Everyone Counts: Building a Culture of Respect

Abstract

“The doctor treats me like an idiot.” “He doesn’t like people who ask questions.” “He makes me feel like I’m wasting his time.” (from a patient)

“The doctor treats me like an idiot.” “He doesn’t like people who ask questions.” “He makes me feel like I’m wasting his time.” (from a patient)

“When did you get your MD degree?” “When I want your advice, I’ll ask for it.” (doctor to a nurse)

“Is that what they teach you in medical school these days?” “Don’t you know anything about renal anatomy?” (doctor to a medical student)

What is this all about? How can the noblest of professions, made up of intelligent, hard-working, dedicated people, have within its ranks some who treat others badly in their time of need? Why doesn’t “professionalism ” for all health-care professionals extend to ensuring that they live up to standards of decency and civility? As we have seen in the previous chapter, the reasons are complex, and disrespectful behavior is but one of many potential failings that doctors may suffer. But its influence is profound.

As the patient safety movement entered its second decade, experience with attempts to change systems led safety leaders to recognize that major progress could not occur without a supportive culture . And it became apparent that the major barrier to creating that culture , the core of the problem, was inappropriate physician behavior. This was, of course, the focus of our work on disclosure and apology : getting physicians to respect the patient’s need for, and right to, full information on what went wrong when they were harmed by their care.

Physician behavior was also the focus of the attempts to reform medical education . The first LLI white paper, Unmet Needs: Teaching physicians to provide safe patient care, documented the alarming frequency of demeaning and dehumanizing treatment by faculty that medical students experienced. It came down with a strong recommendation that medical school deans and teaching hospital CEOs adopt a zero-tolerance policy for disrespectful or abusive behavior [1].

What is the patient experience? In my course on quality and patient safety at the Harvard School of Public Health, I collected disturbing data about the patient experience from my graduate students. Each year, at the beginning of the course, to ground their approach to quality improvement in real-world experience, I asked students to interview someone who had a serious medical problem. The students were to ask just two questions: What is it like living with this condition? What has been your experience with medical care? Consistently, over 10 years, nearly half of patients recounted episodes where they were treated in a demeaning or disrespectful way by their doctors, leaving memories that were often still vivid years later.

Even more than patients and students, nurses are on the receiving end of disrespectful treatment by physicians. Almost all nurses can tell stories of disruptive behavior and humiliation. Most of the physicians they work with treat them well, but it occurs frequently enough to poison the atmosphere and cause some to leave nursing.

Although available evidence does indicate that the percentage of doctors who engage in grossly disruptive behavior is small, many more engage in less flagrant types of disrespectful behavior. Dismissive put-downs of patients and nurses and “education by humiliation” or “pimping” of students are widely experienced. This had to change if we were to create the learning and supportive culture that is essential to safety. I became convinced that pervasive disrespect was the core of the culture problem. What could we do about it?

A Group of Leaders

Perhaps if Harvard took the lead, others would follow. If our staid, old, conservative hospitals could come to grips with the problem, others could as well. I raised the question to a number of knowledgeable, respected leaders who I knew at Harvard Medical School (HMS) and its hospitals. To my delight, but not surprise, they were all interested in taking it on. They knew disrespectful conduct was a serious problem, and they responded to the opportunity to do something about it.

In September 2010, I brought them together for dinner at the Harvard Faculty Club for the first meeting:

• Ron Arky , Professor of Medicine

• Jules Dienstag , Dean for Medical Education

• Susan Edgman-Levitan , Executive Director, Stoeckle Center, MGH

• Dan Federman , former Dean for Medical Education

• Ed Hundert , Director, Center for Teaching and Learning

• Jeannette Ives-Erickson , Vice President for Nursing, MGH

• Gerry Healy , Professor of Otology and Laryngology

• Bob Mayer , Professor of Medicine

• Gregg Meyer , Senior Vice President for Quality and Safety, MGH

• Miles Shore , Bullard Professor of Psychiatry and Chair, HMS Promotions and Review Board

• Richard Schwartzstein , Professor of Medicine, Director of the Academy, HMS

• Andy Whittemore , Professor of Surgery and Chief Medical Officer, BWH

I welcomed the group with a blunt statement that the purpose of the meeting was not to talk about unprofessional behavior, but to determine if we wanted to do something about it. I laid out the scope: disruptive behavior , humiliation of students and nurses, disrespectful treatment of patients, and passive resistance and non-participation in quality improvement. I gave them statistics from surveys of nurses and medical students and read quotes from my students’ papers describing episodes of dismissive and demeaning treatment of patients by their doctors.

