A recent UK survey found that certain high-intensity specialties such as cardiology, general surgery or neurosurgery are more likely to respond to a referral with aggressive, rude or dismissive communication than other specialities.1 While profoundly overworked clinical teams may understandably be reluctant to accept another referral, aggressive, rude or dismissive communication negatively affects both staff and patients. Benjamin C Whitelaw reviews the steps that can be taken to reduce such behaviour.
Aggressive, rude or dismissive communication has multiple adverse effects on both the staff and the organisation. Recipients of aggressive or rude communication report personal distress that affects their mood, confidence and motivation, and they also report that they tend to avoid future contact with the perpetrator.1 Teams subjected to rudeness perform less well, particularly with regard to cooperative working.2 The inclination to be helpful is harmed by rudeness and this type of communication is regarded as a risk to patient safety.3,4 The perpetrator probably also does not benefit from their aggression behaviour because venting of anger is thought to exacerbate rather than relieve frustrations.5 The key factors that contribute to or promote aggressive or rude responses are:1,6
- High-intensity workload with poor systems to support the acute work
- Personality of the individual
- Culture and practices that allow and do not challenge this type of communication
- Low status of the referring doctor; minimal previous working relationship with other specialties
- Poorly structured or vague referral, lacking relevant details
Some of these factors can be addressed. For example, the way in which a department receives and handles internal referrals may vary greatly. Some departments may regard this activity as a low status irritation to be avoided or minimised. The amount of timetabled activity designated to referral work may be inadequate and this can be a major source of stress. Referrals being received by bleep can increase stress since multiple bleep contacts cannot be easily ordered or triaged.
Possible solutions include electronic referral systems for subacute problems and/or a designated referrals registrar who has minimal other activity scheduled. Additionally, keeping a record or audit of referral numbers is important. If the demand tends to exceed the capabilities of one registrar, then referrals could be handled by a clinical team—such as one or more clinical nurse specialists or physicians’ assistants, who would need to work closely and effectively with the consultants and registrars.
Referral training could potentially improve the quality of referrals made and received, which in turn can reduce triggers for aggressive communication.7, 8 In the survey, one justification offered for an aggressive response was that a referral was “poor quality” and that the junior doctor who referred it “had to learn”. I would question whether this punitive educational objective requires rudeness and aggression. If a referral fails to convey the right information or is directed inappropriately, then this can be conveyed clearly but without rudeness.
While the personalities of individuals cannot be changed, departments could consider the implications of recruiting a doctor known to be aggressive and/or narcissistic.9
In an anecdotal report, a doctor who routinely receives specialist referrals commented that none of his colleagues show any concern or interest when they overhear him handling a telephone referral. However when handling a similar referral at home, his wife sometimes comments afterwards “I can’t believe how rude you were to that doctor”. Therefore, it is likely that many of us have lost insight into how we treat each other.
Ultimately it is the professional standards of behaviour to which doctors conform that will determine the extent of this type of communication.10 This is part of the culture within an organisation and a department.
There would need to be a significant and sustained leadership initiative to introduce a change to this way of thinking and behaving. Nevertheless increasing the mutual respect that doctors show each other has to be a positive step and it is difficult to see a convincing long term advantage of opposing it.
- Bradley V, et al. Clinical medicine 2015; 15: 541–45.
- Riskin A, et al. Pediatrics 2015; 136: 487–95.
- Porath CL, et al. Academy of Management Journal 2007; 50: 1181–97.
- Joint Commission. Sentinal Event Alert 40: behavours that undermine a culture of safety. 2008.
- Bushman BJ. Personality and Social Psychology Bulletin 2002; 28: 724–31.
- Leape, et al. Academic Medicine 2012; 87: 845–52.
- Lindfield D et al. Teaching and developing referral skills for new doctors. Medical Education 2015; 49: 1152–53.
- Bradley V, et al. Teaching referral skills to medical students. BMC Research Notes 2015; 8: 375.
- Sutton RI. Hachette UK, 2007.
- Leape LL, et al. Academic medicine 2012; 87: 853–58.
Benjamin C Whitelaw is at King’s College Hospital NHS Foundation Trust, London, UK