R-E-S-P-E-C-T--what it means to patients.

Aretha Franklin’s 1967 adaptation of Otis Redding’s “Respect” gave the song fame, contributed to the feminist movement and is widely credited with propelling her career. In the chorus, Franklin repeatedly sings “R-E-S-P-E-C-T—find out what it means to me”. A new study by Quigley and colleagues in this issue of JGIM turns the lens of this important question onto clinical consultations, reaffirming Franklin’s call in the private realm of physicians and patients.1 Using a large sample of survey data from the Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS), the authors tested the hypothesis that the most important communication predictor of patients’ overall physician rating is the item assessing patient’s perception of whether the physician showed respect. For 23 of 28 medical specialties, showing respect was the most predictive item of overall physician ratings, accounting for more than four times as much variance as the other survey items assessing communication behaviors. The only specialty for which showing respect was not predictive of overall ratings was interventional radiology.1 The question addressed by Quigley and colleagues is especially timely with the much-needed current focus on patient and family engagement in healthcare delivery. Patient and family engagement has been described as the “blockbuster drug” of the 21st century.2 But how do physicians and healthcare delivery organizations develop effective partnerships with patients in direct care—consultations between patients and physicians—and in governance of healthcare delivery? Showing respect will surely be the first necessary step, but how does one do this? And does showing respect perhaps matter even more fundamentally beyond making patients feel better about the experience of the consultation, and therefore rating the physician accordingly? The CG-CAPHS survey includes five survey items assessing patients’ perceptions of physician communication—explains things; listens carefully; gives easy to understand instructions; shows respect; and spends enough time. Arguably, the other four items measure somewhat more discrete categories of behavior. Considerable research has focused on how to teach physicians some of these skills,3 but showing respect seems considerably more ambiguous. How one shows respect to members of different ethnic groups is the source of numerous cultural stereotypes. But, given the intuitively indisputable importance of respect in collaborative human relationships, some general principles of what constitutes treating someone with respect should be deducible. A basic tenet of medical ethics is respect for the autonomy of patients—that a patient has the right to accept or refuse any treatment. One can easily imagine communication behaviors that would demonstrate such a respect for autonomy, and indeed physicians provide more information to patients whom they respect than those they don’t.4 But is engaging in behaviors such as providing more information really the same as showing respect to the patient? From a social psychological perspective, respect has been defined as “the social acceptance of another person”.5 The humanistic clinical psychologist Carl Rogers is well known for the concept of unconditional positive regard. Regardless of what the patient may have thought, felt or have done, Rogers advocated for accepting them unconditionally. Put another way, Rogers advocated for approaching patients by respecting them as individuals who have incontestable worth as they are, and not expecting them to behave differently to earn this respect.6 We are not advocating turning medical consultations into Rogerian psychotherapy sessions. We recognize the immense time pressures physicians operate under and the many competing demands on their time, their cognitive capacity and emotional resilience in the face of obstacles and frequent disappointments. But the increasing call for meaningful patient and family engagement in healthcare, driven in part by a growing dissatisfaction with a profession that is often perceived as unwilling to share information and slow to change, requires some introspection. Accepting patients unconditionally and without judgment does not mean that one has to give up one’s own values and sense of right and wrong.6 But being respectful also means that one cannot simply impose one’s own values and demand change because the physician is the expert. Patients’ behavior may, on the surface, not always seem rational. Why else, for example, would so many patients with hypertension not take their prescribed medicine? But what may not seem rational to a physician may be perfectly reasonable in light of the patient’s life circumstances. Instead of lecturing (whether mentally or verbally) non-adherent patients, physicians can humbly inquire and ask the patient to reveal the reasons behind their behaviors, from which the physician can learn the barriers and identify potential levers for change.7 Such an approach is consistent with motivational interviewing, an approach to counseling patients that aims to draw out their intrinsic motivation for change, which builds on Carl Rogers’ client-centered therapy.8 The physician who launches into a lecture on why it is important to take antihypertensive medications is unlikely to have a receptive audience, much less a partner in care who feels heard and respected for who they are as a person. The benefits of treating patients respectfully are likely to be substantial. Respect engenders trust, and having a trusting relationship makes it far more likely that physician and patient can work together as partners. In turn, a treatment plan that is a product of partnership is far more likely to be one a patient agrees to and is willing to follow. Patient’s non-adherence to prescribed treatment regimens has proven to be a stubborn problem. Being consistently respectful won’t eliminate this problem, but it makes it more likely that a mutually agreeable treatment can be created, instead of patients disagreeing by not adhering to a plan after having left the consultation room. Existing evidence on this topic may not be as rigorous as some might hope, but one cannot conduct a randomized trial of being respectful. As noted above, we acknowledge the time pressure physicians face. Physician time has been repeatedly described as a scarce resource. The perception of scarcity, however, may be associated with behaviors that are counterproductive to showing respect for patients. In Scarcity by Mullainathan and Shafir, the authors describe ample evidence of cognitive shortcuts people take under the scarcity mindset.9 Perceived scarcity of time due to fee-for-service financing mechanisms, and the quest for ever larger panel size dictated by capitation payment, contribute to physicians feeling intense time pressure to have short visits and many patients. This scarcity mindset leads them to be preoccupied about time, overlooking basic tenets of patient-centered communication that require mindfulness to practice.9 Some physicians tell their patients that “I have more patients waiting out there, I must wrap up this visit now. You will need to schedule another visit.” In a study of patient–physician communication, we observed a physician walking over to the patient, who raised her hand intending to say something, took that hand and turned it into a goodbye handshake and proceeded with walking her out of the exam room.10 Patients experiencing such physician behaviors are unlikely to feel respected. Indeed, Quigley and colleagues also show that another CAPHS communication question—spends enough time—has the lowest rating across the majority of specialties.1 Existing evidence suggests that patients are fairly perceptive of their physicians’ respect for them.4 And contrary to what we sometimes hear from physicians, being respectful is not just about being nice. It’s about engaging with patients as human beings and valuing them as such, in the same way that physicians desire to be respected by their patients. By humbly inquiring about a patients life circumstances and beliefs, having the compassion to recognize that patients are most likely doing the best they can and meeting them where they are instead of where one believes they are supposed to be, will go a long way toward showing respect. To repeat Aretha Franklin’s words: “R-E-S-P-E-C-T—Find out what it means to me!”