A great discussion followed: we tolerate disrespect , it is a leadership issue, reform has to come from the top; we have actually rewarded bad behavior, we need a system to deal with it, we should do “360” evaluations of everyone, etc. Members recounted examples of bad conduct and poor support of students and nurses; it was more than just a problem of individual professionalism , as so often described, it was the culture .

We agreed that it was time for action and that a statement from HMS would be powerful. We would meet again.

At the second meeting, we found broad agreement that the problem was severe and prevalent, that leadership is necessary to address the issue, and that we needed a different structure for responding to bad behavior. Our goal would be to develop an institution-wide (all HMS teaching hospitals) program. We would identify structures and processes that need to be put in place to identify and deal with disrespectful conduct of all kinds: i.e., the specifics of what we wanted hospitals to do. We decided to write a white paper laying out the problem and our recommendations and try to get HMS leadership and hospital CEOs on board .

“Champions”

I also convened a second group: frontline safety leaders at each of the teaching hospitals who could advise us on implementation. I dubbed this group of key safety people “Champions” from our QI jargon, i.e., clinical leaders who make things happen. I saw the two groups as symbiotic: the senior, professionalism working group would develop theory and policy, and the frontline leaders would work on the ground-level implementation.

This Champions group, all of whom I knew, and all physicians, included:

• Bob Truog , Children’s Hospital

• Sigall Bell , Beth Israel Deaconess Hospital

• John Herman , Mass General Hospital

• Craig Bunnell , Dana-Farber Cancer Institute

• Jo Shapiro , Brigham and Women’s Hospital

• Elizabeth Gaufberg , Cambridge Health Alliance

• Mitch Rein , North Shore Hospital

• Les Selbovitz , Newton Wellesley Hospital

• Susan Abookire , Mt Auburn Hospital

• Luke Sato , CRICO

As with the senior group, all were eager to participate. I explained the different functions of the two groups: the senior group’s mission was to motivate the Dean and the hospital CEOs to develop and implement more effective policies and processes for dealing with disrespectful behavior; we were writing a white paper for that. The Champions’ group would develop strategies and plans for implementation. An obvious place for them to start was the current situation regarding codes of conduct . So, in preparation for the first meeting, I asked each of them to send me their hospital’s code for dealing with disrespectful behavior.

The Champions first convened in January. The codes were all over the map ! Several hospitals didn’t even have a code! I thought this would be a great opportunity: we could work together to come up with a universal code that all Harvard hospitals could agree to.

But the group had little interest in that. They weren’t sure just what they were interested in, but my various suggestions fell on deaf ears. We spent the first meeting with each person talking about what they were doing in their institutions and agreed to meet again. We met several times over the next year but could never really agree on proceeding in a clear direction. To my great disappointment, in the end the group had no positive impact. But, as we shall see, it did have an unfortunate negative effect.

Meanwhile, the senior working group met monthly over the period of a year and were very active. We wanted the medical school to take the lead here, but that would not be easy. Because of the unusual structure of HMS in which all of the teaching hospitals are fairly autonomous, the Dean was sensitive to their strong sense of independence and not anxious to tell them what to do. We gathered information on codes and practices and outlined the paper. We added several people to the group: deans Maureen Connelly and Gretchen Brodnicki ; the Chairman of Faculty Discipline, Paul Russell; and Luke Sato from CRICO , our liability insurer.

Miles Shore and I went to work drafting a white paper that would lay out the various aspects of disrespect , defining the types of behavior and the varied situations where it occurred. We had learned a great deal from our research; the problem was far worse than we had suspected. There was ample evidence: studies documenting the extent to which nurses, students, and doctors were treated badly, plus the trove of patient stories from my students’ interviews.

The Problem

Disruptive behavior was what brought us together, and it was the situation crying out most loudly for solution. As noted, most nurses experience shouting, demeaning comments, or humiliation by a physician at some time, many frequently. Similarly, while most of their encounters with physicians are positive, many patients have had a bad experience. Almost all medical students can recount humiliating treatment by their teaching attendings in hospitals.

The most disturbing finding from our review of the literature and pooled experience, however, was not about disruptive behavior , but that lesser types of disrespectful behavior are pervasive and not limited to physicians. While only a few “bad apples” engaged in obvious egregious disruptive behavior , lesser degrees of disrespectful conduct were common.

