutes disrespectful behavior. Much has been written about the disruptive physician, and although related literature has examined the crucial role of team communication in promoting safety, the term disruptive potentially allows many clinicians to dismiss themselves from such a descriptive umbrella. The word disruptive conjures images of surgeons throwing phones, swearing at nurses and medical students, physically intimidating colleagues, and generally creating overt mayhem. Although such behavior does exist, it is rare. More commonly, disrespectful behavior is more subtle.
This may include pimping, the practice in which attending physicians or other clinicians pose questions to dependent team members, including nurses, medical students, residents, and nonphysician providers. Detsky describes the historical underpinnings of pimping, indicating that medical education has not changed significantly in more than 50 years. It continues to be based on Socratic methods of serial questioning of students and trainees, and the power discrepancy between them continues as the foundation of medical education. Pimping underscores and even preserves this power discrepancy, in which the teacher knows the answer and the student might not.6 Most pimping precludes the possibility of the teacher learning from the student, reinforcing the traditional medical education model in existence. Of note from a historical perspective is that Abraham Flexner, whose 1910 Flexner Report led to a wholesale reform of medical education, praised the practice of pimping. In notes from his visit to Johns Hopkins in 1916, he wrote: “Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it ‘pimping.’ Delightful.”6
Haizlip and colleagues describe what is known as the negativity bias, a concept long studied in the psychology arena, noting the belief that humans are more attentive to and are more influenced by the negative aspects of their environment than by the positive.7
This framework offers pimping as an example of medical education's negativity bias, noting how the current use of pimping has departed from the more noble Socratic method of teaching students, through which “students either come to the desired knowledge by answering the questions or become more deeply aware of their own limits.” Instead, pimping may more commonly shame students who don't know the correct answer. According to Haizlip, “Simply put, pimping is teaching by intimidation.”7
An example of one student's experience with teaching by intimidation is provided by Miller, who describes her fear-based student experiences and the silencing impact the training had on her as a clinician:
As medical students, whether preclinical or on the wards, we live in fear: afraid to make a mistake, to forget a fact, to appear stupid in front of peers or superiors, or even to cause harm to patients through our ignorance. This fear can silence us during case discussions in the classroom or on rounds. It does not end with graduation; the rigid hierarchy of medical training means that the underlying fear persists, albeit at a more subtle level, as the physician-in-training advances up the ranks. Even outside the confines of academia, the fear of malpractice suits haunts every physician, and is essentially the same: fear of being wrong.8
With disordered communication clearly posing the threat of harm to patients, improving communication and addressing disrespectful clinician behaviors is essential to reducing that harm. Such initiatives include the innovative AHRQ TeamSTEPPS9 project, created to enhance medical team communication and teamwork and improve patient safety. Additionally, medical and institutional initiatives to reshape and reform learning processes, identify and address disrespectful behaviors, and operationalize bioethical principles of beneficence and nonmaleficence can help to decrease dysfunctional medical team communications and reduce related harm to patients.
1. The Joint Commission. Sentinel event. The Joint Commission Web site. http://www.jointcommission.org/sentinel_event.aspx
. Published 2013. Accessed March 11, 2013.
2. The Joint Commission. Sentinel Event Data, Root Causes by Event Type, 2004-2012. http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_04_4Q2012.pdf
. Accessed March 11, 2013.
3. Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471.
4. The Joint Commission. Sentinel event alert. Behaviors that undermine a culture of safety. The Joint Commission Web site. http://www.jointcommission.org/assets/1/18/SEA_40.PDF
. Published July 9, 2008. Accessed March 11, 2013.
5. Leape LL, Shore MF, Dienstag JL, et al. Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Acad Med. 2012;87(7):845-852.
6. Detsky AS. The art of pimping. JAMA. 2009;301(13):1379-1381.
7. Haizlip J, May N, Schorling J, et al. Perspective: the negativity bias, medical education, and the culture of academic medicine: why culture change is hard. Acad Med. 2012;87(9):1205-1209.
8. Miller E. Third-place winner of the 2010 Arnold P. Gold Foundation Humanism in Medicine Essay Contest. http://www.humanism-in-medicine.org/2010_3rd_E_Miller.pdf
. Accessed March 11, 2013.
9. Agency for Health Care and Quality Research (AHRQ). TeamSTEPPS®: National Implementation. AHRQ Web site. http://teamstepps.ahrq.gov/
. Accessed March 11, 2013.