Dear fellow doctors: Please play nice

I have myriad memories from my intern year — good and bad, although perhaps not in equal parts — that will undoubtedly live forever in the recesses of my traumatized mind. One of the most vivid was of a particularly noxious doctor. He was unfailingly curt and condescending, and I dreaded our conversations, which unfailingly made my blood pressure skyrocket. I wasn’t alone: My colleagues concurred.

Most people who have worked in health care have a story about disagreeable providers. There’s been much discussion of doctors bullying nurses, and there’s no doubt that nurses do it, too. But what about rudeness between doctors? As a resident, I’m at the bottom of the heap, and since the contents of a bedpan run downhill, I’m one of many young physicians bearing the brunt of incivility from senior doctors and from my peers, who often feel overworked and abused.

To the cynical among us, perhaps it’s not surprising some doctors act like jerks; some are egotistical, lack social skills, or just don’t care. But I give my colleagues the benefit of the doubt and suspect that burnout — which is worse than ever — is driving many doctors’ rudeness. After all, impatience and short tempers are actually normal human responses to frustration, exhaustion, and constant stress.

“Doctors, especially residents, are so tired and so overworked that we don’t realize that the person on the other end of the phone is also tired and overworked,” a surgery resident at a Boston-area hospital told me. Exasperation with the medical system and sheer exhaustion, she said, “comes out as rudeness.”

Yet lashing out just makes a bad situation worse. And a body of research shows it hurts patients, too.

I know firsthand a rude comment can sidetrack my day and sabotage my ability to focus at work — and many studies show I’m not the only one derailed by bad behavior. Work published in the journal Pediatrics last year found doctors and nurses performed worse on a medical exercise when peppered with rude statements. They were less likely to make crucial diagnoses and performed some key tasks poorly.

“Even seemingly benign, sarcastic comments had rather severe implications on the ability to perform their regular tasks and to engage in basic team processes,” Peter Bamberger, an author on the study and a professor of business at Coller School of Management at Tel Aviv University in Israel, told me in an email.

These effects have been shown in other groups as well, such as teachers and business executives. What’s worse, people have no idea their performance has suffered.

“The danger is that they don’t realize they are making more mistakes,” said Amir Erez, another author of the study and a professor of management at the University of Florida.

Other research has also linked rudeness to medical errors. One report, published in 2004 in Academic Medicine, found that 40 percent of medical mistakes described by resident doctors were at least in part due to poor communication, often stemming from fear of appearing incompetent or from a perception that colleagues weren’t interested in communicating.

Another study linked serious interprofessional conflicts to medical errors. Although it’s impossible to prove that one caused the other, it’s hardly a stretch to say that abusive workplace behavior fosters dysfunction and predisposes people to making mistakes.

One reason conflicts and poor communication lead to errors is because avoiding interactions means withholding information. The surgical resident I talked to recalled an important conversation that ended up being cut short because of the rudeness encountered during a discussion about a patient being transferred to another department in the hospital. Important information easily could have been lost, which is bad news because doctors are grappling with more data than ever in an increasingly complex medical system, experts say.

“You really need to be able to talk with your peers,” said Alan Rosenstein, an internist in the Bay Area and a consultant in health care management. He led a 2006 study that found that disruptive behaviors — such as condescension and disrespect — were perceived to negatively affect patient care and safety.

Disrespectful interactions stifle intellectual exploration between colleagues, especially in situations in which the right diagnosis or action isn’t clear-cut, which turns out to be a fair chunk of them.

“Medicine is very rarely black and white,” Rosenstein said.

In fact, teamwork is often key to making the best diagnosis and plan, said Kathleen Sutcliffe, a coauthor of the 2004 study and a professor of business and medicine at Johns Hopkins University.

“Sometimes it takes different people’s perspectives to make sense of how things are unfolding,” Sutcliffe said in an interview. “Discussions between teams are ways to make sense of what’s going on and what to be concerned about.”

Rudeness also is distracting, which can be a disaster when patient care is involved.

“Cognitive resources are allocated away from the tasks at hand and towards processing the signals that may be indicative of threat,” Bamberger said in an email. When those tasks pertain to someone’s medical care, patients suffer, he said.

Plus, disrespectful behavior permeates the work environment, experts say. Rude colleagues amplify stress and burnout, perpetuating a vicious cycle of negativity. In those sorts of work environments, Rosenstein said, everyone suffers. Employees become increasingly cynical, angry, and tired, and the impact of medical errors on patients is obvious.

“Every interaction matters, and everybody’s interactions are shaping the culture all the time,” Sutcliffe said. “It’s hard work, but being civil and building a context of respect and trust is critical.”

I’m the first to admit that I’m not at my best when I’m sleep-deprived, on my 80th hour of work, and subjected to the pressure cooker that is day-to-day patient care. But I hope that as doctors, we can together take a little extra effort to work collaboratively — both for each other and for our patients.