Here are six words you will soon read again.
ASTONISHING. AMAZING. TERRIFYING. DEVASTATING. HORRIFYING. SHOCKING.
And I stand by every one of them.
Rudeness wears its victim down. Psychologically, of course, but there’s growing evidence that those subjected to the stress of incivility for too long or too often find their immune systems weakened. A weakened immune system can lead to a raft of major physical health problems like diabetes, cancer and heart disease.
The Journal of the American College of Cardiology has shown that hostility has a direct link to heart problems38 and rude, hostile words can even cause brain changes and long-term psychiatric risks for young adults.39 According to the Wallace Report, well over half those asked – 56 per cent – feel that rudeness has indeed affected their mental wellbeing.
Even witnessing rudeness – or going over rude moments again and again in your head, just as I did in the days after my failed bid to buy a processed meat product cooked to order – elevates levels of hormones called glucocorticoids throughout the day. Too many can lead to a whole host of health issues, but one of the first effects is an increased appetite.
So now we can say that in addition to everything else, rudeness can make you fat.
But it can also affect your health in a much more frightening way.
Since not buying a hotdog, I have become a bit of a fan of an Israeli academic. I am also the only person ever to have typed that sentence.
Dr Amir Erez is an expert in positivity and positive thinking. Or was, until he also became an expert in rudeness.
‘This is kind of a strange story,’ he tells me when we speak. ‘Until seven or eight years ago I was not interested in rudeness at all. But I had to give a talk at the University of Southern California on the power of being positive. There I met another researcher, called Christine Porath.’
I’ve also become a bit of a fan of hers. She’s the woman who made people come up with new ideas for how to use a brick.
‘We had lunch together,’ says Erez, ‘and she told me all about her research into rudeness and incivility, and I just told her that I didn’t believe in any of this research.’
‘That was rude,’ I say.
‘Yes! I said it in a very rude manner.’
‘So much for the power of being positive.’
‘I told her, why would it have any effect? These small insults? It’s not violence, not aggression, just small incidents! And we’re good at ignoring these minor things. Because otherwise we would walk around all depressed all the time. So I told her, no, I don’t see much evidence for it.’
‘You mean scientific evidence?’
‘It’s all self-reported. People saying “oh, this happened” or “that happened” and they felt insulted and like it affected their performance and so on.’
Erez said the only way he’d believe that rudeness had an impact was if Porath could actually induce rudeness and measure the effects it had. She struck back, saying fine, if you don’t believe me, let’s do it together. Each simply wanted to prove the other wrong.
‘So this was essentially the academic version of a drunken bet?’ I ask.
‘It was. It was pretty much a bet. And she was right and I was wrong. Since then we’ve conducted many studies and the effects are just absolutely amazing. Each and every time I conduct a study, I don’t believe I will find much. But I always find something. And the effects of rudeness to me are astonishing.’
It’s astonishing, because what doctors Erez and Porath found was that rudeness can kill.
‘One of the reasons rudeness is so devastating is that it affects cognition. When people encounter rudeness they can’t think in the same way. We know now that it affects working memory.’
Working memory is important. It’s used in reasoning, decision making and in determining our behaviour.
‘That’s the part of the process where everything is happening. Planning, goal management, memory – pretty much everything is dependent on working memory.’
In one of their studies, the team looked at attention. They found that when people experience rudeness, they miss obvious information.
‘Even when it’s in the centre of their visual field. So I said to one of my friends, “This is really scary. Can you imagine if this happened in surgery? Can you imagine if a surgeon was rude to an anaesthetist, and the anaesthetist now starts to miss information that’s right in the centre of their visual field, for like 30 seconds?”’
And as the words sank in, they decided they had to test it.
‘And we found that it has devastating effects,’ he says, before pausing. ‘It is terrifying.’
The study, ‘The Impact of Rudeness on Medical Team Performance’, took place in Tel Aviv.
Erez and his colleagues gave 24 medical teams – each one comprised of one doctor and two nurses from neonatal intensive care units – one hour to diagnose and treat a sick baby.
It was all simulated, of course – and for the experiment they chose a case of something called necrotising enterocolitis.
Put simply, that’s a potentially fatal disease that moves rapidly around a premature infant’s intestinal tissue. If it’s not treated immediately it begins to inflame the tissue, which starts to die. So does the baby.
Before any of the teams got to work, they were told that a leading expert from the United States would be observing them through a webcam. In front of the teams, a researcher then rang a fake phone number and played a message from that ‘expert’.
Half the teams heard a perfectly normal message.
The other half heard this expert rudely inform them that he had observed other medical teams from their country and was ‘not impressed with the quality of medicine in Israel’.
The simulation began. The teams got to work.
Ten minutes later, another message arrived.
Half the teams heard the expert say he hoped that the simulation would help them in their work.
The other half were told that based on their work so far, they ‘wouldn’t last a week’ in his department.
So what happened?
The teams that experienced no rudeness did just fine.
The teams that experienced rudeness fell to pieces.
They had trouble communicating, they couldn’t work out how to cooperate, they forgot basic instructions and they misdiagnosed the illness. The doctors asked for the wrong drugs. The nurses prepared the wrong things. They didn’t ventilate the patient in the way they should have, nor did they resuscitate well.
Three outside judges appraised the results, without knowing what the experiment was all about. The difference in the quality of their work was incredible. What Erez and Porath discovered is that even one rude comment in a high-pressure environment decreased performance by doctors and nurses in a life or death situation by more than 50 per cent.
The doctors who’d been treated rudely could well have killed their tiny patient as a result.
If you’re a little brusque with the man in the hospital sandwich shop, he might hand you a cheese and pickle sandwich instead of cheese and ham.
