Bachelor Thesis What is arrogance in healthcare and how does it affect healthcare?

Maastricht University Faculty of Health, Medicine and Life Sciences Maastricht, 29-6-2014 Name: C.J.M. Egelmeer Student ID: i6031982 Studies: BSc in European Public Health, Maastricht University Supervisor: P. Schröder-Bäck European Public Health 3013: Thesis

Abstract INTRODUCTION: This bachelor thesis conducts a research in which the concept of arrogance and its different impacts on healthcare and interrelated sectors are discussed. The research question is: “What is arrogance in healthcare and how does it affect healthcare?”.

METHODS: The presented research was conducted using a literature review. In this literature review, Google Scholar, PubMed and Maastricht University quick search (a search engine displaying the literature present in the library of Maastricht University) (Maastricht University, 2014) were used. A set of keywords closely related to the concept of arrogance were used. These search terms are ‘arrogan*’, ‘disdain’, ‘doctor disdain’, ‘selfrespect’, ‘arrogance doctor’, ‘doctor patient arrogance’, ‘medical arrogance’, ‘disdain medical errors’, ‘doctor’s arrogance’ and ‘arrogance health’. Furthermore, combinations of these search terms were used in order to narrow down search results. An inclusion criterion was the close relation to healthcare. Exclusion criteria were the focus on arrogance related to non-health sectors, only an abstract of the article was available, the article was not written in English or Dutch, or the article was not related to Western societies. Analysis was done by reading the abstract - if available - and by scanning for key terms, such as ‘arrogance’, ‘disdain’ and ‘self-respect’. If the article was found to be relevant, it was thoroughly read. Significant parts on relevant subjects to the thesis were highlighted and recorded. The presence of arrogance in healthcare will be discussed by means of five sub-questions. With the help of these questions, the results chapter will be structured. RESULTS: Firstly, the following criteria can be attributed to arrogance: it is aggressively assertive, presumptuous and overbearing. Furthermore, it has the ability to manifest itself in various ways, such as a lack of respect, being abusive or being critical of subordinates or valuing the information or knowledge presented by others as important to improve one’s own perception. Arrogance is a concept which is closely related to other concepts relevant to ethics: it can be subdivided into two kinds of arrogance: interpersonal arrogance and unwarrantable claims arrogance (Dillon, 2007). Furthermore, arrogance can be presented as a prejudice. Moreover, arrogance causes relationships between individuals who have different beliefs towards morality to be uneven and morally unhealthy. Additionally, arrogance among medical staff such as doctors and nurses, affects relationships between a doctor and their patient negatively. The trustworthiness and quality of healthcare towards patients is affected negatively by arrogance. Furthermore, arrogance affects the relationships between the healthcare sector and other sectors negatively, since physicians appear to have disdain

towards professions who try to regulate healthcare. Finally, time is of great importance when looking at the development of the definition and meaning of arrogance in healthcare. The reason for this is the possible acquisition of different meanings throughout time, related to the concept of arrogance, this development is increasingly influenced by the media. What may have been seen as the legit superiority of the doctor to the patient fifty years ago, may currently be identified as arrogance. DISCUSSION: Firstly, the same definition of arrogance is not used throughout every piece of literature. Different authors may have different perceptions on what can be identified as arrogance, and what cannot, which is a limitation to this research. Secondly, there are situations in which arrogance is not the only factor influencing the quality, trustworthiness, communication, and other matters addressed in the sub-questions in the healthcare setting. It is important to note that time is a limitation in this study, since arrogance is a concept that is highly influenced by time. Therefore, the definition of arrogance and the articles used in this paper, may not thoroughly reflect the current situation regarding this matter. More research should be done in order to provide an update regarding arrogance in healthcare in its current form. Finally, this study is only applicable in the healthcare setting. By incorporating a chapter on the characteristics of arrogance, a proper way to define arrogance has been presented in this thesis. Finally, additional factors may have influenced the outcome of this study. One of these factors is stated in the article written by Rudland and Mires (2005). It is argued that doctors deem the nurses to be inferior to them. However, in the article of Pronovost (2010), it is added that physicians may not receive feedback from nurses due to cultural, social, educational and financial differences. This does not automatically mean that doctors would not welcome the feedback which can be given by nurses. CONCLUSION: Generally, it can be stated that arrogance has a negative effect on healthcare. It is, therefore, important to tackle the problem of arrogance in healthcare in order to improve the provided care, and possibly preventing negative healthcare outcomes.

List of Tables 1. Table 1: Literature search results. 2. Table 2: Sources of difficulties between doctors and nurses (Rudland and Mires, 2005)

Contents 1.

Introduction of the problem ................................................................................................ 6

2.

Goal and research questions ............................................................................................... 6

3.

Conceptual framework ....................................................................................................... 8

4.

Methods ............................................................................................................................ 12

5.

Results .............................................................................................................................. 13 5.1 How does arrogance among medical staff affect relationships between the doctor and their patient? .................................................................................................................. 15 5.2 “How does arrogance among medical staff affect relationships among them and how does it affect relationships between healthcare institutions?” .............................................. 17 5.3

How does arrogance affect the quality and trustworthiness of healthcare? .............. 19

5.4 How does arrogance affect the effectiveness of the communication between healthcare sectors represented by doctors, and other sectors represented by other professions? .......................................................................................................................... 23 5.5 6.

How is the concept of arrogance in healthcare subject to changes throughout time? 25

Discussion ......................................................................................................................... 27 6.1

Limitations ................................................................................................................ 27

6.1.1. Definition of arrogance .............................................................................................. 27 6.1.2. Importance of time in the definition and meaning of arrogance in healthcare .......... 29 6.2 Methods and subjectivity regarding interpretation......................................................... 30 6.3 Strengths ......................................................................................................................... 31 6.4 Factors possibly influencing the outcome of this study ................................................. 31 6.5 Future recommendations ................................................................................................ 32 7.

Conclusion ........................................................................................................................ 34

References ................................................................................................................................ 37

1. Introduction of the problem In Greek mythology, the existence of arrogance in healthcare was already discussed. The very first tale of an arrogant doctor was the myth of Asclepius. He received “Gorgon’s blood”, a magical serum that could resurrect the dead or kill them, depending on the will and skill of the physician who used it. When Aesculapius used the potion to bring a patient back to life, Hades, the lord of the underworld, was angered by the doctor’s arrogance in doing so. He complained to Zeus, who agreed with him. They agreed it should be acknowledged that all doctors must painfully learn that they have to let their patient go at some point (Weishaus, 2006).

Health outcomes are said to be negatively influenced by the existence of the interpersonal phenomenon identified as arrogance in healthcare (Dyer, 2000, Pronovost, 2010). Therefore, it is important to create a comprehensive overview of the impact of arrogance in healthcare, in order to improve healthcare services in the future. After all, Calman (1994) states that discourtesy and arrogance reflect badly upon a profession of which the primary purposes are to take care of patients and to improve health and the quality of life by preventing illness.

Furthermore, health promotion, care, treatment and the optimal use of resources guided by a team approach are essential to improve health and the quality of life as well. A key issue regarding this matter is the focus on the patient. There is, after all, great power in the process of serving the patient and the public if it can be harnessed effectively. Therefore, discourtesy and arrogance should be minimized to the greatest extent possible (Calman, 1994).

2. Goal and research questions This thesis conducts a research in which the concept of arrogance and its different impacts on healthcare and interrelated sectors are discussed. Researching arrogance in healthcare is important, since the quality of healthcare seems to be influenced by this matter throughout Europe (Dyer, 2000, Pronovost, 2010). Furthermore, the culture and ethos of health services have changed since patients have become increasingly important in the provision of patientcentered healthcare. Due to the fact that health literacy has increased among lay people, they are increasingly informed about the healthcare they receive and should receive. (Sørensen , 2013) They, therefore, form an important focus group regarding this matter. 6

Since healthcare has a special bond with the patients it serves, it is subject to a continuous development when it comes to education, the role of research development, and quality. As a result, the value base of medicine has been readjusted, presenting a need for a proper organisation and structure of health services and constructive debates on the implementation of values such as humility - as opposed to arrogance - in healthcare (Calman, 1994). A thesis on the matter of arrogance in healthcare would contribute towards forming the theoretical base to start these developments, regarding the proper organisation and structure of health services by means of the implementation of values, such as humility - as opposed to arrogance -. This is the main goal of this study.

