Rudeness in Medical Settings Could Kill Patients

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Imagine this: You’re a cardiac surgeon who is pushing into the five-hour mark of a complicated seven-hour surgery. You ask a nurse for a specific tool, and he drops it. It’s now contaminated and useless. The nurse stands dumbstruck until you snap at him to hurry up, grab another tool, and stop being so clumsy. You were rude, but he deserved it, right? He’ll get over the uncivil remark and everybody will move on. But that “moving on” actually might not happen — according to a recent study, rude comments in high-pressure medical settings could have potentially deadly effects on patients.

The study, "The Impact of Rudeness on Medical Team Performance: A Randomized Trial," which was published in the September issue of Pediatrics, shows that a rude comment from a third-party doctor decreased performance among doctors and nurses by more than 50 percent in an exercise involving a hypothetical life-or-death situation. “We found that rudeness damages your ability to think, manage information, and make decisions,” said Amir Erez, an author on the study and a Huber Hurst professor of management at the University of Florida. “You can be highly motivated to work, but if rudeness damages your cognitive system then you can’t function appropriately in a complex situation. And that hurts patients.”

For the experiment, Erez and his colleagues gave 24 medical teams from neonatal intensive care units in Israeli hospitals, each composed of one doctor and two nurses, an hour to diagnose and treat a simulated case of necrotizing enterocolitis, a rapid and potentially fatal disease in which a premature newborn’s intestinal tissue becomes inflamed and starts to necrotize, or die.

Before beginning, the teams were informed that a leading ICU expert from the United States would be observing them via webcam. The researcher running the experiment then dialed a fake phone number and played a (prerecorded) message that was supposedly from the observer. The message informed half of the participants that he had observed other medical teams and was “not impressed with the quality of medicine in Israel,” but told the control group simply that he had observed other teams, without making any rude comments or insults. Ten minutes into the simulation the teams were interrupted by another prerecorded message from the researcher. He told the control group that he hoped the workshop helped them improve as physicians; he told the other teams, however, that the Israeli physicians and nurses he’d been observing “wouldn’t last a week” in his department.

The rudeness had dramatic effects. The teams who experienced it struggled to cooperate, communicate, and do their jobs effectively, all of which caused their performance to plummet: They misdiagnosed the illness; they forgot instructions; they didn’t ventilate the patient well; they didn’t resuscitate well; they didn’t ask for help when they needed it; doctors asked for the wrong medication, and nurses mixed the wrong medication. Overall, the rude comments appeared to cause a 52 percent difference in how well teams diagnosed the disease, as measured by three independent judges who were blind to the study’s thesis, and a 43 percent difference in how well they treated it. In the real world, as Erez pointed out, these performance discrepancies could have made the difference between the tiny patient living and dying.

This may seem dramatic, but it’s well in line with prior research suggesting that while we’d like to think we can easily shrug off rudeness, this just isn’t the case. These studies — including one Erez is a lead author on — suggest that disruptive behaviors like rudeness are so powerful because they spread like a contagion and sabotage a person’s working memory, which plays a crucial role in our in-the-moment ability to learn, reason, comprehend, and recall information.

In the morning, a rude quip to a barista might cause them to mess up an order. But the stakes are much higher in medical settings. When disruptive behaviors cause these mental resources to fail, medical teams are putting patients at risk because they are physically unable to focus past the rude comment. These doctors and nurses are making mistakes, and then they can’t recognize or adapt to those mistakes. And as a result, the study authors suggest, rudeness could contribute to many of the preventable deaths caused by medical error in U.S. hospitals each year, which, according to a Journal of Patient Safety study, is between 210,000 and 440,000 people.

Our results highlight the potential role of human interaction in [medical treatment errors], indicating that occurrence of even a mild rudeness can have adverse consequences on the diagnostic and procedural performance of NICU team members,” the authors of the Pediatrics study write. And they’re clear about the ramifications, noting that these findings “show that even the mild incivility common in medical practice can have profound, if not devastating, effects on patient care.”

While Erez wasn’t surprised that rudeness affected doctors’ and nurses’ work, he did say he was surprised by the magnitude of the effect rudeness had on doctors’ working memory. It’s troubling, he pointed out, given how often medical workers experience rudeness caused by stress, burnout, and miscommunication all the time. For example, a 2010 study shows nearly two thirds of health-care workers in operating rooms have witnessed rude behavior, and nearly one half have been on the receiving end. Because of this frequency, Erez said he expected that the experienced medical teams in his experiment would get over the rude comments and keep working effectively — especially given that their task was diagnosing a newborn in an emergency situation (albeit a simulated one). “But we found consistently and dramatically that rudeness isn’t something people can easily get over,” he says. “It’s not something that you can postpone emotionally to a later time because it affects the cognitive system.”

Christine Porath, an associate professor at Georgetown University who is an expert on the effects of incivility and is not involved in Erez’s study, said she wasn’t surprised by the Pediatrics study’s findings. Her research shows that people spend time and energy processing why rude comments were made toward them and how it affects them, which saps away mental resources from the task at hand. “What we found is that being around any kind of rudeness takes people off track and makes it so they have a very difficult time focusing,” Porath says. “And that’s the biggest explanation we find for performance decreasing.”

Erez and Porath both say that hospitals need to take a more aggressive stance against rude behaviors among medical staff, and doctors need to consider the long-term effects of acting rudely toward one another. Because, as it turns out, these everyday slights could be catastrophic for patients.

Travis McKnight is a freelance writer who covers health, science, technology, and video games. He can be followed on Twitter at @Khellendos.