KeyLIME Podcast #177: Summer Re-run of episode #147 Riskin Rudeness breaks teams

Welcome to our summer “re run” series!  Over the next few weeks, we will be revisiting some of our best KeyLIME episodes to jog your memory!  Read on, and check out the podcast here (or on iTunes!)


KeyLIME Session 177:

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Riskin A1, Erez A2, Foulk TA2, Kugelman A1, Gover A1, Shoris I1, Riskin KS3, Bamberger PA1. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015 Sep;136(3):487-95.

Reviewer: Jonathan Sherbino (@sherbino)


As a clinician I think a lot about the function of a system to optimize the quality of patient care and prevent error. For example, our hospital is transitioning to a new EMR and our group is carefully considering the impact of our new digital record on patient care. (See here for a past episode on this topic…) As an educator, I’m often thinking of how to effectively teach and structure patient encounters for learners to facilitate their acquisition of knowledge and experience. With improved experience learners can provide better care. (See here for a past episode on this topic… )

However, how often do I consider the psychology of team performance on the outcomes of my patients. We have discussed the effect of the healthcare environment on the wellness of learners. (See here …) But I have not given serious attention to the psychology of team performance on patient outcomes. We’re going to fix that this week!


“Our objective was to explore the impact of rudeness on the performance of medical teams”

Type of Paper

Research: randomized trial

Key Points on Method

This was a randomized, double-blind trial recruiting from neonatal intensive care units at four hospitals. 24 teams (one physician, two nurses) participated. Mean year of experience was > 10 years.

Each team participated in a 30 minute simulation of a 28-day old critically ill child. Prior to initiating the simulation each group received an audio message from an “expert observer” participating by webcam. At ten minutes a second message was received. This message was recorded (standardized), but felt to be live to the participants. The control group received an emotionally benign message. The experimental group received two messages that indicated that the expert was “not impressed with the quality of medicine” and that the participants “wouldn’t last a week in his department.” Using a validated measure, participants found the intervention to be significantly more rude than the control.

The management of the simulated scenario was assessed by two senior physicians and an experienced nurse, blinded to intervention. The written documentation (orders, diagnosis) and video recording of the team functioning were graded on a 5 point scale along 4 domains:

  •  Diagnostic performance
  •  Procedural performance
  •  Information-sharing
  •  Help-seeking

Key Outcomes

The composite diagnostic scores were lower for teams exposed to rudeness (2.6 vs 3.2 [P = .005].

The composite procedural performance scores were lower for teams exposed to rudeness (2.8 vs 3.3 [P = .008], respectively).

Rudeness had a negative effect on information-sharing (estimate = –0.51 [P , .01] and help-seeking (estimate = –0.38[P , .05]).

Rudeness alone explained nearly 12% of the variance in diagnostic and procedural performance. A model linking rudeness to team performance (information-sharing, help-seeking) explained an even greater portion of the variance in diagnostic and procedural performance (52% and 43% respectively). Other demographic features of participants did not explain the differences in performance.

Key Conclusions

The authors conclude…

“Not only does rudeness harm the diagnostic and procedural performance of practitioners, it also seems to adversely affect the very collaborative processes that might otherwise allow for teams to compensate for these effects.”

Spare Keys- other take home points for clinician educators

1. Figure 1 is an elegant example of how to visually represent the interaction of various elements of a model on outcomes.

2. The author group offers a diversity of potential explanations for their empiric findings, including the capacity of working memory (occupied by rumination on rude comments) and the impairment of social collaborative processes that allow a team to optimally function.

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