To attain this goal, the following research question will be used as a red line throughout this research: “What is arrogance in healthcare and how does it affect healthcare?” In researching the meaning of arrogance in healthcare, both medical staff and patients will be discussed. Whilst elaborating on issues of arrogance among medical staff, the medical staff will be reduced to three groups of professions in this thesis: physicians, doctors, and nurses. This is done in order to keep the research structured and somewhat concise regarding target groups.

In the previous paragraph, the main research question is stated. The main question stated in the last paragraph, will, however, not be enough to fully cover all aspects of arrogance and its impact on healthcare. Therefore, firstly, a conceptual framework needs to be constructed to provide the reader with a definition of arrogance. Furthermore, sub-questions have been formulated in order to give the research a comprehensive structure throughout the entire study. These sub-questions are: “How does arrogance among medical staff affect relationships between the doctor and their patient?”, “How does arrogance among medical staff affect relationships among them and how does it affect relationships between healthcare institutions?”, “How does arrogance affect the quality and trustworthiness of healthcare?”, “How does arrogance affect the effectiveness of the communication between healthcare sectors represented by doctors, and other sectors represented by other professions?” and, “How is the concept of arrogance subject to changes throughout time?” By answering these sub-questions, the information which is necessary to answer the main research question is provided.

7

When it comes to the content of this study, the overall definition of arrogance will first be discussed. Discussing this definition provides the reader with both a background and a conceptual framework in order to understand the term “arrogance” in the most constructive way and to make it operable for this research. After all, this term will be a recurrent and important theme throughout this study. Secondly, the sub-questions shall be answered using the appraised literature, and will be elaborated in the results section. Finally, the discussion and conclusion at the very end of this bachelor thesis are dedicated to indicating the strengths and limitations of this study, creating a comprehensive overview of the impact of arrogance on healthcare, and indicating the need towards further research regarding the matter of arrogance.

3. Conceptual framework To be able to answer the main research question, the first important matter is to understand how arrogance can be defined. Therefore, in this chapter, a definition of arrogance will be given. This definition provides this paper with a conceptual framework. By means of this framework, the results found can be placed in a comprehensive context.

In several pieces of literature, the characteristics and criteria of arrogance in different fields of interest are addressed (Dillon, 2007, Tiberius and Walker, 1998). The Oxford Dictionary refers to the adjective “arrogant” as a state of “having or revealing an exaggerated sense of one’s own importance or abilities”. It is derived from the verb “arrogare’, from “ad”, which means “to” and “rogare”, meaning “ask”. Furthermore, the term is closely related to the Latin “arrogat” meaning “claimed for oneself” (Oxford Dictionaries, N.D.). This definition of arrogance provides the reader with the sole linguistic meaning of this concept. It is of great importance of stating the linguistic characteristics of this term, in order to understand its origin.

This approach, however, does not represent the importance of arrogance within a certain context. In order to provide the reader with a deeper understanding of the term “arrogance”, ethical approaches to this terminology will be discussed. In Kant’s perspective, self-respect is central to living one’s life as a person, and arrogance, at its very core, is the failure to selfrespect (Dillon, 2007, Sackett, 2002, Tiberius and Walker, 1998). Kant states that arrogance, in its base, is a pernicious moral perspective that disvalues and therefore, disrespects the self

8

(Dillon, 2007). Most importantly, in the context of healthcare, self-respect involves the proper valuing of the self that makes fully rational judgment, moral agency and the proper valuing of other people - among other things - possible. Therefore, self-respect prevents misjudgment and misappraisal (Dillon, 2007).

Furthermore, Aird (2012) argues that arrogance has a strong link with anxiety. Even though anxiety mainly relates to feelings of inadequacy and uncertainty, these feelings could be related to the belief that everything depends on the decision of the healthcare worker as well. Therefore, the healthcare worker alone could be held accountable for the health outcome of the patient he or she treated. This instantly provides the healthcare worker with feelings of god-like qualities like omnipotence and omniscience, since he or she thinks he or she can save the patient on his or her own, without the influence of external factors, as Aird (2012) assumes. Next to the link with anxiety, Sackett (2002) argues that arrogance also has a link with primary healthcare. Arrogance in primary healthcare is argued to have three characteristics. Firstly, it is aggressively assertive. This characteristic represents the phenomenon relating to the pursuit of individuals who do not suffer from any kind of disease symptoms, and ordering them to do what must be done, in order to maintain their health. Secondly, arrogance in primary healthcare is presumptuous, for it has confidence in the fact that its interventions will improve health and decrease ill health to the individuals who follow the set guidelines. Finally, arrogance in preventive healthcare is overbearing, since it attacks the individuals who doubt the exact value of the given recommendations (Sackett, 2002). Additionally, Pronovost (2010) argued that arrogance is a result of mindless autonomy. When actions are acted out simply because a physician demands it, reliability is deemed to be of a lower interest to the result than autonomy. In these situations, arrogance is identified as a main flaw of the physician.

Furthermore, the ways in which arrogance may manifest itself are addressed by Berger (2002). In this article, examples such as a lack of respect and consideration are argued to be ways in which arrogance is shown by an individual. Additionally, a lack of good manners towards nurses, patients and other medical staff is also identified as a manifestation of arrogance. Finally, being abusive or critical of subordinates is addressed as a last outcome of arrogance among medical staff. (Berger, 2002).

9

Tiberius and Walker (1998) present additional manifestations of arrogance. According to their article, the arrogant individual does not relate itself to most other people and the information provided by them. In the individual’s perception, others do not even have the capability to contribute anything to his personal pool of knowledge. This affects the relation with subordinates, as presented by Berger (2002). Rather the relationship between the arrogant individual and their superiors is influenced as well, since taking an uncritical stance towards the information received from the superior is very inappropriate and not morally responsible (Tiberius and Walker, 1998). The exact meaning, however, of the term “arrogance” in a healthcare context has yet to be elaborated, because limited literature is available on this matter. Therefore, the concept of arrogance needs to be thoroughly investigated, in order to formulate a clear set of criteria which are attributable to arrogance. According to Tiberius and Walker (1998) and Dillon (2007), the concept of this term is addressed in such a way, that a definition can be deducted by it.

Regarding this definition, the first thing that has to be acknowledged is that it is very important to understand that arrogance is a concept that is very much related to other concepts. These concepts comprise human morality, such as self-confidence, insecurity and vanity (Tiberius and Walker, 1998). Furthermore, arrogance is an interpersonal concept. This also proves the way society presents the negativity around arrogance. Due to the fact that morality standards which are present within the arrogant person differ from those manifested in society, the relationship between the two is perceived to be morally unhealthy and uneven (Tiberius and Walker, 1998).

Dillon (2007) elaborated upon the interpersonal aspect of arrogance. This kind of arrogance can be described as “a sense of overbearing self-worth or self-importance, marked by or arising from an assumption of one’s superiority towards others” (Dillon, 2007, page 103). She stated that this specific sort of arrogance presents four broad dimensions in the definition of this term. Firstly, one has a settled conception of the self in the sense of having a distinguished worth or significance, and a valued position that others cannot share. Secondly, one does not only value the self highly, one also places a higher value towards one’s own worth and status, which is both great and greater than others’. Thirdly, the inordinateness of the valuing of self in 10

relation to others. Fourthly, the manifestation of the own mindset in one’s attitude towards the treatment of - others is the final dimension in the definition of interpersonal arrogance (Dillon, 2007).

Besides interpersonal arrogance, unwarrantable claims arrogance is a distinctive kind of arrogance as well, as identified by Dillon (2007). This kind of arrogance can be described as “the taking of too much upon oneself as one’s right; the assertion of unwarrantable claims in respect of one’s own importance; undue assumption of dignity, authority, or knowledge; aggressive conceit, presumption, or haughtiness” (Dillon, 2007, page 107). This kind of arrogance has three broad dimensions. Firstly, its core lies at the disposition to arrogate, meaning to appropriate or lay claim to things of significance. Secondly, the things that are arrogated towards have to have a certain connection to great worth and high status. Finally, this kind of arrogance can operate on different levels and in a variety of ways. It can be expressed in an open way, however it mostly is more stealthy and subtle, e.g. by means of implicit expectations, or taking something as the truth before evidence or justification ever arose (Dillon, 2007).

The ways in which arrogance may manifest itself, presented earlier by Berger (2002), can be linked to the interpersonal aspect of arrogance as discussed by Dillon (2007). The actions of individuals represent their moral standards, and may therefore present arrogance on an interpersonal level (Berger, 2002).

