Abstract
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-affiliated public hospital.
PARTICIPANTS: Four ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students.
DESIGN: Teams were studied using participant observation of rounds (160 hours); in-depth semistructured interviews (n=23); a structured task involving thinking aloud (n=4, attending physicians); and patient chart review. Codes, themes, and hypotheses were identified from transcripts and field notes, and iteratively tested by blinded within-case and cross-case comparisons.
MAIN RESULTS: Attending physicians identified three categories of potentially problematic behaviors: showing disrespect for patients, cutting corners, and outright hostility or rudeness. Attending physicians were rarely observed to respond to these problematic behaviors. When they did, they favored passive nonverbal gestures such as rigid posture, failing to smile, or remaining silent. Verbal responses included three techniques that avoided blaming learners: humor, referring to learners’ self-interest, and medicalizing interpersonal issues. Attending physicians did not explicitly discuss attitudes, refer to moral or professional norms, “lay down the law,” or call attention to their modeling, and rarely gave behavior-specific feedback. Reasons for not responding included lack of opportunity to observe interactions, sympathy for learner stress, and the unpleasantness, perceived ineffectiveness, 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, uncaring, or hostility toward patients by members of their medical team. They tended to avoid, rationalize, or medicalize these behaviors, and to respond in ways that avoided moral language, did not address underlying attitudes, and left room for face-saving reinterpretations. Although these oblique techniques are sympathetically motivated, learners in stressful clinical environments may misinterpret, undervalue, or entirely fail to notice such subtle feedback.
Similar content being viewed by others
References
Peabody FW. The care of the patient. JAMA. 1927;88:877–82.
Subcommittee on Evaluation of Humanistic Qualities in the Internist, American Board of Internal Medicine. Evaluation of humanistic qualities in the internist. Ann Intern Med. 1983;99:720–4.
Self DJ, Schrader DE, Baldwin DC Jr, Wolinsky FD. The moral development of medical students: a pilot study of the possible influence of medical education. Med Educ. 1993;27:26–34.
Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students’ perceptions of their ethical environment and personal development. Acad Med. 1994;69:670–9.
Lipkin M. Integrity, compassion, respect. J Gen Intern Med. 1986;1:65–7.
Pellegrino ED. Teaching medical ethics: some persistent questions and some responses. Acad Med. 1989;64:701–3.
Sulmasy DP, Geller G, Levine DM, Faden R. Medical house officers’ knowledge, attitudes, and confidence regarding medical ethics. Arch Intern Med. 1990;150:2509–13.
Rest JR. Background: theory and research. In: Rest JR, Narvaez D, eds. Moral Development in the Professions: Psychology and Applied Ethics. Hillsdale, NJ: Lawrence Erlbaum Associates; 1994.
Ozar DT, Sokal DJ. Dental Ethics at Chairside: Professional Principles and Practical Applications. St. Louis, Mo: Mosby-Year Book; 1994.
Miles SH, Weiss Lane L, Bickel J, Walker RM, Cassel CK. Medical ethics education: coming of age. Acad Med. 1989;64:705–14.
Tosteson DC. Learning in medicine. N Engl J Med. 1979;301:690–4.
Mattern WD, Weinholtz D, Friedman CP. The attending physician as teacher. N Engl J Med. 1983;308:1129–32.
Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med. 1992;67:630–8.
Spradley JP. Participant Observation. New York, NY: Holt, Rinehart, and Winston; 1980.
Bernard HR. Research Methods in Anthropology: Qualitative and Quantitative Approaches. Thousand Oaks, Calif: Sage Publications; 1994.
Ericsson KA, Simon HA. Verbal reports as data. Psychol Rev. 1980;87:215–51.
Spradley JP. The Ethnographic Interview. Chicago, Ill: Holt, Rinehart, and Winston; 1979.
Blumer H. Symbolic Interactionism: Perspective and Method. Englewood Cliffs, NJ: Prentice-Hall; 1969.
Fischer C, Wertz F. Empirical phenomenological analyses of being criminally victimized. In: Giorgi A, ed. Phenomenology and Psychological Research. Pittsburgh, Pa: Duquesne University Press; 1975:135–58.
Miles MB, Huberman AM, Qualitative Data Analysis. Thousand Oaks, Calif: Sage Publications; 1994.
Mizrahi T. Getting Rid of Patients: Contradictions in the Socialization of Physicians. New Brunswick, NJ: Rutgers University Press; 1986.
Hanson PG, Giving feedback: an interpersonal skill. In: The 1975 Annual Handbook for Group Facilitators. San Diego, Calif: University Associates Publishers; 1975.
Ende J, Pomerantz A, Erickson F. Preceptors’ strategies for correcting residents in an ambulatory care medicine setting: a qualitative analysis. Acad Med. 1995;70:224–9.
Ende J. Feedback in clinical medical education. JAMA. 1983;250:777–81.
Bosk CL. Forgive and Remember: Managing Medical Failure. Chicago, Ill: University of Chicago Press; 1979.
Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.
Eskedal GA. Symbolic role modeling and cognitive learning in the training of counselors. J Counsel Psychol. 1975;22:152–5.
Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–71.
Reiser SJ. The ethics of learning and teaching in medicine. Acad Med. 1994;69:872–6.
Author information
Authors and Affiliations
Additional information
Dr. Burack was supported by a National Research Service Award, U.S. Public Health Service (5 T32 PE1002). This research was further supported by cooperative agreements (1U76MB 00005-01 and -02) with the Bureau of Health Professions, Health Resources and Service Administration, U.S. Public Health Service.
Rights and permissions
About this article
Cite this article
Burack, J.H., Irby, D.M., Carline, J.D. et al. Teaching compassion and respect. J GEN INTERN MED 14, 49–55 (1999). https://doi.org/10.1046/j.1525-1497.1999.00280.x
Issue Date:
DOI: https://doi.org/10.1046/j.1525-1497.1999.00280.x