Disrespect, Lucian Leape believes, is the elephant in the hospital.
According to the adjunct professor of health policy at the Harvard School of Public Health, disrespect is the reason why so many patients leave the E.R. feeling belittled or ignored. It’s why medical workers feel so “demoralized.” And it’s why—despite attempts at change in the last decade—we still see medical errors that cause needless suffering and even cost lives.
Thirteen years ago, the Institute of Medicine released a groundbreaking report titled “To Err is Human” that called for a new paradigm in the medical field. Bad people don’t cause errors, the report’s authors said—bad systems do. At the time, studies estimated that as many as 98,000 patients died in American hospitals each year because of preventable medical mistakes, more than were lost to car crashes, breast cancer, or AIDS (though the exact number is difficult to pin down). The solution, the IOM suggested, was not to punish “bad apples” who miscalculated a drug dose. Rather, it was to learn from those errors to build a safer heath care system.
This was supposed to mark a turning point in medicine. But even as we’ve made important strides—for example, the famous “checklist“ from Atul Gawande has been proven to reduce surgical mistakes by reminding physicians of simple things like hand-washing—studies still show that somewhere around 15 percent of patients suffer treatment-related complications, about half of which are preventable.
That’s where Leape, a long-time advocate and researcher of patient safety, comes in. As he recently told a roomful of social scientists at a Washington symposium, he believes “that disrespectful behavior—our ability to tolerate it, and not do anything about it—is the root cause of the dysfunctional culture we have in medicine.” It’s a culture that’s hurting “an awful lot of people,” he says. And he is not just talking about nurses and patients.
In a pair of papers published in July in the journal Academic Medicine, Leape and his co-authors outlined six categories of disrespect, ranging from the obvious to the subtle. On one end lies the overtly disruptive behavior: the angry outbursts, swearing, and bullying. More common is humiliating and demeaning treatment (by teachers to medical students, surgeons to nurses, physicians to patients). But there are also behaviors and attitudes that we might not think of as “disrespect”: passive-aggression (harshly criticizing colleagues to psychologically harm them), passive disrespect born of apathy and burnout (“I don’t have to wash my hands”), and dismissive treatment of patients (refusing to return their calls or answer their questions).
The final category may be the most crucial for changing hospital cultures—and the most difficult to combat. Leape and his co-authors refer to this as the “systemic” disrespect that’s baked into the profession. It’s why doctors won’t admit error for fear of malpractice suits and keep patients waiting. It’s also why physicians are required to work excessive hours. When doctors work all night, Leape said after his lecture, “they’re more likely to hurt somebody. And so you are deliberately putting them in a position where they may hurt somebody. And that’s very disrespectful”—to the doctors and to their patients.
So far, the idea is too new to know how large swathes of the field will react to it. Indeed, one might think that the very culture Leape is critiquing might prevent doctors and medical schools from embracing his diagnosis.
In their papers, Leape and his co-authors spell out a few strategies to eradicate this culture of disrespect—starting with medical school deans and hospital CEOs. A new expectation of respect, they suggest, must be built into hospital codes of conduct and performance reviews, as well into the very culture of medical education.
That’s where his audience in Washington comes in. The solution may lie with social scientists. The healthcare field needs them, he believes, to research what it will take to dislodge medicine’s deeply rooted traditions of individualism over collaboration, “education by humiliation,” and disregard for patients themselves.
“Doctors have always felt entitled—we teach them that in medical school,” Leape said in Washington. “That’s the challenge. How do you teach them to know a lot and really be outstanding at what they do and not feel that they need to be treated specially?”
If only the answer were as simple as hand-washing.