Finally, Tiberius and Walker (1998) present arrogance as a certain sort of prejudice, as judgments of the arrogant individual will be brought with him or her to interactions with other individuals. This thereby hinders the arrogant individual from understanding the importance of other sources of knowledge and understanding presented by others in a meeting.

By means of the literature addressed in this chapter, criteria for the definition of the concept of arrogance are aimed to be constructed. This can be done by narrowing the several sources of information used in this chapter down to comprehensive statements suggested by each piece of literature. These statements offer criteria to understand the many facets the concept of arrogance has, and subsequently form a conceptual framework. This framework is to be used in order to place the information presented in the results section in a comprehensive context.

11

This is of great importance to the coherence of this paper. In conclusion, the overall definition of arrogance can be defined according to the following criteria: -

Arrogance is aggressively assertive, presumptuous and overbearing;

-

Arrogance is manifested in various ways, among which are a lack of respect, being abusive or critical of subordinates or valuing the information or knowledge presented by others as important to improve one’s own perception;

-

Arrogance is a concept which is closely related to other human moral concepts;

-

Arrogance can be subdivided into two sorts of arrogance o Interpersonal arrogance, which can be described as “a sense of overbearing self-worth or self-importance, marked by or arising from an assumption of one’s superiority towards others” (Dillon, 2007) o Unwarrantable claims arrogance, which can be described as “the taking of too much upon oneself as one’s right; the assertion of unwarrantable claims in respect of one’s own importance; undue assumption of dignity, authority, or knowledge; aggressive conceit, presumption, or haughtiness.”

-

Arrogance can be presented as a prejudice. Arrogance causes relationships between individuals who have different beliefs towards morality to be uneven and morally unhealthy.

4. Methods In order to answer the sub-questions, this research was conducted using a comprehensive plan for the collection of information. The sub-questions and overall research question were answered by means of a literature review. In this literature review, Google Scholar, PubMed and Maastricht University quick search - a search engine displaying the literature present in the library of Maastricht University - (Maastricht University, 2014) were used.

In this literature review, a set of keywords closely related to the concept of arrogance were used, as presented in the conceptual framework chapter. These search terms are ‘arrogan*’, ‘disdain’, ‘doctor disdain’, ‘self-respect’, ‘arrogance doctor’, ‘doctor patient arrogance’, ‘medical arrogance’, ‘disdain medical errors’, ‘doctor’s arrogance’ and ‘arrogance health’. Furthermore, combinations of these search terms were used in order to narrow down search results. This provided the author with a more comprehensive file of search results. Additionally, in- and exclusion criteria were defined in order to select an appropriate set of

12

articles to conduct the literature review in the most efficient way. An inclusion criterion was the close relation to healthcare. Exclusion criteria were the focus on arrogance related to non-health sectors, only an abstract of the article was available, the article was not written in English or Dutch, or the article was not related to Western societies. After all, e.g. African or Asian perceptions on arrogance may differ too much from the type of arrogance addressed within this thesis. Time limitations were not included in the in- or exclusion criteria, since the differences of the aspect of arrogance throughout time were a needed source of information in order to answer the last sub-question “How is the concept of arrogance in healthcare subject to changes throughout time?”.

Finally, in the search for literature, snowball sampling was used to create a comprehensive overview of articles on the matter of arrogance in healthcare.

This study was conducted by means of a qualitative literature review. This research is explorative (Monroe College, 2011). Therefore, by means of the qualitative literature review, the possible issues surrounding the presence of arrogance will be attempted to be defined. Subsequent analysis was done by reading the abstract - if available - and by scanning for key terms, such as ‘arrogance’, ‘disdain’ and ‘self-respect’. Significant parts on relevant subjects to the thesis were highlighted and made notes of. These highlighted sections were subsequently summarized by writing down their main thought and categorised per subquestion to be able to create a comprehensive base for the results section. Furthermore, the findings were linked to the conceptual framework by means of attributing its categories to the kind of arrogance found in the literature. The process of attributing, however, took place whilst formulating the answers to the sub-questions. This will be discussed in the limitation section in the chapter regarding the discussion. Summarising the given information from the articles is important, in order to keep the results section of the thesis comprehensive and concise. It is of great significance to the clarity of the thesis to arrange and appraise information in the right order and structure, to guide the reader through the research in the most optimal way.

5. Results In this chapter, the results of the literature analysis of arrogance in healthcare are presented.

13

Firstly, the literature search results are presented. Secondly, by means of these results, the effect of arrogance on the sector and on the individuals affected by this phenomenon will be presented. Subsequently, this literature will serve to thoroughly answer the following subquestions: “How does arrogance among medical staff affect relationships between the doctor and their patients?”, “How does arrogance among medical staff affect relationships among them and how does it affect relationships between healthcare institutions?”, “How does arrogance affect the quality and trustworthiness of healthcare?”, “How does arrogance affect the effectiveness of the communication between healthcare sectors represented by doctors, and other sectors represented by other professions?”, and “How is the concept of arrogance subject to changes throughout time?”. Therefore, these sub-questions will be used as independent headings in the results sections. This will provide the reader with a comprehensive overview of the questions and their individual answers.

The literature was analysed via reading the title and the key terms included in the search results. Via this method, the amount of articles found under e.g. “arrogance AND health” was reduced from 49.900 to two relevant articles. The author did, however, not appraise all of these 48.898 articles included in the search results. The search provided the author with interesting results on the first pages of the search results. Therefore, the titles and their key words were read and appraised, up until the page where the search results were not applicable to the exact search terms anymore. The initial search query provided the research with the results found in table 1. Therefore, this table does not represent the amount of articles which were incorporated in the thesis, it merely represents the amount of articles that were analysed in the aforementioned manner, after the search results were corrected for a specific inclusion criterion.

PubMed (title or abstract)

All

In either Dutch or English

Arrogance

151

135

Google Scholar

All

In either Dutch or English

Arrogance AND Health

102.000

49.900

Arrogance AND Doctor

89.600

35.900

Doctor AND patient AND arrogance

51.500

17.700

14

Patient AND Arrogance

58.600

28.300

Doctor AND Disdain

88.100

34.100

Medical AND Arrogance

77.100

37.900

Disdain AND Medical AND Errors

38.700

18.200

Doctor’s AND Arrogance

27.100

16.500

Maastricht University quick search

All

In either Dutch or English

Arrogance

48.757.199 42.305

Table 1, Literature search results.

This table identifies the search terms the author has worked with, and how many search results they have provided the author with in different search engines. The table also shows how many of these results were written in either Dutch or English, since articles were excluded when they were not written in either of these two languages, as can be read in the methods chapter. The articles left after the incorporation of these criteria were subsequently appraised by means of the methods mentioned before this table.

5.1 How does arrogance among medical staff affect relationships between the doctor and their patient? According to Calman (1994), doctors have three broad roles. Firstly, they need to provide their patients with care of a high quality. They need to be particularly concerned with diagnosis, prognosis, treatment, the planning of the care that is to be received by the patient, and the communication of these matters to the parties involved. Secondly, a doctor needs to be concerned with the individual and the entire community. Finally, he or she needs to manage resources in an effective way, including acquired skills, time, finance, and facilities.

Furthermore, in the article written by Berger (2002), the effectiveness of communication between patients and doctors is argued to be negatively influenced by arrogance. Examples to support this statement are that arrogance of the individual causes a lack of proper respect in general, and causes bad manners towards nurses, patients and ancillary staff. (Berger, 2002)

15

Additionally, the arrogance of doctors does not only affect a particular doctor, patient, or nurse. In the article of Kasteler (1976), the behavior of doctors is characterised as an underlying issue causing doctor shopping behavior. Patients that show this behaviour, virtually go out ‘shopping’ for another doctor when they are not satisfied by the performance of their own physician. In a research conducted by Vuori et al. (1972), several years before Kasteler’s research (1976), the prevalence of this phenomenon was emphasised. 73 per cent of the seven hundred respondents in the investigation reported they would return to their doctor, leaving 27 per cent who would not return. Arrogance is regarded as an important matter causing this specific kind of behaviour. In the study of Kasteler (1976), which was conducted as a follow-up to this investigation, personal qualities of doctors were proven to be of a great importance in both lower- and upper- income groups when it came to deciding whether to shop for another doctor or not. Therefore, the first half of one of the hypotheses stated in this research, namely “patients who are not favourably impressed with their doctors personal qualities or who are hostile towards him will be more likely to seek the advice at some other physician than those who like the doctor as a person” (Kasteler, Kane, Olsen, and Thetford, 1976, page 329) has been proven to be true among lower- and upper income groups. However, the second half of the hypothesis on hostility is only true for upper-income groups. These findings therefore confirm a negative development concerning the acceptance of the services of a doctor as arrogance increases, among both lower and upper income groups. In the past, the physician chose whether to treat the patient or not. However, in the future, the patient will decide whether he or she would like to be treated by a specific doctor (Kasteler, Kane, Olsen, and Thetford, 1976). This may have negative consequences for public health, since a majority of individuals do not have a high degree of health literacy. Therefore, they may have difficulties deciding for themselves whether they need care or not (Sørensen , 2013).