Passive aggressive behavior is a pervasive form of disrespect , but it is seldom commented on. For example, many physicians have not been enthusiastic about patient safety—they claim to not see the problem in their own practices, and they are too busy to participate in hospital-organized “quality improvement” projects. When asked or required to participate, they act out their resistance passively—by missing or coming late to meetings, by not offering ideas or doing the work, by being slow to carry out their tasks.

Another pervasive aspect of disrespect that is not even recognized by those affected is systemic or institutionalized disrespect . This is the disrespect embedded in many of the well-accepted practices that are part of everyday care in hospitals. The most obvious example is working conditions . Research evidence is clear that long hours, sleep deprivation , and excessive workloads cause increased errors . Yet, long hours and heavy workloads are standard operating procedures in health care, especially in teaching hospitals.

If you stop and think about it, requiring doctors and nurses to work under these conditions is the ultimate in disrespect . Not only are you treating them badly, you are knowingly putting them in a position where they are more likely to harm their patients. For hospital leaders, administrative or clinical, to do so is unconscionable, yet it is the norm almost everywhere.

A more subtle form of institutionalized disrespect is waiting times . Millions of hours are lost every day in the USA by patients waiting for care. We say, in effect, your time is worth less than my time. We ignore the immense costs , social and fiscal, of keeping people out of work and children out of school. Patients bear the brunt of this form of disrespect , but the inefficiency also exacts its toll from the physicians and employees who also wait.

And it is unnecessary. Operational research has developed methods for “queuing” and task management that virtually eliminate waiting and are well-known; they just need to be implemented. Some hospitals have done that and even eliminated waiting rooms [2]. All hospitals and doctors’ offices should.

The evidence of pervasive disrespect in health care is clear, but the literature was remarkably shy of insight into the causes of disrespect . For this we had to rely on the insights about general human behavior gathered over the years by psychologists. We did find examples of some very well-thought-out policies and procedures for dealing with egregious behavior, particularly the College of Physicians and Surgeons of Ontario’s Guidebook for Managing Disruptive Physician Behavior [3].

A Culture of Respect

By March we had completed a first draft, and various members were working on revisions. Jeff Flier , Dean of HMS , had indicated that he would welcome a proposal for a policy on respectful behavior. However, in the end he preferred that we distribute the white paper to Harvard hospitals and not to colleagues on the quad, the formal HMS campus.

The group thought it should also be published in the medical literature, so Miles Shore and I worked with several other members to finish the paper, and in July 2011 we submitted it to Academic Medicine . I was dubious that such a long paper would be published by a journal. Fortunately, the editor recognized its value and accepted it with the proviso that we break it into two papers that were published in the same issue:

A Culture of Respect , Part 1: The Nature and Causes of Disrespectful Behavior by Physicians [4]

The first paper described the dimensions and the extent of the problem of disrespectful behavior.

The numbers are arresting: 95% of nurses have witnessed or received abuse, and 64% reported an episode of verbal abuse at least every 2–3 months. But the number of doctors responsible is small: 5.7% [5]. More than a third of nurses believe disruptive behavior is a cause of nurses leaving an institution [6].

As noted in Chap. 20, abuse of medical students is also common. Dismissive comments or humiliation is experienced by two thirds of students [1, 7, 8]. More than half show signs of burnout, and 14% have symptoms of serious depression . Half of residents are victims of bullying, belittling, and humiliation [9]. Patient surveys show that 13–27% of patients report problems with doctor communication [10]. Patient interviews show the percentage is closer to 50% [11].

The paper then defined the types of disrespectful behavior and their effects and explored the causes of disrespect . We proposed that the slow progress in patient safety results from the dysfunctional culture of health-care institutions, and the root cause of that dysfunctional culture is disrespectful behavior.

Six different forms of disrespect were identified as common in health-care organizations:

• 1. Disruptive behavior, such as angry outbursts, threats, bullying, and the use of profane and abusive language

• 2. Humiliating and demeaning treatment of nurses, residents, and students

• 3. Passive-aggressive behavior , such as blaming others for your failures and making frequent negative comments about the hospital or colleagues

• 4. Passive disrespect, such as being chronically late to meetings, delay in dictating charts, and resistance to following safe practices , such as hand washing

• 5. Dismissive treatment of patients

• 6. Systemic disrespect : practices that are taken for granted, such as long hours and excessive workloads for nurses and residents, long waiting times for patients, and not disclosing and apologizing after harm caused by an error

All of these forms of disrespect create barriers to communication among all parties—doctors, nurses, residents, and patients. Disrespect is a major barrier to efforts to improve patient safety. It undermines the teamwork that is essential to changing systems to improve safety; it saps meaning and satisfaction from work, leading to burnout and low morale. It is particularly damaging to students and patients, especially when they are harmed by a medical error .

