Hurtful comments are harmful comments: respectful communication is not just an optional extra in healthcare

In a study reported in this issue of Health Expectations, 76 Australian adults talked with Samantha Thomas et al. about their experiences of living with obesity. ¹ Half of them described instances in which they had been humiliated by healthcare professionals because of their weight. This is perhaps not surprising given the social stigma that now attaches to obesity, but it represents a significant failing on the part of health services.

Respectful communication is widely endorsed by patients as an important feature of good quality healthcare provision. ² But while health service providers are often committed to it as a good thing in principle, it is too readily reduced to the status of an optional extra in practice. Respectful communication is considered separately from the healthcare interventions that are regarded as the core business of healthcare provision, so failures of respect can be viewed as deviations from the perfect that do not necessarily bring healthcare below a tolerable quality threshold.

But respectful communication should not be an optional extra in healthcare. Studies of patients’ or service users’ experiences and perspectives allow us to recognize more readily that hurtful comments are harmful comments and that failures of respect can be both unhelpful and damaging to health.

Lisa Beatty et al.’s paper in this issue draws attention to women’s experiences of challenges to their self concepts in the acute survival phase of breast cancer. ³ It reminds us that the preservation or re‐establishment of self‐identities that we are comfortable with is a key indicator of a successful response to our health problems. If health professionals communicate in ways that fail to positively acknowledge and engage with patients as individual persons, they will miss opportunities to help them cope with and recover from their health problems.

If the communications or broader actions of healthcare providers are more radically disrespectful, they may actively threaten patients’ personal identities and damage their self esteem and sense of self worth as members of society. ⁴ From patients’ perspectives, experiences of being treated in accordance with negative stereotypes, of being belittled, demeaned and dehumanized are among the preventable harms of health care. ⁵ If we take seriously the definitions of health that incorporate psychological and social as well as physical functioning or wellbeing, and that look beyond the absence of disease or infirmity, then we must recognize that these are harms to health as well as to self‐evaluations.

But even if we adopt narrower definitions of health, disrespectful communication can be seen to be a threat to health. It is likely to have a negative impact on patients’ trust in health care providers and on the development of constructive professional‐patient relationships, so it may impede patients’ uptake of beneficial health care (including effective support for their own self care activities). In extreme cases it may lead people to disengage from health service use.

In this issue, Nancy Pandhi et al. report data from a large survey panel of American adults in their early 60s who were asked whether they would feel safe visiting another doctor or clinic if their own doctor were not available. ⁶ The 12% of people who said they would not feel safe included a higher proportion of women, people with more chronic conditions, people who had longer relationships with their own doctor, and people who reported trusting their physician to discuss treatment options with them as long as they wanted. ⁶ Pandhi et al. did not examine what aspects of safety people considered, but the value of relational continuity to patients depends on having a usual healthcare provider who understands them as a person, ⁷ and it seems plausible that people who feel vulnerable to disrespectful treatment (perhaps as a result of having been humiliated by health professionals in the past) will be more wary of consulting new health care providers once they have developed a trusting relationship with one.

Recent analyses of the excess prevalence of depression and other forms of morbidity associated with obesity suggest that these may be largely because of experiences of social stigma. ⁸ , ⁹ If these analyses are correct, then derogatory treatment from health professionals may be among the contributors to some major public health concerns – especially if the significance of health professionals’ remarks is heightened by their perceived status in society. And if the analyses extend to other ‘conditions’ associated with stigma, including various forms of disability, low literacy and poverty, then they may also contribute to social inequalities in health.

All this suggests that failures of respect in healthcare might appropriately be described as iatrogenic as well as less than ideal displays of manners and morals. Anton Kuzel and Steve Woolf have suggested that the kinds of psychological harm that patients incur as a result of discriminatory treatment or disrespectful communication might appropriately be considered as issues within the domain of concern of patient safety. ⁵ Adoption of this suggestion might help to ensure that respectful communication is not viewed as an optional extra in health care. It might also discourage the development of the view that disrespectful communication is a problem attributable to the poor behaviour of a few individual health professionals. Social stigma is a social and cultural problem and the damaging effects of disrespectful communication on health need to be tackled collectively as a matter of some urgency.