In conclusion, arrogance among medical staff affects relationships between the doctor and their patient negatively. Due to the fact that an arrogant doctor may not treat his or her patient in a well-behaved way and does not show a sufficient level of respect (Berger, 2002), the patient may not have a good relationship with his or her doctor. Even more so, when they feel mistreated by their doctor, they are very likely to go ‘shopping’ for another doctor, leaving the patient with a possible – increasing - level of mistrust at every doctor they visit since they do not tend to trust their caretakers automatically anymore. Consequently, it may be argued that the attitude of the doctor may also be affected in a negative way due to the phenomenon of 16

doctor-shopping. As mentioned before, patients who show this behaviour, virtually go out ‘shopping’ for another doctor when they are not satisfied by the performance of their own physician. This may cause doctors to take the health problems introduced by their patients less seriously, after they have seen another professional in the field already. 5.2 “How does arrogance among medical staff affect relationships among them and how does it affect relationships between healthcare institutions?” Not only communication between patients and doctors is affected negatively because of arrogance. In the article of Pronovost (2010), it is stated that the communication among medical staff is affected negatively as well. A nurse questioning a doctor induces embarrassment or shame to the doctor. Therefore, many nurses refrain from questioning the doctor. This may lead to a lack of communication on the work floor between these professionals, causing mindless actions in healthcare, due to a lack of a clear rationale regarding the care which is to be provided to the patient.

This phenomenon does not limit itself to the actual questioning of the doctor. When a doctor does not act according to set guidelines, the article states that “there is no way the nurse would speak up” (Pronovost, 2010, page 204). These hierarchies are primarily driven by arrogance from the doctor, causing psychological subordinance of the nurse. Arrogance, therefore, is a result of overdone autonomy. When autonomous actions are mindless instead of mindful, they are very likely to be driven by arrogance.

The hierarchical relationship between doctors and nurses is reaffirmed by the study of Rudland and Mires (2005), in which medical students assess the sources of difficulties between doctors and nurses.

Table 2: Sources of difficulties between doctors and nurses (Rudland and Mires, 2005) 17

As can be seen in table 2, 83 comments were made on the attitude of professions, more specifically, the superiority and arrogance of doctors. Therefore, 26.18% of the total amount of comments in this investigation regarded the superiority and arrogance of doctors. This quote explicitly proves that this sub-question can be answered by stating that the relationship between healthcare personnel, or at least doctors and nurses, is affected negatively by the presence of arrogance (Rudland and Mires, 2005).

Furthermore, junior medical students assessed doctors involved in this study as significantly more detached, confident, arrogant and dedicated compared to nurses. Nurses were considered to be more dithering and caring (Rudland and Mires, 2005). This statement can be linked to the role of doctors. After all, a doctor’s aim is to save peoples’ lives and fight mortality (Berger, 2002). These characteristics can be of great use in fulfilling these aspirations.

Additionally, Caplan (1994) stated that not only the relationship between healthcare staff within one healthcare institution in particular is affected. As an example, it is stated that physicians have a low level of psychological or economic motivation to involve themselves in resource-intensive and time-consuming efforts to recover tissues or organs, when the patients and transplant teams who benefit from their efforts are located hundreds of miles away. Therefore, distance between one healthcare institution and another may cause ignorance when it comes to serving a greater purpose. This ignorance may lead to mistrust and arrogance between institutions, which are definite negative effects. Even more so, since the so-called psychological motivation of the doctor may also be influenced by arrogance, it is no surprise that Calman (1994) states the importance of decreasing the amount of fragmentation within the healthcare sector, and emphasises the need to become more integrated and collegiate within the healthcare sector, in order to improve cooperation between branches of the profession. The psychological motivation of the doctor namely determines his or her commitment to their job. Arrogance and increased fragmentation within the healthcare sector may influence this commitment, since doctors may feel less dedication towards helping patients they do not treat themselves.

To conclude, the relationship between doctors and nurses is affected negatively by arrogance. It is stated by Rudland and Mires (2005) that, due to arrogance, doctors deem nurses inferior 18

to them. Therefore, their relationship is not in an optimal state. Furthermore, distance between healthcare institutions, and the psychological motivation of their doctors - which may include arrogance - influences the relationships between healthcare institutions as well as the care they provide within their own institutions.

5.3 How does arrogance affect the quality and trustworthiness of healthcare? In many articles, the negative effects of arrogance on the nobility of the medical professions and its quality are addressed (Berger, 2002, Pronovost, 2010, Rudland, 2005, Dyer, 2000). Furthermore, Berger (2002) stated that there has been significant negative publicity on the mistakes of physicians, their greed, self-serving behaviour and their wealth. Therefore, the increasing public awareness and literacy on both medicine and health is the cause of an informed and questioning consumer. Thus, there are more phenomena which ‘degrade’ physicians from their almighty position. This shows us that, to a certain extent, the media have an influence regarding this matter as well.

The case presented by Dyer (2000) can be taken as an example regarding these matters. In 2000, a severe scandal regarding the retention of organs of deceased children without the consent of parents made it into the British Medical Journal. In this article, this specific behaviour, that routinely took place for years, was blamed on the arrogance of doctors.

However, it did not take long before it became apparent that this behaviour was not confined to this city only. Apparently, pathologists throughout the entire nation kept the organs of children after coroners had performed postmortem examination (Dyer, 2000). This example presents the negative effects of the arrogance of doctors on the trustworthiness of healthcare. The phenomenon regarding the retention of organs without any consent may be related to arrogance, since doctors may value their own research above the will of others. This is related to the concept of interpersonal arrogance, as mentioned in the conceptual framework. It can be described as “a sense of overbearing self-worth or self-importance, marked by or arising from an assumption of one’s superiority towards others” (Dillon, 2007). This example closely relates to the overbearing self-worth or self-importance, and the feeling of the superiority of the doctor towards, in this case, parents. After all, parents were said to be ‘devastated’ when they discovered they had buried their children with one or more organs missing. It has, however, been stated that pathologists have

19

realised their actions were no longer acceptable, and therefore stopped retaining organs. However, this statement may be doubtful.

The confidence in healthcare may have been seriously damaged after these scandals were made public. Even more so, there still are doctors who disagree with the individuals who state that actions like these are not acceptable. As an example, Hoffenberg (2001) can be mentioned. He was involved in retaining organs in a disputable manner. Hoffenberg (2001) states “I don’t regard the removal of tissues at autopsy for later study as evil or shocking or gruesome”. He did receive a written consent for the autopsy from the coroner. He, however, did not receive such consent from the relatives of the involved individual. Furthermore, he states that he does not see the use of informing them about details of the tissue and the organs that are going to be retained, what they will be used for, and the time span for which the organs can be retained (Hoffenberg, 2001). These kinds of perceptions on the matter could damage the trustworthiness of healthcare negatively.