We identified both internal (individual) and external (environmental) causes of disrespectful behavior. Internal causes include personal feelings of insecurity and anxiety, depression , narcissism, aggressiveness, and prior victimization. The extent to which these antecedent problems result in disrespectful behavior, however, is largely determined by the external environment.

Key environmental factors that foster disrespect are the hierarchical nature of health-care organizations and a blaming culture . But also important are the long hours, heavy workloads, and “production pressure” to deliver quality care.

A Culture of Respect , Part 2: Creating a Culture of Respect [12]

The main theme of the second paper is that creating a culture of respect is the core of the broader cultural transformation that is needed to create a culture of safety in health care. The responsibility for creating a culture of respect falls squarely on the shoulders of the organization’s leader “because only he or she can set the tone and initiate the processes that lead to change.”

We challenged health-care organization CEOs to accomplish five major tasks:

• 1. To motivate and inspire others to take action “and to create a sense of urgency around doing so”

• 2. To establish preconditions for a culture of respect by showing concern for the well-being of faculty and staff by addressing issues of hours and workloads and physical hazards

• 3. To establish policies regarding disrespectful behavior, i.e., codes of conduct

• 4. To facilitate engagement of frontline workers by addressing systemic stressors

• 5. To create a learning environment by modeling professional behavior and valuing the learner

The paper then provided extensive and explicit recommendations on creating a code of conduct, drawing on experience from various sources, especially the College of Physicians and Surgeons of Ontario’s Guidebook for Managing Disruptive Physician Behavior [13]. We emphasized the importance of developing effective means of implementing and enforcing such a code, including enabling safe reporting and responding promptly.

The final section dealt with prevention, which includes education at all levels, the design and use of appropriate performance evaluations, and support of individuals at all levels who work to create a safe environment. Creating transparency , breaking down authoritarianism, learning to work in teams , and creating a “just culture ” are all part of the challenge of creating a respectful culture.

A Strange Twist

When we submitted the papers to Academic Medicine in July 2011, I sent a copy to each member of the Champions group knowing they would be interested in what we had learned. To my great surprise, several were upset that they hadn’t been included as authors! I thought this was a bit weird, because 6 months earlier I had sent them a draft so they would know what we were doing (presumably the foundation for their work), and we discussed the findings at a Champions meeting. Only one person sent me any comments about it, and no one suggested any edits. Given this prior behavior, it was a mystery to me why any of them would now think they were entitled to authorship.

Clearly, however, there was a major miscommunication that even in retrospect neither Miles nor I nor any of the authors were able to understand. We spent a great deal of time trying to mollify the Champions and resolve differences. Several disagreed substantially with the emphasis of the paper on consequences and response rather than on a supportive culture. They were upset about being left out of a major paper on this subject coming from Harvard—despite the fact they had contributed nothing to it!

Meanwhile, the paper was provisionally accepted, with the usual request that we respond to reviewers’ comments. We saw this as an opportunity to ask several of the disaffected to write an additional section in response to the reviewers, in which they could weave in some of their ideas and be legitimately added as authors. I thought this was a good solution.

However, despite the general angst, only two of them volunteered to do this. Unfortunately, instead of writing an additional section, they set about rewriting the whole paper! This would obviously not be acceptable to the editors, but they were insistent. So the whole effort ended in naught. I felt very bad about it—especially since a number of the group were old friends and associates.

Response

The two papers came out in the Academic Medicine in July 2012 and were well received. The earliest most obvious impact in our hospitals was that several tightened up their procedures and fired some of their most outrageous offenders, physicians whom colleagues had complained about for years.

A more impressive tangible result was that Virginia Mason Medical Center (VMMC) took the papers to heart. Nationally recognized as the leader in reducing errors and creating a culture of safety , VMMC was a fertile field in which this seed could germinate. Not only did VMMC upgrade their standards and processes for dealing with disrespectful behavior, they developed a comprehensive continuing education course on respect and required all 5000 of their staff and employees to take it. The course has subsequently been marketed to hundreds of other hospitals worldwide.

It is hard to measure the impact of the papers nationally, but I noticed that the word “respect” began to appear in conversations and writings about quality and safety. More specifically, medical schools and residency programs now routinely survey students and residents about receiving abusive behavior . Questions about how their doctors treated them were added to the post- hospitalization questionnaires that were sent to patients to evaluate their care. The feedback from those surveys puts immense pressure on hospitals, which, perhaps more than anything else, is slowly leading to a more respectful environment.