By PERRI KLASS, M.D.
Just how much rudeness is there in the hospital, and who bears the brunt of it?
A few weeks ago I wrote about a study that looked at what happens to medical teams when parents are rude to doctors. In these studies of simulated patient emergencies, doctors and nurses working in the neonatal intensive care unit were less effective in teamwork and communication, and in their diagnostic and technical skills, after an actor, playing a parent, made a rude remark about the quality of the hospital.
These results bothered me, not because I was surprised that there might be rudeness (and worse) coming from parents, but because I pride myself on a kind of professional immunity. Sure, parents are sometimes rude, and occasionally openly hostile; and sure, I acknowledge that that can be upsetting. But I wouldn’t have imagined that it would actually affect my medical skills or decision making.
If those supremely highly trained NICU personnel are actually worse at resuscitating newborns or diagnosing life-threatening complications after exposure to rudeness, though, what happens to the rest of us as we go through the lower-stakes but still important interactions of our clinical days?
Many of the readers who responded to that column seemed to think that the doctors and nurses were somehow doing it on purpose, responding punitively to the simulated “rude parent.” But in fact they were performing at a lower level on observed — and graded — tests of their medical abilities.
Other readers pointed out that it’s always good policy to be polite to the people taking care of you. And many others just wanted to register that the medical environment is full of rudeness on all sides: Patients complain about egregious rudeness by doctors, nurses, ward clerks and receptionists, while nurses tell stories of harsh patients and family members, not to mention rude doctors.
None of that is a surprise, and in fact, there is a good deal of literature to suggest that the medical environment includes all kinds of harshness, and that much of the rudeness you encounter as a doctor or nurse is likely to come from colleagues and co-workers. An often-cited British study from 2015 called “Sticks and Stones” reported that rude, dismissive and aggressive communication between doctors (inevitably abbreviated, in a medical journal, as RDA communication) affected 31 percent of doctors several times a week or more. The researchers found that rudeness was more common from certain medical specialties: radiology, general surgery, neurosurgery and cardiology. They also established that higher status was somewhat protective; junior doctors and trainees encountered more rudeness.
In the United States, a number of studies have looked at how rudeness affects medical students and medical residents, as part of tracking the different ways in which they are often mistreated.
One article earlier this year in the journal Medical Teacher charted the effect on medical student morale of a variety of experiences, including verbal and nonverbal mistreatment, by everyone from attending physicians to residents to nurses. Mistreatment of medical students, the authors argued, may actually reflect serious problems on the part of their teachers, such as burnout, depression or substance abuse; it’s not enough to classify the “perpetrators” (that is, the rude people) as unprofessional and tell them to stop.
Similarly, in the British study, when the researchers asked about “why rudeness happens,” they identified five themes: workload, lack of support, patient safety, hierarchy and culture. It may not be obvious that all of these can be specifically addressed, but it’s important to recognize the different ways that they can play into harsh and disrespectful language in a hospital.
As a senior doctor, to be rude to a medical student or a resident is to fall short of being the teacher you hoped to be; to be rude to a patient or a family member is probably to fail as the physician and human being you thought you were. And from the point of view of that patient or that family member, the medical hierarchy is often somewhat opaque; if someone has been rude to you, you may not know whether this is the clumsiness of a nervous trainee or the arrogance of a senior doctor with god delusions.
Sometimes rudeness comes from pressure, and heaven knows there is plenty of pressure in medical settings. In the “Sticks and Stones” article, the only context in which there was some justification for rudeness was when patient safety was at stake and someone spoke sharply to demand immediate action or to reprimand someone for a mistake.
And of course, when you know you’ve made a mistake or put someone at risk, you may become that much more sensitive. Many years ago, I made an intern cry on morning rounds by asking more than once why he hadn’t checked a certain blood test; he clearly experienced it as a public shaming, with a strong suggestion that he had risked the patient’s life. Was my manner a little thoughtless? Probably, and maybe even a little righteous; the intern’s well-being was not my priority. But it’s hard to see that the public shaming helped the patient — or the doctor.
Sometimes rudeness is a matter of perception. When my mother was in the hospital three years ago, I felt irritated when one of the rounding doctors kept looking down at her phone, even though she probably was using the phone to act on every one of the decisions being discussed, changing drug doses, ordering labs, requesting consultations, or at least, making notes to herself to do those things. It was a generational problem, I told myself; if she’d been scribbling on a clipboard, I wouldn’t have minded.
In almost any setting, rudeness does tend to beget rudeness, whether because the top people in a hierarchy are modeling it for those they should be teaching or because it engenders anger, stress and a desire to strike back. It’s not enough to say rudeness is unprofessional, so therefore don’t be rude. And it’s not enough to say, being affected by rudeness would be unprofessional, so therefore, I’m not affected.
Rudeness affects your spirit, your morale, your connection to your job and your effectiveness in that job. It gets in the way of health, and it gets in the way of healing.