This is not the only negative news related to the presumed arrogance among medical staff. Pronovost (2010) related more negative news to the presence of arrogance. His article stated that the overconfidence of physicians about the quality of care they personally provide has led to a significant amount of medical errors. This article spoke of 100.000 patient deaths of healthcare-associated infections, tens of thousands deaths due to diagnostic errors and 44 000 to 98 000 deaths due to other preventable errors. Doctors tend to believe their decisions simply cannot lead to negative health outcomes; evidence is not taken seriously and doctors believe they alone have the sufficient skills and knowledge to provide care. Therefore, teamwork is regarded as unimportant and communication problems arise from the presence of personal arrogance, which subsequently causes harm to patients. This development is currently not subject to any changes, at least not within the United States, since the healthcare culture in this country still does not offer a good platform for the questioning of physicians’ behavior. However, Pronovost (2010) also states that physicians are often sleep deprived, overworked and rushed. Furthermore, they are not offered sufficient training on conflict resolution and teamwork. Therefore, they cannot be totally blamed for these medical errors. In order to improve the situation, healthcare professionals must be taught to train physicians in accepting that they can make mistakes. Additionally, they have to teach physicians how to ensure their competencies and role model their behaviour, support social and emotional development, and finally, hiring physicians who 20

have competencies in relating to other individuals. After all, when it comes to preventable negative health outcomes, the context in which the care is delivered to the patient has a bigger influence on the health outcomes than the physicians who actually treat the patients. In this way, the responsibility is a shared one between physicians who can be held responsible for their clinical behaviour, and healthcare leaders who can be held accountable for patient outcomes (Pronovost, 2010). Berger (2002) stated that doctors perceive death as ‘the enemy’. The doctor pictures himself as the hero overcoming the inevitable, namely death. This can be related to the ancient myth stated in the introduction of this thesis. In this myth, “Gorgon’s blood” was said to be used by Asclepius to bring a patient back to life. This relates to the perception of the doctor as a hero, who is meant to overcome death. Its negativity is mentioned in the myth using a statement made by Hades, who agreed with Zeus that it should be acknowledged that all doctors painfully must learn that they have to let their patient go at some point. (Weishaus, 2006). Denying the inevitable, namely death, fosters the use of elaborate procedures which are unwarranted, and trying heroic measures to prolong the life of the patient, sometimes against his or her will. This may affect the quality of life of the patient in a negative way. They may, in some way, be forced to live longer and to be subjected to intensive healthcare procedures against their will. When a patient wishes to end their life peacefully, outside of the hospital, these wishes may not be respected.

Furthermore, Aird (2012) presents more flaws regarding the phenomenon in which doctors perceive themselves as heroes or “high priests of the god of health”. If doctors present themselves as all-knowing entities, the human mistakes they make will be regarded as severe ones. Therefore, the representation of doctors as heroes, impose others, who do not see themselves as heroes, with a high pressure to perform. As an example, a patient with a headache can be presented. When the patient goes to the doctor presenting symptoms of a normal headache, the patient will be sent home with the advice to take two aspirins. However, if the patient turns out to have a brain tumour, the doctor will be held responsible, even though he or she could never have diagnosed the patient without the appropriate material, such as an MRI scanner, immediately available. In Sackett’s article (2002), the trustworthiness of healthcare is also infringed in the area of preventive healthcare. The author directly places the blame for this phenomenon on so-called 21

medical experts, “who, to gain private profit from their industry affiliations, to satisfy a narcissistic need for public acclaim or in a misguided attempt to do good, advocate ‘preventive” maneuvers that have never been validated in rigorous randomized trials” (Sackett, 2002, page 364). He concludes his article by stating that experts do not learn from history, until they make an addition to it themselves. The price for their actions is paid by the innocent patients whom they treat.

As may become apparent by addressing the negative health outcomes presumably caused by arrogance, research needs to be dedicated towards improving the situation surrounding arrogance in healthcare. In this sub-question, its presence and effects have merely been discussed. The article of Rudland and Mires (2005) could already provide the researcher with a starting point towards improving this matter. It provides the reader with guidance as where to start solving the difficulties regarding crooked relationships among doctors and nurses by means of the comments made by 353 students regarding arrogance. In these comments, 139 comments went into methods of improved education, 114 comments were made on better communication, 81 on an improvement in attitudes, 73 on earlier team working and finally thirty on an improvement in working conditions of healthcare staff. Furthermore, the article written by Sackett (2002) may provide the researcher with a good example of outcomes of interventions made based on these kinds of comments. In his article, he states that he tells his patients, he promises them to only do his best, but never guaranteed that his interventions would cure them from their diseases (Sackett, 2002). After all, in each treatment, uncertainties are involved. One of the skills within the profession of medicine is to be able to constructively communicate these uncertainties to the patient. (Calman, 1994). Improving these matters using these methods may affect the quality and trustworthiness of healthcare in a positive way.

To conclude, the trustworthiness and quality of healthcare is affected negatively by doctors’ arrogance. The retention of organs without having a written consent for this action was attributed to doctors’ arrogance, as are high numbers of medical errors due to the overconfidence of doctors. Subsequently, the overconfidence of doctors and the belief of the patient that their doctor will solve everything without making any mistakes leaves doctors with an enormous pressure to achieve high-set aims. Improving the trustworthiness of healthcare is an important matter, since this particular profession has a special relationship with its patients. This relationship needs to be based on 22

common ethical grounds, such as manners and social standards, since it is self-regulating and is to be held accountable to both the patients and the profession within healthcare itself. Improving and promoting both characteristics could lead to an improvement of confidence in healthcare and its credibility (Calman, 1994). This can be done by means of the comments made by 353 students regarding arrogance in the study of Rudland and Mires (2005). Furthermore, providing good examples, such as the one set in the article of Sackett (2002), is an important matter in improving the current situation as well.

5.4 How does arrogance affect the effectiveness of the communication between healthcare sectors represented by doctors, and other sectors represented by other professions? In Caplan’s “Professional Arrogance and Public Misunderstanding” (1988), another negative aspect of arrogance within the healthcare sector is presented. It is stated that arrogance negatively affects the effectiveness of communication between the healthcare sector and the political sector. It is stated that physicians resist complying with new laws, at least in the USA. However, the existence of this phenomenon in the USA may indicate its worldwide existence. In the example taken by Caplan (1988), rates of compliance with a new law on organ transplantation did not exceed fifty per cent. Apparently, this non-compliance presented by physicians appears to be a primary result of the resentment held by physicians against those who are not physicians. To be more specific, physicians hold a resentment against legislators and bureaucrats, who tell physicians what to do. Physicians appear to have a disdain towards governmental attempts to regulate the practice of medicine (Caplan, 1988).

This article, however also takes a closer critical look at the statements made regarding these compliance rates. The factors mentioned might not be the only cause of such a low compliance rate, according to Caplan (1988). No state in the United States of America has provided a close to adequate level of professional education to the healthcare staff. This may however be needed, since they bear the task of requesting the family of the patient to think about organ donation (Caplan, 1988). People practicing this profession should be educated in making such emotion-laden requests. Organ transplantation and required request has not yet seen the importance of putting ethical concerns first, by training healthcare professionals. They need to feel comfortable with laying their priorities in other patients who can still be saved, instead of their own patients who are dying or have already died. Until healthcare staff has been provided with these resources, the clinical, ethical, and legal impact of required request will remain unknown (Caplan, 1988), and compliance rates by means of the 23

enforcement of these laws cannot increase. Only when this is done, the compliance rate with these laws can constructively be increased.

Additionally, there are other interesting remarks that can be made regarding the low compliance rate. Healthcare staff often claimed that the lack of tissue donation was due to the lack of awareness of the population towards the need for organ procurement (Caplan, 1988). However, opinion surveys prove the exact opposite. These surveys state that the public apparently is fully aware of the need for transplants (Caplan, 1988). It therefore may be speculated that the public simply is not ready to make an informed choice on whether to donate their organs or not. This may also lead to low organ donation rates.

The article of Caplan (1988) is not the only article that reflects these thoughts on communication between individuals practicing different professions. Quinn, Anderson and Finkelstein (1996) reaffirmed that members of every profession use their peers as examples in determining their own acceptable standards of performance and codes of behaviour. However, it is stated that they often refuse to accept thoughts and evaluations presented by individuals working outside their discipline. In the healthcare sector, this phenomenon is specifically reflected by basic doctors who disdain researchers, since they think they do not understand causation. Physicians disdain researchers and nurses who subsequently “do not understand practical variations among real patients” and “who do not understand the discipline”. Nurses disdain both researchers and doctors since they have the impression they “lack true compassion”. All three groups disdain administrators, who are seen as “nonproductive bureaucrats”. This last assumption is again reflected in the aforementioned article of Caplan (1988).

