• J H Burack, D M Irby, J D Carline, R K Root, and E B Larson.
• Division of Health and Medical Sciences, School of Public Health, University of California, Berkeley, Calif., USA.
• J Gen Intern Med. 1999 Jan 1; 14 (1): 495549-55.

ObjectiveTo describe how and why attending physicians respond to learner behaviors that indicate negative attitudes toward patients.SettingInpatient general internal medicine service of a university-affiliated public hospital.ParticipantsFour ward teams, each including an attending physician, a senior medicine resident, two interns, and up to three medical students.DesignTeams 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 ResultsAttending 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.ConclusionsBecause 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.

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