CAEP GeMES | Impact of Rudeness on Overall Medical Team Performance

In Great Evidence in Medical education Summary (GEMeS) by Harinee SurendraLeave a Comment

Eric is a first year Emergency Medicine resident who just started his shift.  The emergency department gets notified of an incoming patient with a history of liver cirrhosis who started to vomit frank blood.  As the team is preparing the resuscitation room, the respiratory therapist asks Eric what intubation equipment he would like to use.  Before he has a chance to answer, one of the nurses tells the respiratory therapist, “He’s just a first year resident; he’s not going to know that.”  Eric kept thinking back on this comment, which made him more hesitant about voicing his thoughts to the team during the resuscitation.  

Exposure to rude behaviour/comments can have a negative impact on the performance of healthcare practitioners.  This “Great Evidence in Medical education Summary” (GEMeS – pronounced “gems”), titled “Impact of Rudeness on Overall Medical Team Performance” was originally posted by the CAEP EWG GEMeS Team in July 2017 and answers the question: “What is the impact of rudeness on overall medical team performance?” A PDF version of the GEMeS summary is available here.

Article Reference

Riskin A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskin KS, Bamberger PA. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. PEDIATRICS 2015; 136(3). DOI: 10.1542/peds.2015-1385

Why is this paper relevant to Emergency Medicine education?

Emergency departments (ED) rely strongly on team-based medicine. Such environments are also impacted by stressful situations that can result in less than professional behavior. Mild rudeness/incivility has been found to affect cognitive tasks, decrease creativity and flexibility, and result in less helpful and prosocial behavior (1). Understanding the impact of negative human behavior on the overall performance of medical teams is important for patient safety and reducing iatrogenic events.

Level of Evidence/Level of Learning/Funding Sources

1B/Hospital-based medical teams/Israel Science Foundation – no potential conflicts of interest to disclose.

Study Design and Setting

Randomized, double-blinded trial using 72 NICU professionals (physicians and nurses). This study took place at four urban Israeli hospitals.


Researchers examined the effect of mildly rude behavior on a medical team’s diagnostic and procedural performance. It was hypothesized that mildly rude behavior would negatively impact the overall performance of the team. The outcome measures of this study included the following:

  • Diagnostic performance (i.e., participants identified the cause of the patient’s deterioration).
  • Procedural performance (i.e., participates provided appropriate resuscitative measures).
  • Information-sharing (i.e., participants shared vital information in a timely manner).
  • Help-seeking (i.e., participants appeared comfortable seeking help from colleagues).

To study these parameters, 24 NICU teams (1 physician and 2 nurses per team) participated in a pediatric simulation-based resuscitation. These teams were randomly divided into 2 groups:

  • Study group: Participants were exposed to standardized, mildly rude feedback (regardless of team performance) from an independent observer before and during the simulation scenario.
  • Control group: Participants were exposed to standardized neutral feedback.

Both teams were independently rated by a blinded, 3-person panel of NICU professionals, with respect to their team diagnostic and procedural performance, information-sharing, and help-seeking.

Researchers concluded that mildly rude behaviour had a significant adverse effect on procedural (P=0.008) and diagnostic (P=0.005) performance of a medical team.

Specifically, when teams were exposed to rudeness, tasks that required information-sharing adversely affected diagnostic performance, and tasks requiring help-seeking adversely affected procedural performance.

Of note, research in patient safety and quality improvement has largely focused on improving broad systems and technology (2, 3). This study highlights the potential role of negative human behaviour on iatrogenic events.


Researchers concluded that mildly rude behavior had a significant adverse effect on the procedural and diagnostic performance of a medical team.  They noted that in particular, tasks that required information-sharing adversely affected diagnostic performance, and tasks that required help-seeking adversely affected procedural performance when teams were exposed to rudeness.


1. Engle RW, Kane MJ. Executive attention, working memory capacity, and a two-factor theory of cognitive control. In: Ross B, ed. The Psychology of Learning and Motivation. Vol. 44. New York, NY: Elsevier; 2004:145–199
2. Ligi I, Millet V, Sartor C, et al. Iatrogenic events in neonates: beneficial effects of prevention strategies and continuous monitoring. Pediatrics. 2010;126(6). Available at: content/full/126/6/e1461
3. Starmer AJ, Spector ND, Srivastava R, et al; I-PASS Study Group. Changes in medical errors after implementation of a handoff program. N Engl J Med. 2014; 371(19):1803–1812

Emergency departments can be a stressful environment, which may sometimes lead to rude behavior. What steps can you take to minimize the occurrence of these behaviors? If you witness someone behaving rudely, what can you do to address it?


More About the CAEP GEMeS

This post was originally authored for the Canadian Association of Emergency Physicians (CAEP) Great Evidence in Medical Education Summaries (GEMeS)  project sponsored by the CAEP Academic Section’s Education Working Group and edited by Drs. Teresa Chan and Julien Poitras. CAEP members receive GEMeS each month in the CAEP Communiqué. CanadiEM will be reposting some of these summaries, along with a case/contextualizing concept to highlight some recent medical education literature that is relevant to our nation’s teachers.


Harinee Surendra

Dr. Harinee Surendra is an editor for the GEMeS series and recently started an emergency medicine fellowship with the University of Calgary. In her free time, she enjoys pottery, traveling the globe, hiking, and kayaking.

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Aaron Leung

Aaron is a fourth year medical student from Western University with an interest in emergency medicine, medical education, and POCUS. Outside of school, he enjoys playing the piano and trying out new restaurants.