Since medicine and healthcare are increasing in complexity, it becomes more and more necessary to communicate and relate to other sectors. Working in teams with different professions could improve the current situation tremendously. Furthermore, for Calman (1994) the idea of integrating and being more collegiate even within the healthcare sector, throughout different branches, is certainly worth considering. Especially the connection between primary and secondary care is one worth improving (Calman, 1994). Furthermore, mutual understanding and respect for professional roles outside healthcare need to be improved. The article of Rudland and Mires (2005) emphasizes that negative professional stereotypes are still present within interprofessional relations. Improving these 24

conditions would provide society with comprehensive solutions to current problems, to be implemented throughout different sectors. After all, according to the medical imperialism thesis, medical institutions are expansionist in nature. Therefore, they will keep on growing and intertwining with other sectors (de Swaan, 1989). During this process, issues such as arrogance have to be overcome in order to prevent both issues of legitimation and issues of doctors deeming themselves superior to individuals working in other professions.

To conclude, arrogance negatively affects the relationships between the healthcare sector and other sectors, where other professions are prevalent (Caplan, 1988, Quinn, Anderson and Finkelstein, 1996). Furthermore, literature has suggested that arrogance also negatively affects relationships between professions within the healthcare sector. Since physicians appear to have disdain towards professions who try to regulate their profession, their relationships are influenced in a negative manner. Additionally, specific kinds of disdain can be found within relationships between healthcare staff, researchers, nurses and administrators. It is very important to overcome these issues, in order to provide society with comprehensive to current problems, not only in healthcare, but also outside this sector.

5.5 How is the concept of arrogance in healthcare subject to changes throughout time? It is important to note that the concept of arrogance and the presence of arrogance as a phenomenon in healthcare is one that has changed over time. However, the ways in which time was of significance is viewed differently in different sources of literature.

Berger (2002) stated that in an earlier era, professors presented their students with a better example, by learning them the qualities of ethical behaviour and humility in healthcare. The development of sociological and psychological factors throughout time has influenced the persistence of doctors’ arrogance, which was mainly related to their preferred position within society. Sociologic elements that evolved negatively throughout time induced a lack of proper respect in general, bad manners towards nurses, patients, and ancillary staff.

However, in contrast with earlier times, physicians are less likely to be idealised in modern times. The relationship between the patient and the doctor has depersonalised and the patient is more likely to be seen as a job to be dealt with instead of a person. Furthermore, patients also behave more like consumers of healthcare in contemporary society (Berger, 2002). 25

These developments created a systematic arrogance within healthcare (Berger, 2002). It may even be argued that the arrogance of doctors may be a reaction to their decrease in status. Moreover, according to Berger, arrogance in healthcare is a concept that arose due to a lack of good role models. Subsequently, systematic arrogance in healthcare arose due to the lower likelihood of idealisation of doctors and their attitudes towards patients.

Hoffenberg (2001) also emphasizes the preferred position of doctors within society in earlier eras. However, he presents the opposite development compared to Berger (2002). Hoffenberg states that certain deficiencies present in doctors may reflect arrogance. He stated that to the extent that these deficiencies still exist, they are mere exceptions compared to the situation fifty years ago. In those days, doctors rarely involved patients in the care they were about to receive. They discouraged questioning of the doctor by telling their patients they should leave it to them, since they were doctors. Military hierarchy was a much followed phenomenon in a lot of hospitals, where junior staff and nurses subordinately followed the hospital consultant on his daily ward round. Nowadays, the exaggeration of the media is also of significant importance to the impression of this phenomenon in society. However, it must be admitted that arrogance is still present within the healthcare sector and cannot be tolerated (Hoffenberg, 2001).

Finally, in the article of Weishaus (2006) on philosophy, ethics, and humanities in medicine, the statement made by both Hoffenberg and Berger is reaffirmed. Weishaus states that in earlier eras, people were more likely to look at their own family doctor like their one and only savior. In this article, Weishaus (2006) explains that his family doctor was somewhat appraised like a god by his family. Their doctor was perceived to possess arcane knowledge that shepherded their family safely through dark valleys of illness. Picturing one’s doctor as a god may have led to an increased level of arrogance of that very same doctor, as already has been stated in the article of Tiberius and Walker (1998).

To conclude, time is of great importance when looking at the development of the definition and meaning of arrogance in healthcare. However, opinions differ in the way in which this phenomenon has an influence. Hoffenberg (2001) and Tiberius and Walker (1998) state that doctors were significantly more arrogant in earlier times compared to the modern age. However, Berger (2002) states that arrogance is a result from negative developments in 26

sociological elements, therefore stating that arrogance is increasingly prevalent in current society. What can be deducted from these conclusions drawn by separate authors is that the phenomenon of arrogance may have acquired different meanings throughout time, and is increasingly influenced by the media, as stated by Hoffenberg (2001). What may have been seen as the legit superiority of the doctor to the patient fifty years ago, may currently be identified as arrogance.

6. Discussion The statements made in the results section should be placed in a relevant perspective. In order to provide the reader with this perspective, weaknesses, limitations and strengths of the results section will be discussed. Finally, it will go into factors possibly influencing the outcome of this study.

6.1 Limitations 6.1.1. Definition of arrogance Firstly, the same definition of arrogance is not used throughout every piece of literature. Even though the definition is given in the conceptual framework chapter, this does not automatically mean that every author has agreed upon incorporating arrogance in this specific way whilst writing his or her article. This issue can already be seen in the last sub-chapter of the results regarding the influence of time on the matter of arrogance. Different authors may have different perceptions on what can be related as arrogance, and what cannot be related to this concept. This is due to the fact that arrogance is a phenomenon which is subjected to personal experience, knowledge, and values. This forms a limitation to the research, but also forms an interesting point for discussion, and later research in this field.

The conceptual framework provided in this study can be used to appraise the way in which articles relate to the given criteria which can be attributed to this concept. This is of great importance, in order to interpret the results given in the previous chapter in the context of this study. The overall definition of arrogance can be defined according to five criteria. Firstly, arrogance is aggressively assertive, presumptuous and overbearing. Secondly, arrogance is manifested in various ways, among which are a lack of respect, being abusive or critical of subordinates, or valuing the information or knowledge presented by others as important to improve one’s own perception. Thirdly, arrogance is a concept which is closely related to 27

other human morality concepts. Fourthly, arrogance can be subdivided into two sorts of arrogance. The first sort is interpersonal arrogance, which can be described as “a sense of overbearing self-worth or self-importance, marked by or arising from an assumption of one’s superiority towards others” (Dillon, 2007, page 103). The second is unwarrantable claims arrogance, which can be described as “the taking of too much upon oneself as one’s right; the assertion of unwarrantable claims in respect of one’s own importance; undue assumption of dignity, authority, or knowledge; aggressive conceit, presumption, or haughtiness” (Dillon, 2007, page 107). Finally, arrogance can be presented as a prejudice. Arrogance causes relationships between individuals who have different beliefs towards morality to be uneven and morally unhealthy. When we have a closer look at these aspects attributed to the concept of arrogance, we see that some of them are not taken into account in every article. In the article of Rudland and Mires (2005), many aspects of arrogance as mentioned in the conceptual framework are addressed. The ability of arrogance to manifest itself in various ways, including a lack of respect and being abusive or critical to subordinates, and its presumptuous and overbearing nature is firstly addressed. After all, in this article, it is stated that doctors who present an arrogant attitude towards nurses, induce them with a grudge against doctors; they feel subordinate due to the lack of respect from doctors. Furthermore, its relation to interpersonal arrogance is also addressed. The arrogance of the doctor is namely closely related to “the sense of overbearing self-worth or self-importance marked by superiority towards others” (Dillon, 2007, page 103). Finally, the arrogance presented in this article can be interpreted as a prejudice, since it stipulates that, when one doctor confronts a nurse with arrogant behaviour, arrogance can be attributed to every doctor by this nurse, which is closely related to the creation of prejudices. However, this article does not address the relation to other human morality concepts and unwarrantable claims arrogance, which are the remaining two characteristics of the concept of arrogance.

The example taken from the article written by Rudland and Mires (2005) is not the only one which shows that not all characteristics of arrogance are taken into account in every analysed article in the results section. This is also true for the article written by Berger (2002). In this article, it is stated that arrogance of the individual causes a lack of proper respect in general, causing bad manners towards nurses, patients, and ancillary staff. Therefore, this article states the importance of the ability of arrogance to manifest itself in various ways, among which a lack of respect. Furthermore it presents arrogance as a cause for bad manners towards nurses, 28

patients, and ancillary staff. This corresponds with the concept of interpersonal arrogance, since this is “a sense of overbearing self-worth or self-importance, marked by or arising from an assumption of one’s superiority towards others” (Dillon, 2007). However, the characteristics of arrogance related to human morality concepts and prejudice are not discussed in this article.

