Skip to main content

Advertisement

Log in

Teaching compassion and respect

Attending physicians’ responses to problematic behaviors

  • Original Articles
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Peabody FW. The care of the patient. JAMA. 1927;88:877–82.

    Google Scholar 

  2. 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.

    Google Scholar 

  3. 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.

    Article  PubMed  CAS  Google Scholar 

  4. 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.

    Article  PubMed  CAS  Google Scholar 

  5. Lipkin M. Integrity, compassion, respect. J Gen Intern Med. 1986;1:65–7.

    Article  PubMed  CAS  Google Scholar 

  6. Pellegrino ED. Teaching medical ethics: some persistent questions and some responses. Acad Med. 1989;64:701–3.

    Article  PubMed  CAS  Google Scholar 

  7. 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.

    Article  Google Scholar 

  8. 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.

    Google Scholar 

  9. Ozar DT, Sokal DJ. Dental Ethics at Chairside: Professional Principles and Practical Applications. St. Louis, Mo: Mosby-Year Book; 1994.

    Google Scholar 

  10. Miles SH, Weiss Lane L, Bickel J, Walker RM, Cassel CK. Medical ethics education: coming of age. Acad Med. 1989;64:705–14.

    Article  PubMed  CAS  Google Scholar 

  11. Tosteson DC. Learning in medicine. N Engl J Med. 1979;301:690–4.

    Article  PubMed  CAS  Google Scholar 

  12. Mattern WD, Weinholtz D, Friedman CP. The attending physician as teacher. N Engl J Med. 1983;308:1129–32.

    Article  PubMed  CAS  Google Scholar 

  13. Irby DM. How attending physicians make instructional decisions when conducting teaching rounds. Acad Med. 1992;67:630–8.

    Article  PubMed  CAS  Google Scholar 

  14. Spradley JP. Participant Observation. New York, NY: Holt, Rinehart, and Winston; 1980.

    Google Scholar 

  15. Bernard HR. Research Methods in Anthropology: Qualitative and Quantitative Approaches. Thousand Oaks, Calif: Sage Publications; 1994.

    Google Scholar 

  16. Ericsson KA, Simon HA. Verbal reports as data. Psychol Rev. 1980;87:215–51.

    Article  Google Scholar 

  17. Spradley JP. The Ethnographic Interview. Chicago, Ill: Holt, Rinehart, and Winston; 1979.

    Google Scholar 

  18. Blumer H. Symbolic Interactionism: Perspective and Method. Englewood Cliffs, NJ: Prentice-Hall; 1969.

    Google Scholar 

  19. 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.

    Google Scholar 

  20. Miles MB, Huberman AM, Qualitative Data Analysis. Thousand Oaks, Calif: Sage Publications; 1994.

    Google Scholar 

  21. Mizrahi T. Getting Rid of Patients: Contradictions in the Socialization of Physicians. New Brunswick, NJ: Rutgers University Press; 1986.

    Google Scholar 

  22. Hanson PG, Giving feedback: an interpersonal skill. In: The 1975 Annual Handbook for Group Facilitators. San Diego, Calif: University Associates Publishers; 1975.

    Google Scholar 

  23. 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.

    Article  PubMed  CAS  Google Scholar 

  24. Ende J. Feedback in clinical medical education. JAMA. 1983;250:777–81.

    Article  PubMed  CAS  Google Scholar 

  25. Bosk CL. Forgive and Remember: Managing Medical Failure. Chicago, Ill: University of Chicago Press; 1979.

    Google Scholar 

  26. Bandura A. Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice-Hall; 1986.

    Google Scholar 

  27. Eskedal GA. Symbolic role modeling and cognitive learning in the training of counselors. J Counsel Psychol. 1975;22:152–5.

    Article  Google Scholar 

  28. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994;69:861–71.

    Article  PubMed  CAS  Google Scholar 

  29. Reiser SJ. The ethics of learning and teaching in medicine. Acad Med. 1994;69:872–6.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

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

Reprints 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

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1046/j.1525-1497.1999.00280.x

Key words

Navigation