longitudinal study of nearly 3000 medical students from 16 medical schools was
just published the British Medical
Journal. Dr. Erica Frank and her
colleagues at the Emory Medical School found that 42 percent of seniors reported being harassed by fellow
students, professors, physicians, or patients; 84 percent reported they
had been belittled and 40 percent reported being both harassed and belittled. You can see a nice summary on Yahoo!
or can download the study at the BMJ website.
Dr. Frank’s study is unusually careful, but the finding that hospitals are nasty places to work – especially for nurses, medical students, and residents – has been replicated again and again. An earlier study of 594 “junior physicians” (similar to “residents” in the U.S.) in the United Kingdom found that 37% had been bullied in the prior year (especially by more senior physicians) and 84% indicated they had witnessed bullying that was aimed at fellow junior physicians. Nurses appear to have it especially bad, and unlike these medical students or residents, they don’t graduate to positions as doctors where they are relatively free from getting abuse, and apparently, also relatively free to dish it out.
I first saw the abuse that nurses face in the 1980s, when I was a PhD. student at The University of Michigan. My colleague Daniel Denison and I spent a week interviewing and observing a team of surgical nurses, and we were appalled by how rude, oppressive, and downright abusive the male doctors were to the (largely) female nurses. Take the surgeon that we dubbed “Dr Gooser,” after we saw him chasing a female nurse down the hall while trying to pinch her behind. The nurses we interviewed bitterly complained that it was useless to report him to administrators because they would be labeled as troublemakers and be told “he is just joking.” The told us that all they could do was to avoid him as much as possible.
study after study shows that too many hospitals let people like Dr. Gooser get
away with their dirty work. A 1997 study of 130 U.S. nurses in the Journal of Professional Nursing found that 90% reported being
victims of verbal abuse by physicians during the past year; the average
respondent reported 6 to 12 incidents of abusive anger, being ignored, and
treated in a condescending fashion. Similarly,
a 2003 study of 461 nurses published in the journal of Orthopaedic Nursing found that 91% had experienced verbal abuse in
the past month, defined as mistreatment that left them feeling attacked,
devalued, or humiliated. Physicians were the most frequent source of such nastiness,
but it also came from patients and their families, fellow nurses, and
The author of this most recent study, Dr. Frank, was quoted as saying, "This kind of culture change is not going to happen with any particular rapidity." And that, "We give a lot of lip-service to teaching professionalism [and] to reducing the prevalence of disruptive physicians, but unless we train physicians not to do this, it still falls into the action-speaks-louder-than-words category." Her comments raise the question of how to start such a process of cultural change. I agree it wouldn’t be easy, but at the same time, this attitude is dangerous because of the power of the self-fulfilling prophecy. If you believe that cultural change is difficult and takes a long-time, then it will be difficult and take a long time.
Hospitals operate under severe cost pressures, especially since the rise of HMOs. So the first thing that comes is start with a serious effort to calculate the total cost of assholes in hospitals (or TCA), to calculate the amount of money lost on turnover, absenteeism, additional health care costs and so on. I provide some examples and a list of possible costs in The No Asshole Rule, but one cost that I left out for hospitals is the failure to learn from and report medical errors. There is a fascinating study by Harvard Business School's Amy Edmondson of eight nursing units that sheds light on the human and financial costs. She found that when nurses worked in units with demeaning and critical co-workers and supervisors, they were less likely (as much as 10 times less likely) to report drug treatment errors. Edmondson’s research suggests to me that, when asshole poisoning runs rampant in a nursing unit, the fear of being demeaned and belittled can increase the chances that patients will get sicker and die, because people are so afraid to admit and talk about mistakes.
Of course, there are no magical cures for organizational problems, but they only way they get better is by taking one step at a time, and looking for intervention points that seem likely to get noticed. And confronting hospital and HMO administrators with the financial costs strikes me as a good place to start.