In some articles, such as the one written by Kasteler (1976), merely the effects, not the characteristics of arrogance are not discussed. Therefore, the limitations which already have been presented in this discussion are emphasized by this article. After all, when incorporating articles that do not stipulate the characteristics attained to arrogance at all in the results, differences in interpretation of the term “arrogance” may arise.

6.1.2. Importance of time in the definition and meaning of arrogance in healthcare. Time is of great importance when looking at the development of the definition and meaning of arrogance in healthcare. Therefore, the definition of arrogance and the articles used in this paper, may not thoroughly reflect the current situation regarding this matter. The study of Kasteler (1976) was conducted in the year of 1976, leaving a lot of space for a change of this phenomenon up until now. However, no recent literature has been found to give an update on this matter which is to be placed within the last decades. The most recent literature incorporated in this study was dated around 2000. This may indicate a lack of interest regarding this matter during the last few years, or at least in the articles written in English and Dutch. More research should be done in order to provide an update regarding arrogance in healthcare in its current form. This is increasingly important, since the impact of modern ways of communication has increased. Social media and the overall existence of the internet, allowing people to access and appraise a bigger variety of information, may have a great impact upon healthcare. People are able to educate themselves regarding the care they receive, and from whom, in an easier way. Therefore, patients can increase their health literacy, as defined in the article written by Sørensen (2013). However, the accessibility of information and the freedom to publish any kind of information on the internet may also have negative influences upon the education of lay people. Individuals are able to spread their ideas in any way they wish to express them, even if these ideas are biased or disputable. This may lead to the spread of prejudices and false information regarding healthcare, its quality, and the possible degree of arrogance within healthcare.

29

6.2 Methods and subjectivity regarding interpretation In this research, only papers written in either English or Dutch were assessed. In articles written in other languages, different perspectives could be presented about this issue. However, they could not be appraised by the author due to language limitations and were therefore not incorporated in this research. Due to the fact that arrogance is a matter which is closely connected to values, often determined at a local base, this may constitute an information bias.

Furthermore, the interpretation of this subject by means of a literature review may also have influenced the results of this study. A matter which often coincides with the intuition, values, and feelings of individuals, may be hard to write down in a comprehensive manner. This study had its time limitations, and the author was not able to perform a qualitative research by means of interviews and qualitative analysis. Therefore, its results could be less conclusive compared to studies performed with the incorporation of qualitative analysis of interviews with the involved parties. Additionally, closely connected to the previous statement, is the interpretation of the articles of the author herself. Due to the fact that the author has own perceptions, values, and interpretations regarding the matter of arrogance, these factors may have influenced the outcome of this study without being noticed by the author. Finally, this study is only applicable when its perspective remains within the healthcare sector. Since this sector was used as a starting point, this research cannot be interpreted in a proper way when another sector - such as marketing - is taken as a baseline.

Therefore, there are several limitations to this study. Firstly, the same definition of arrogance is not used throughout every piece of literature. Thus, there are limitations to the extent to which conclusions can be drawn based on a set of different articles. Secondly, there are situations in which arrogance is not the only factor influencing the various aspects in healthcare, addressed in the sub-questions, influencing the outcome of the intervention, as can be seen with regard to the work of Caplan (1988). Thirdly, time is a limitation in this study, since arrogance is a concept that is highly influenced by time - as has been proven in the answer to the last sub-question. Since there is a lack of articles from the last ten years, the concept may have changed and, therefore, have influenced the effect of arrogance in healthcare. Fourthly, only papers written in either English or Dutch were assessed in this study. Additionally, the interpretation of this subject by means of a literature review may also have influenced the results of this study. This is firstly caused by possible difficulties in 30

writing about matters which often coincide with the intuition, values, and feelings of individuals, such as arrogance. Secondly, the author’s own perceptions, values, and interpretations regarding the matter of arrogance is a limitation to this study. Finally, this study is only applicable in the healthcare setting. When it comes to other professional branches, the facts presented in this study may not be relevant.

6.3 Strengths However, next to limitations, this study also has its strengths. Many aspects of the presence of arrogance in healthcare have been presented by means of an extensive amount of subquestions in this thesis. Therefore, the presence of this phenomenon throughout the entire healthcare system, and even its effects outside this sector, has been discussed. This provides the reader with a comprehensive overview of this phenomenon in this sector, not merely focusing on details such as doctor shopping behaviour. In this thesis, these matters are incorporated into a bigger perspective, enabling the reader to have a better overview regarding the current situation.

Furthermore, by incorporating a chapter on the characteristics of arrogance, a proper way to define arrogance has been presented. The characteristics discussed in this chapter have provided the reader with a clear overview of the criteria according to which arrogance is to be understood in this study. Additionally, the way in which the term “arrogance” should be placed in a comprehensive perspective throughout the study is presented. Where some studies completely lack a chapter on this matter, such as the one of Kasteler (1976), this study manages to grasp the essence of the term “arrogance”. This provides this study with a decent conceptual framework, where others may lack one. This framework may also be used in future research. This is necessary, as can be seen in the limitations regarding the definition of arrogance, presented earlier in this discussion. This section emphasized that only a selection of articles used a certain set of these criteria in their appraisal of arrogance. Some of them did not incorporate any of the given criteria whatsoever.

6.4 Factors possibly influencing the outcome of this study Additionally, there may be factors that might have influenced the outcome of this study. Besides the limitations stated at the beginning of this discussion, more factors may be involved when it comes to assessing the situation surrounding arrogance in healthcare.

31

It has been stated in the article written by Rudland and Mires (2005), where students assess the sources of difficulties between doctors and nurses, doctors deem the nurses to be inferior to them. However, in the article of Pronovost (2010), it is added that physicians may not receive feedback from nurses due to cultural, social, educational, and financial differences. This does not automatically mean that doctors would not welcome the feedback which can be given by nurses.

Furthermore, one has to remain careful with attributing certain phenomena in healthcare to arrogance. Hoffenberg (2001) indicates the importance of scarcity within the healthcare sector. Priorities and limitations have already been established, and healthcare staff is left to make the decisions on how to allocate these scarce resources. Labeling these choices as being arrogant would disregard the efforts of the doctor, and “shows a poor understanding of the limitations of medical care” (Hoffenberg, 2001, page 340). Furthermore, Hoffenberg (2001) stipulates the influence of the media. This can especially be seen in the article by Clare Dyer (2000) regarding the retention of children’s organs, should also be taken into account before naming arrogance as the causal personal trait to the presented scandal or error.

6.5 Future recommendations There is a need for further research regarding this matter. Since arrogance does not only affect healthcare, it should be researched with regard to other sectors as well. Even more so, since arrogance may not only be a phenomenon present in doctors. It may as well be prevalent in e.g. lawyers and accountants. After all, it must not be forgotten that healthcare staff is not the only group of workers who are to care for patients within society. Of course, individuals practicing this profession require expertise when it comes to commitment and compassion towards their clients. However, they have no monopoly in investigations, care, research, or every kind of treatment. Therefore, the influence of arrogance on healthcare is not the only relevant thing to be discussed when it comes to finding solutions (Calman, 1994). As can be seen in the sub-question regarding the relationship between the healthcare sector and other sectors, arrogance has an influence that spreads beyond one sector only. Future research on the influence of arrogance in other sectors, such as the political or educational sector, is needed.

Additionally, more research on the impact of arrogance in an intersectoral perspective should be performed in the European Union. As can be seen in the article of Caplan (1988), the 32

compliance with laws on organ donation may be influenced by arrogance and disdain from one sector to another. However, Caplan’s research regards the United States of America. It is important to state the existence of this phenomenon, even when it takes place on another continent. However, it should not be neglected to research whether these phenomena are also present in the European Union.

Furthermore, projects such as the one conducted by Rudland and Mires (2005) need to be supported, since they alter the perceptions based on stereotypes throughout healthcare. Involving the perceptions that students bring to medical school and take to their internships is a step tackling the very base of the problem that arises between nurses and doctors identified in the article (Rudland and Mires, 2005). Not only students could be integrated in future research regarding this matter. Research should also be conducted on the incorporation and education of patients regarding the matter of arrogance in the healthcare they receive. The patient plays an important role in the process of appraising and dealing with the matter of arrogance in healthcare, since they are very much subjected to it. Their opinions should be mapped and researched, in order to provide good advice and education on this matter in the future. Finally, research regarding this matter could be used as feedback towards healthcare institutions such as hospitals. When the matter of arrogance in healthcare is properly mapped, hospitals may be able to provide their staff with feedback and education regarding their expected role towards their patients.

