R-E-S-P-E-C-T: Even More Difficult to Teach than to Define

It is important to point out that in everyday life, it is common to hear one say “In order to have my respect, you have to earn it.” In common vernacular, respect and admiration are synonyms. Respect is not unconditional regardless of one’s personal characteristics, behaviors, or intentions. We see examples of this on TV and the Internet, in the grocery store, and even among our own family members. If you ask people on the street who they respect, they may name someone famous, someone whom they aspire to be like or who is accomplished in their field, or perhaps someone who is altruistic or who has “done good.” Rarely will they tell you that they respect “everyone.”

Inherent in this acknowledgment is the necessity for educators to voice their awareness of how hard it can be to respect patients, particularly those from whom they are different. Learning to be a doctor involves becoming an expert—acquiring massive amounts of knowledge and then learning to apply it to promote a patient’s health. After all that hard work, it may feel frustrating or demeaning to trainees when patients do not follow their advice, or even worse, contradict their professional or personal values. Learning to respect patients who do not “respect” you is difficult. It becomes doubly difficult when you are sleep-deprived, overworked, and feel you will never know enough to be a competent physician5‐7.

How can one teach respect given the reality of medical education? First, we can role model respect in our behavior toward the students. If we believe that patients are worthy of our respect because of their “unconditional intrinsic value as human beings,” so are trainees8,9. Trainees are unfortunately quite attentive to the values (or lack thereof) taught by their superiors as part of the hidden curriculum6,7,9,10. In this context, the flurry of articles on student abuse is particularly disturbing, as they suggest that while we tell trainees that they should respect their patients, their teachers do not respect their trainees11‐16. Second, educators need to attend to the effect of the environment on trainees’ behavior9. Every parent knows that a child is less likely to exhibit a “desired behavior” when s/he is tired, hungry, or stressed. Similarly, if we want trainees to show respect in difficult situations, we need to make sure the environment attends to their basic needs. Third, it may be useful to explicitly explore with trainees the reasons it may be difficult to respect patients. Safe forums such as support groups, Balint groups, or individual or group self-reflection exercises can encourage introspection and may serve as appropriate venues for exploring barriers to respect17,18. By inquiring about, acknowledging, and helping to eliminate the barriers to respect, educators can create a learning environment that promotes respectful behaviors.

Branch17 argues that teaching respect requires “an ongoing synergy ... whereby active learning and practicing the skills of respectful interacting with patients alternates with reflection...” He suggests the use of: 1) formal clinical exercises in which students practice eliciting and appreciating the patient’s story; 2) bedside role modeling and identifying respectful behavior; and 3) critical reflection away from the clinical setting. Other proposed mechanisms for teaching respect include the use of appreciative inquiry, self-disclosure, video review, seminars, or role-playing,18,19. A training program that incorporates a combination of such methods has been shown to improve patient-centered interviewing skills20, but no similar studies of respect exist.

Beach et al argue that physicians must both behave and think respectfully. In fact, they speak disparagingly about behaving respectfully without the proper attitude. In an ideal world, both respectful attitudes and respectful behaviors would come naturally to physicians or would at least be learnable simultaneously. But as educators, we worry that focusing on attitudes may come across as moralistic or “preachy” to trainees. Furthermore, the literature on attitudes suggests rather than being “formally taught”, attitudes are acquired through enculturation and reflection5,9,18. We also wonder how one could ever tell if a learner had a truly “genuine” attitude of respect.

We are not saying that attitudes are unimportant. Nor do we deny that physicians should ideally display respectful behaviors as well as have a respectful attitude toward their patients. In fact, possessing positive attitudes may make it more likely that physicians will automatically engage in behaviors consistent with such attitudes21,22. However, because attitudes are more difficult to teach and measure than are behaviors, we propose that a better way to approach teaching respect is to focus first on the development of behaviors or skills. This approach seems to be consistent with those used to teach other aspects of medicine. In teaching medical interviewing, for example, we focus on the observable behaviors that display compassion or empathy, rather than on the trainee’s attitudes toward such qualities. In fact, we often explicitly acknowledge that one does not have to feel compassion to act compassionately22,23.

A behavior-first focus may be particularly important for those trainees whose attitudes of respect are incongruent with what is expected. For example, when a trainee shows frustration in caring for a patient with unhealthy behaviors, or is blatantly disrespectful, it is a wonderful time to discuss what a doctor’s role is, what our ethical obligations toward patients are, and what these things mean in terms of behavior9,24. The large body of literature on the theory of cognitive dissonance supports this approach and is consistent with our thought that through continued practice, reflection, and reinforcement of respectful behaviors, respectful attitudes will follow25.

Whereas the work by Beach et al provides an excellent basis for discussion, there is a great deal of theoretical and empirical work that needs to be done to flesh out what is meant by respect, what it entails, and how to teach it. What does it mean to have an attitude that values a “patient as a person?” How is this concept of respect different from kindness, dignity, patient-centeredness, or politeness? In assessing whether a behavior is respectful, are there objective criteria, or is a subjective patient standard primary? Whereas Beach et al give a deontological argument for being respectful, data on the patient and physician consequences of being respectful would be important to have. Finally, as educators, we are interested in what methods and learning environments most effectively promote respect.