Our finding that one out of four student narratives about events that “taught them something about professionalism” was about (dis)respect suggests that students find the topic important, although relatively little scholarly attention has been focused on this concept22
. Student narratives in our setting point to numerous characteristics of respect already extant in the literature including: autonomy10,11
, maintaining non-judgmental attitudes2
and maintaining patient privacy3,12
. At the same time, they broaden the concept beyond any one type of act, behavior or attitude23
. Respect is regarded as multifaceted15
, experienced by students as a way of being that applies in all settings; crossing power and status hierarchies, but mainly exerted by physicians toward patients and students; and is relevant under all circumstances including valuing others’ time, needs, experiences, preferences, choices, opinions and privacy. Students describe respect as more than a rote behavior; rather, they describe it as a deep value that guides behavior1
, even behind closed doors. They notice the way their role models communicate and focus on the importance of relationality7
in all aspects of care and education.
In their pre-clinical years, students often assume that respect in medicine is based on norms of behavior that are expected in everyday life. When a perceived breach occurs in training, it is both noticeable and reportable24
, precisely because it contrasts with conventional expectations and values. Ironically, this phenomenon may also explain why two themes (treating others as equals and honoring preferences and decisions) contained mainly positive narratives. Based on their own negative expectations about equality and patient-centered care, they were surprised and excited to see how their role models acted in these challenging situations. Beach et al.10
suggest that respect is a moral imperative that is every patient’s right irrespective of personal characteristics. Students’ narratives about respect for stigmatized populations indicate their appreciation for how respect comes to “life” in these populations.
In trying to deepen our understanding of respect and disrespect, we observed that students discerned respect in small gestures of apologizing, asking permission, and investing an effort in maintaining the right setting or manner in routine communication and behavior. By contrast, disrespect included not adhering to rules of common courtesy such as being insensitive to or violating others’ (patients and students) emotional and physical needs. These behaviors often provoked strong responses, suggesting that students pay particular attention to the details of interaction in which disrespect is embedded.
Concerning this issue, our findings add new information about the perceived consequences of (dis)respect16
. For example, disrespectful behavior was observed to lead to loss of trust, strong negative emotions and damage to relationships, whereas respectful behavior was seen as leading to increased trust, satisfaction, willingness to share information, adherence to treatment and positive emotion. Perhaps most importantly, the student narratives underscore the important role that both positive and negative role modeling can play in shaping student attitudes and behavior. The fact that students view respect as an important way of being professional suggests that we—as medical educators and role models—have an amazing opportunity to influence the next generation of physicians by embodying respect in every clinical and educational context and interaction. The ‘future health’ of our health care system may depend upon our success in this endeavor.
The narratives are from a single clerkship at one institution and may not generalize across institutions or clerkship types. All data were derived from a single source, without triangulation between methods or member checks. At the same time, intra- and inter-rater coding accuracy was maintained in both phases of the analysis.
An Educational Action Agenda
Despite the AAMC pledge that teaching faculty “…will not tolerate anyone who manifests disrespect or who expresses biased attitudes towards any student or resident,” the student narratives indicate that opportunities for improvement abound. The large number of disrespectful narratives is concerning and suggests that even though they are noticed (by patients, nurses, faculty and certainly by students), they are not always dealt with or officially recognized. Using students’ "fresh eyes" and observations as a basis for discussion is a novel way of developing a curriculum based on the “lived experience” of (dis)respect and can serve as a basis for deepening learning, increasing awareness, developing positive ideals, and identifying ways of handling these challenges and building community.