Additionally, more attention should be spent on researching the importance of arrogance among other professions within healthcare. In this thesis, only physicians, nurses, and doctors were taken into account. The study could be elaborated by including professionals such as dentists, surgeons, and psychologists.

Finally, qualitative research should be performed to create a comprehensive, practical, modern definition of arrogance that can be used as a base for writings regarding this matter. The most recent article regarding this matter dates back to 2007. The oldest article found, dates back to 1976. Therefore, there has been a gap of research regarding arrogance during the last seven years. Furthermore, there are no articles available in which an overview regarding both the definition and the importance of arrogance in healthcare and other sectors is presented. In order to be able to write articles with a comprehensive base regarding this matter, articles laying down the very foundation of this concept should be produced. 33

Especially since more research needs to be done regarding the presence of arrogance in other sectors, it is of great essence to have a description that can serve as a base. When this base is laid, comprehensive and conclusive research can be produced and compared to each other. Such a research could be done via questionnaires where individuals indicate the terms that they feel are associated with “arrogance”.

7. Conclusion This thesis aimed to firstly specify the definition of arrogance by means of a conceptual framework. Subsequently, it aimed to answer the five sub-questions. In chapter 4, it was found that the conceptual framework can be constructed by attaining five criteria to the concept of arrogance. These criteria were used to appraise information throughout the study in a comprehensive and critical manner.

The five sub-questions guiding this research will subsequently be answered. The first subquestion was “How does arrogance among medical staff affect relationships between the doctor and their patients?” can be answered by stating that relationships between the doctor and their patient are negatively influenced by arrogance. Due to the fact that an arrogant doctor does not treat his or her patient in a well-behaved way and does not express a sufficient level of respect (Berger, 2002), the patient will not have a good relationship with their doctor. Secondly, in answer to the second research question “How does arrogance among medical staff affect relationships among them and how does it affect relationships between healthcare institutions?”, it can be concluded that the relationship between doctors and nurses is affected negatively by arrogance. Since it is stated in the article of Rudland and Mires (2005) that, due to arrogance, doctors deem nurses inferior to them and their relationship is not in an optimal state. Furthermore, distance between healthcare institutions and the psychological motivation of their doctors - which may include arrogance - influences the relationships between healthcare institutions as well as the care they provide on their separate bases negatively. Furthermore, “How does arrogance affect the quality and trustworthiness of healthcare?” is to be answered by stating that the trustworthiness and quality of healthcare is affected negatively by arrogance. The retention of organs without having written consent for this action was attributed to doctors’ arrogance, as are high numbers of medical errors due to the overconfidence of doctors. Subsequently, the overconfidence of doctors and the belief of the

34

patient that they will solve everything without making any mistakes leave doctors with an enormous pressure to achieve high-set aims. The fourth sub-question is “how does arrogance affect the effectiveness of the communication between healthcare sectors represented by doctors, and other sectors represented by other professions?”. The conclusion to this question is that arrogance affects relationships between the healthcare sector and other sectors in a negative way. Since physicians appear to have disdain towards professions who try to regulate their profession, their relationships are influenced in a negative manner. Furthermore, specific kinds of disdain can be found within relationships between healthcare staff, researchers, nurses, and administrators. Finally, literature has suggested that arrogance also negatively affects relationships between professions within the healthcare sector. Finally, regarding the last sub-question “how is the concept of arrogance subject to changes throughout time?”, it can be stated that time is of great importance when looking at the development of arrogance in healthcare. However, opinions differ on the way in which this phenomenon has an influence. Hoffenberg (2001) and Tiberius and Walker (1998) state that doctors were significantly more arrogant in earlier times compared to the modern age. However, Berger (2002) states that arrogance is a result of negative developments in sociological elements. He therefore states that arrogance is increasingly prevalent in current society. What can be deducted from these conclusions drawn by separate authors is that the phenomenon of arrogance may have acquired different meanings throughout time, and is increasingly influenced by the media, as stated by Hoffenberg (2001) and Rudland and Mires (2005). What may have been seen as the legit superiority of the doctor to the patient fifty years ago, may currently be identified as arrogance.

In providing the answers to the sub-questions, the criteria provided in the conceptual framework were highly valued. By means of these criteria, the kind of arrogance presented in the article could be interpreted and valued in a comprehensive way. However, only certain criteria mentioned in this framework, could be attained to the arrogance presented in the articles incorporated in this study. This can be seen in the discussion regarding this matter in chapter 6.1.1. regarding the definition of arrogance.

35

Using the answers to the sub-questions, an answer can be given to the main research question “What is arrogance in healthcare and how does it affect healthcare?”. On a broad note, it can be stated that arrogance has a negative effect on healthcare. As has been stated in the answers to the sub-questions, it affects the relationship between doctors and patients, the relationship between doctors and nurses, the trustworthiness and quality of healthcare and the relationship between the healthcare sector and other sectors in a negative manner. Therefore, it is important to tackle the problem of arrogance in healthcare, in order to improve the care provided and possibly preventing negative healthcare outcomes. However, it has to be taken into account that the concept of arrogance is one that has continually been subject to change throughout different eras in history. Different perceptions are present, in which errors, traits, and health outcomes can be attributed to something that is labeled as arrogance.

36

References Aird, P. (2012, June). Health - it'll be the death of us: institutional arrogance in the health service? British Journal of General Practice, 62(599), 317-318. Berger, A. S. (2002, February). Arrogance among Physicians. Academic Medicine, 77(2), 145-147. Calman, K. (1994, October 29). The profession of medicine. Biomedical Journal, 309(6962), 1140-1143. Caplan, A. L. (1988, April). Professional Arrogance and Public Misunderstanding. The Hastings Center Report, 18(2), 34-37. de Swaan, A. (1989). The reluctant Imperialism of the Medical Profession. Social Science and Medicine, 28(11), 1165-1170. Dillon, R. S. (2007). Arrogance, Self-Respect and Personhood. Journal of Consciousness Studies, 14(5-6), 101-126. Dyer, C. (2000, May 20). Doctors' arrogance blamed for retention of childrens' organs. Biomedical Journal, 320(7246), 1359. Hoffenberg, R. (2001, September). Medical arrogance. Clinical Medicine, 1(5), 339-340. Kasteler, J., Kane, R. L., Olsen, D. M., & Thetford, C. (1976, December). Issues Underlying Prevalence of "Doctor-Shopping" Behavior. Journal of Health and Social Behavior, 17(4), 328-339. Maastricht University. (2014). Quick Search – Summon. Opgeroepen op 03 11, 2014, van Online Library: https://onlinelibrary.maastrichtuniversity.nl/service/quick-searchsummon/ Monroe College. (2011, June 16). Exploratory, Descriptive, and Causal Research Designs. Opgeroepen op July 2, 2014, van Monroe College: http://www.monroecollege.edu/academicresources/ebooks/9781111532406_lores_p01 _ch03.pdf Oxford Dictionaries. (N.D.). Definition of arrogant in English. Opgeroepen op January 26, 2014, van Oxford Dictionaries - Language Matters: http://www.oxforddictionaries/com/definition/english/arrogant Pronovost, P. J. (2010, July 14). Learning Accountability for Patient Outcomes. Journal of the American Medical Association, 304(2), 204-205.

37

Quinn, J. B., Anderson, P., & Finkelstein, S. (1996, March). Managing professional intellect: making the most of the best. Harvard Business Review, 74(2), 71-80. . Rudland, J. R., & Mires, G. J. (2005). Characteristics of doctors and nurses as perceived by. Medical Education, 39(5), 448-455. Sackett, D. L. (2002, August 20). The arrogance of preventive medicine. Canadian Medical Association Journal, 167(4), 363-364. Sørensen , K. (2013). Health literacy: a neglected European public health disparity. School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, International Health. Maastricht: Maastricht University. Tiberius, V., & Walker, J. D. (1998, October). Arrogance. American Philosophical Quarterly, 35(4), 379-390. Vuori, H., Aaku, T., Aine, E., Erkko, R., & Johansson, R. (1972, December). Doctor-patient relationship in the light of patients' experiences. Social Science and Medicine, 6(6), 723-730. Weishaus, J. (2006, May 17). "The physician as poet" review of: Pereira, Peter Saying the World. Philosophy, Ethics and Humanities in Medicine, 1(8), 1-5.

38