R-E-S-P-E-C-T: The health of health care depends on it

December 13, 2010

INDIANAPOLIS - Along with integrity and compassion, respect for patients, colleagues and other team members is an essential attribute of medical professionalism. A new study examines how medical students learn respectful or disrespectful professional behavior.

"Exploring the Meaning of Respect in Medical Student Education: An Analysis of Student Narratives" appears in the December 2010 issue of the Journal of General Internal Medicine. From the observations and conclusions of third-year medical students, the article provides insight into how future physicians acquire knowledge of respectful and disrespectful professional behavior.

Of the 595 narratives on professionalism reviewed by the study authors, one in four focused on the respect category. Two-thirds of these narratives were negative, a high percentage, especially when compared with other aspects of professional behavior, in which the proportion of negative narratives was significantly lower.

Narratives cited as examples of disrespectful behavior by the students include: a physician who brought a doughnut and coffee into a patient room; a physician who continued a personal call while on medical rounds; a physician who patted a patient on the stomach while making a vulgar gesture about how much weight the patient needed to lose; an attending physician making a joke at the students' expense; and a student who surfed the Internet while another student made a presentation.

"Disrespectful behavior was observed to lead to loss of trust, strong negative emotions, and loss of relationships. Respectful behavior was seen as leading to satisfaction, willingness to share information, adherence to treatment and positive emotion," said study first author Orit Karnieli-Miller, Ph.D., of the Department of Community Mental Health at the University of Haifa in Israel. She is a former post-doctoral fellow at the Regenstrief Institute.

In those narratives focusing on the issue of respect, respectful or disrespectful behavior was identified 55 percent of the time in physicians' behavior toward patients; 24 percent of the time in physicians' behavior toward medical students; 11 percent of the time in interactions among other members of the health care team including students with other students and physicians with other physicians; 7.5 percent of the time in nurses' behavior toward medical students; and 2.5 percent of the time in physicians' behavior toward nurses.

"When physicians communicated or behaved disrespectfully toward the medical students, these students expressed loss of motivation to be involved and take an active part in their learning," said Dr. Karnieli-Miller.

"The influence of the informal curriculum is as great or even greater than what students learn in the classroom. These student narratives underscore the major role that both positive and negative role modeling can play in shaping student attitudes and behavior," said senior author Richard M. Frankel. Ph.D., a Regenstrief Institute investigator, Indiana University School of Medicine professor of medicine and an investigator with the Richard L. Roudebush VA Medical Center.

Students perceived respect as important in both public and private settings and with all members of the health care team including patients, family members, nurses, faculty and fellow student, and under varying circumstances such as the classroom and providing patient care at the bedside.

The fact that students view respect as an important aspect of professionalism "suggests that we, as medical educators and role models, have an amazing opportunity to influence the next generation of physicians by embodying respect in every clinical and educational context and interaction," the study concluded.

"It is important to put this study into perspective," study co-author Thomas S. Inui, Sc.M., M.D. past president of the Regenstrief Institute and a professor of medicine at the IU School of Medicine said. "The IU environment is as humane and respectful as any I know, but students - like the rest of us - expect exemplary behaviors, regret departures from this expectation, and seek to do better themselves. The good news and the challenge for us as educators is that students are learning from everything we do - and in every moment."
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In addition to Dr. Karnieli-Miller, Dr. Frankel and Dr. Inui, co-authors of the study are Amanda C. Taylor, M.S., of the School of Science at Indiana University-Purdue University Indianapolis; Ann H. Cottingham, M.A., of the IU School of Medicine; and T. Robert Vu, M.D., of the IU School of Medicine and the Roudebush VA Medical Center.

The Regenstrief Institute, IU School of Medicine and the School of Science are located on the Indiana University-Purdue University Indianapolis campus.

Indiana University School of Medicine

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