Ethics Corner
David Hanscom, MD
Ethics & Professionalism Committee Member
Are We All Equals?
Scenario:
Dr. Jones’s behavior has become a concern of the hospital administration at the institution in which he practices. He has been very hard on the nursing staff, both on the inpatient ward and in day-surgery. There have been several documented exchanges in which he showed disrespect to the nursing staff, berated them in a public environment, used abusive language, and behaved in a very condescending manner. In fact, several nurses had recently resigned directly linking their decision to do so to Dr. Jones’ disruptive behavior.
When spoken to, Dr. Jones felt that the biggest problems simply centered around telephone verbal orders not being carried out in a timely manner, or that he’s asked too frequently for clarification, and he expects better. What can Dr. Jones do to recognize his contribution to this problematic setting, and work to improve himself?
Discussion:
It’s not uncommon for physicians to aggressively criticize what they determine is “unacceptable behavior”, which varies dramatically from person to person and on one’s mood. We, as a profession, need to be better than this. What are some of the primary factors leading to this behavior?
One is anxiety. Our self-image is based on a “can do” and bring it on” mindset. Weakness isn’t tolerated by our mentors, peers or even our patients. We are masters of suppressing anxiety and disguising it. However, it’s presence has contributed to a burnout rate well over 50%, and increasing.
A 2009 study showed that the compassion index of pre-med students was above the national average but by the 3rd year of medical school, it had plummeted to well below the average. (1) This is well before the rigors of residency and the demands of surgical training. We receive little training in the area of stress management skills.
Another factor is the drive to be perfectionists. Physicians often respond to this by saying, “I’m not a perfectionist. I just have high standards.” Whatever term you would like to use, we have an idealistic self-image of what we would like to accomplish and who we want to be. We work long hours, delay gratification and in many ways sacrifice much of our life to achieve our professional goals. It’s this same drive that can also create unbecoming behaviors, and burnout.
With this concept of perfectionism, physicians will be hard on themselves, and on others. In the scenario illustrated above, the nursing staff became a point of focus. (2)
A third factor contributing to abusive behavior toward others is that physicians become and remain judgmental, often labelling individuals positively or negatively. When we do so, we are at risk of losing awareness of that person’s true qualities.
Getting back to Dr. Jones’ concerns of telephone orders, when he speaks to someone harshly or berates them, he’s unconsciously internally labeled them negatively in some way. In reality, the nurse on the other end of the phone is simply trying to do his or her job.
Solutions:
Awareness of the problem is the first step. Criticism is normalized in the medical culture and it may not seem problematic. Why am I being so judgmental of others? What am I anxious about? How is becoming upset about things you have little control over affecting the quality of your day?
What is the impact of your words on others and also how you appear to them. A leader who is reactive loses effectiveness and respect. You are the highly educated professional whose reassuring demeanor can go a long way towards allowing people to feel safe and do their job more effectively. Do you want to be perceived as someone who frequently loses control of your emotions?
Understanding the neurochemical link between anxiety and anger is critical. Anxiety causes you to act in a manner to solve a problem or threat and remain safe. It’s an unconscious survival response, which is much stronger than the conscious brain. If you lose control (anxious), your body will respond with more adrenaline (anger) in an effort to regain control. Anger is anxiety with a chemical kick. Neither are subject to rational control.
Once you understand this sequence, there are many ways to decrease this chemical kick and calm down this reaction. You can train your body to be less reactive to external stimuli, and as your body experiences endogenous oxytocin, dopamine, serotonin, and GABA versus adrenaline, cortisol, and histamines, you’ll calm down. It’s not difficult and is a learned skill. The essence of the outcome is play. If you have to be at work anyway, you can remain agitated with the unpredictability of the day or you can choose to embrace the variety and have a great time.
Getting back to the phone again, one of the basic approaches to improving communication with others is to reframe your reality. You have a well-paying job, an opportunity to help people, societal respect, many interesting challenges, and comradery with many staff and colleagues. When the phone rings, you can choose to view it as opportunity to help someone or feel bothered and hassled. How do you view the person who is calling you and helping you to do your job? It’s going to ring regardless of how you relate to it. What is your choice?
- Mohammadreza Hojat, et al. “The devil is in the third year: A longitudinal study of the erosion of empathy in medical school. Acad Med (2009); 84: 1182-1191.
- Rosenstein, Alan H., et al. "Disruptive physician behavior contributes to nursing shortage: study links bad behavior by doctors to nurses leaving the profession. (Doctors, Nurses and Disruptive Behavior)." Physician Executive, Nov.-Dec. 2002, p. 8+.
Chair: B. Stephens Richards, III Committee: Kamal N. Ibrahim, Past Chair (E); James M. Eule; Timothy A. Garvey; H. Robert Tuten; Christian P. DiPaola (C); Sang D. Kim (C); Olavo B. Letaif (C); Jonathan N. Sembrano (C); Paulo J. Silva Ramos (C); Bekir Y. Ucar (C); Anthony M. Petrizzo; Jochen P. Son-Hing; Jacob M. Buchowski; David A. Hanscom; Steven D. Glassman, Chair Elect; Sherif M. El Ghamry; Hee-Kit Wong