Teaching compassion and respect - Attending physicians' responses to problematic behaviors

OBJECTIVE: To describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients. SETTING: Inpatient general internal medicine service of a university-affili ated public hospital. PARTICIPANTS: Four ward teams, each including an attending physician, a sen ior medicine resident, two interns, and up to three medical students. DESIGN:Teams were studied using participant observation of rounds (160 hour s); in-depth semistructured interviews (n = 23); a structured task involvin g thinking aloud (n = 4, attending physicians): and patient chart review. C odes, themes, and hypotheses were identified from transcripts and field not es, and iteratively tested by blinded within-case and cross-case comparison s. MAIN RESULTS: Attending physicians identified three categories of potential ly problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely obser ved to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or rema ining silent. Verbal responses included three techniques that avoided blami ng learners: humor, referring to learners' self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attit udes, refer to moral or professional norms, "lay down the law," or call att ention to their modeling, and rarely gave behavior-specific feedback. Reaso ns for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffective ness, and lack of professional reward for giving negative feedback. CONCLUSIONS: Because of uncertainty about appropriateness and effectiveness , attending physicians were reluctant to respond to perceived disrespect, u ncaring, or hostility toward patients by members of their medical team. The y tended to avoid, rationalize, or medicalize these behaviors, and to respo nd in ways that avoided moral language, did not address underlying attitude s, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical en vironments may misinterpret, undervalue, or entirely fail to notice such su btle feedback.