Thursday, June 14, 2012
The insidious power of disrespect
"I just love working here!" my nurse told me. "We have great supervision, I have wonderful colleagues. We all help each other in an emergency. The doctors are really responsive and I feel like I am doing important work. I thought I would only stay for a year because oncology is so hard, but I've been here ten and I still love it."
This is what we want to hear from the people who are taking care of us.
But sometimes we don't. In two articles by patient safety leader Lucian Leape and his colleagues, recently published as part 1 and part 2 in Academic Medicine, we learn that physician disrespect of their co-workers and patients is fairly common and that it stymies efforts to improve patient safety. The two papers describe this phenomenon in detail and suggest what hospitals and health systems can do to build a "culture of respect."
While the audience for these articles is medical educators, clinicians and hospital administrators, those of us who are interested in people's engagement in their health care should take a look. The authors:
--Recognize the existence of what we have long suspected: that health care is organized around a physician ethos that favors their "individual privilege and autonomy" as opposed to collaboration, teamwork and our inclusion in decisions about our treatment.
--Validate our experience of being disrespected by some of our clinicians, for example, when our questions are met with disdain, when we are excluded from decisions about our preferences for care, or when we are not provided an honest explanation when things go wrong.
--Note that disrespect is reflected in the organization of health care, through such common occurrences as the disregard of the value of our time manifested by long hours spent in waiting rooms and requests that we fill out that questionnaire on our medical history for each clinician for each visit.
Most of us have had some experience with all these varieties of disrespect. But reading the details about the effects of physician disrespect on the operation of hospitals and practices and the functioning of colleagues and staff is chilling. This behavior distorts relationships. It contributes to an atmosphere of intimidation and damages their willingness to be accountable, undermines cooperation, and ultimately distracts them from delivering good care leading to errors, apathy and burn-out.
It's difficult to imagine that professionals working in a practice or department or unit where they are constrained by their own colleagues' misbehavior are going to have the energy to invite us to learn about and share in decisions about our treatment; where preoccupation with hurt feelings and temper outbursts among staff will allow them to imagine what we must know and do to care for ourselves when we leave the hospital, and then help us plan how we will do it.
We patients are insignificant bit players in an intense ongoing interpersonal drama among those who provide our care. We come and go, but the squabbles and turf battles and grudges among them spool out over years. Meanwhile, we can object directly, complain to administrators, change clinicians or institutions to protect ourselves. And we can express our dissatisfaction in surveys and go public with our concerns on various rating sites, although our individual efforts will have little impact on a culture where disrespectful behavior by professionals is tolerated.
Assessment of our experience of care through HCAHPS and satisfaction surveys can provide a general whack to a hospital or a department by indicating that we notice just how bad things are. And theoretically, since payment is increasingly tied to such measures, there is an incentive to tackle these problems.
But I'm not holding my breath. There are many factors that might make me rate as poor my experience of care, and while the attribute of "disrespect" may be behind many of them, it is easier to offer free coffee and wireless in the waiting rooms than it is to fix the personal and systemic problems that the disrespect causes.
Dr. Leape and his colleagues suggest specific and direct remedies that are certain to meet with stiff resistance from the physician champions of the ethos of individual privilege and autonomy. Take a look here: How have hospitals run all this time without these basic controls?
Contemplate all this and then recall the clinicians who have listened to you and cared for you over the years. The ones who, like my nurse, love their work and are committed to doing the best they can for each of us; the ones who work in settings where they are valued and respected and who bring energy and focus to their efforts to help us. A culture of respect in health care may be a heavy lift in some places, but it already exists in practices and hospitals and clinics all over the country.
Patients and families can't fix the problem of disrespectful physicians. But it needs to be addressed, and the first step in addressing it is identifying it. These two papers are a good start.
Jessie Gruman, PhD, is the founder and president of the Washington, D.C.- based Center for Advancing Health. She is the author of Aftershock: What to Do When You or Someone you Love is Diagnosed with a Devastating Diagnosis. This post originally appeared at the Prepared Patient Forum.
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