Be rude to a doctor, and you might never eat again.
Now, rudeness in these high-pressure situations is one thing. As surprised as we might be by the results, they’re understandable. But the banal drudgery of everyday rudeness does much the same thing, and once again the results can be just as scary. The reason we don’t know about them is that, quite simply, no one’s thought to trace them back to rudeness before.
We think people make mistakes when they’re tired, when they’re stressed, when they’re going through a rough time at home. Rarely do we think they might be making mistakes because of an off-hand comment or a cruel aside.
There was another simulation, more recently. This one lasted far longer than an hour, and took place over the course of a medical team’s day.
They were made to encounter rudeness at the start of their day, this time not from a colleague, but from the presumably distressed mother of an infant. What Erez found was that the rudeness they experienced didn’t just affect their ability to treat the woman or her child in the moment. Nor did it only affect the next person or problem they encountered.
‘It affects them all day,’ says Erez. ‘They go through five patients afterwards. And they just don’t treat them appropriately. The entire day.’
One moment of rudeness in the morning can affect every single patient a doctor meets in their day.
Medical errors are a major issue. In the United States, it’s the third leading cause of death after cancer and heart disease: 400,000 people die every year because of them.40 That’s more than 1,000 people a day. Ten times that amount suffer from the serious complications that arise after medical mistakes: like the Minnesotan woman who underwent a bilateral mastectomy to treat a cancer she then found out she never had in the first place.
Then there’s the financial cost – and the knock-on effects. A report on the economics of health care quality and medical errors puts that cost at a genuinely unbelievable $1 trillion a year in the United States alone, with 10 million days of lost productivity thrown in for good measure.41
In Europe, the World Health Organization reports that medical errors consistently occur in 8 to 12 per cent of all hospitalisations. You have a one in ten chance of it happening to you. One in 20 patients in Europe sit in hospital with an infection they didn’t arrive with and didn’t really want. In Britain, these infections cost the country £1 billion a year.42
It suddenly feels like ambulances should be rushing people out of hospitals, not into them.
Yet most efforts to limit medical errors focus on improving the IT systems and ‘comprehensive systematic approaches to patient safety’, which is another way of saying spreadsheets.
Erez thinks there’s more we can do than agree to a software update on our Excel.
He suggests that the entire field of medicine is investigating the wrong things when it comes to limiting medical errors. It’s social interaction, he believes, that needs the focus.
‘It explains so much more of medical errors than anything else. In our last rudeness study, [rudeness] explained 40 per cent of errors.’
Rudeness clouds judgement. And a little-known side effect is that a doctor who experiences it will therefore find it much harder to adapt their thinking. Whatever the first diagnosis is, Erez says, that’s what they’ll be more likely to stick with, even when strong new information enters the frame. It’s called a fixation error.
‘If you give doctors an initial diagnosis – even if it’s a diagnosis that comes from, say, the daughter of a patient, which is very unreliable – but then give them signs that actually point to a different problem, [you find that] people that experience rudeness don’t move from their first, wrong diagnosis.’
Put simply, rudeness fogs our brain and stops us processing new information properly.
Doctors know all about this. A survey of 4,530 doctors, nurses and hospital personnel showed that 71 per cent of them believed that disruptive behaviour – rudeness, abuse, condescension or insulting personal conduct – led to real medical errors; 27 per cent tied it to patient deaths.43
But rudeness isn’t limited just to the medical profession, of course. Think of the number of times we put our lives in the hands of other people: the bus driver, the pilot, the guy who weighs us up before he straps us to the bungee cord and kicks us off a bridge. If any of them have experienced rudeness that day, their ability to do their job properly is compromised. It’s a little like they’ve had a drink. With alcohol, though, there are clues: you smell the booze on the pilot’s breath, you see the glassy eyes, you’re aware of the sway, and maybe they’re holding a kebab or talking to a mannequin. But even a sniffer dog can’t seek out traces of rudeness.
Erez broadened his research to truck drivers and their daily interactions with their dispatchers. Those who experienced rudeness violated more safety laws. And we can’t blame them for it. Their brain just wasn’t able to cope with driving as well any more.
Now, fair enough, if you’re a young doctor, you’re already underpaid, sleep deprived, unappreciated, overworked and stressed, and backed by a government who want you to work harder for longer for less. Add to that some lunatic screaming obscenities in your face when you should have been on your break and, yes, your focus may waver. But the really scary thing about all this is the levels of rudeness involved.
It is incredibly mundane.
‘It’s amazing,’ says Erez. ‘We find effects even when you just prime it.’
‘When rudeness is just on people’s minds?’
‘So we’ll give people sentences to reconstruct. And if those sentences have rude words in them, it influences people’s working memory.’
If even seeing a rude word slows you down, I ask him what constitutes a rude word. Are we talking about swear words? Or words that describe rude actions?
‘Just words,’ he says, ‘like “rude”, “ignore”, “bother”.’
I take a moment.
‘As gentle as “bother”?’ I say.
There’s a pause.
‘Every time I get results, they are just totally shocking to me.’
All of a sudden, rudeness seems a far more serious issue – this well of frustration and muddle-headedness that can arise from a mild insult, a banal word, someone not holding a door open for us or forgetting to say thank you. It eats us up, plays on our mind, clouds our judgement. So I tell Dr Amir Erez about the Hotdog Incident, about how it stuck with me for days.
‘What you describe with the hotdog is really interesting,’ he says, ‘because we all wonder – how should I have behaved in that moment? It’s so surprising and shocking that someone could behave in that way. Often you don’t react immediately precisely because it disrupts cognition.’
Which is okay if you’re a writer trying to buy a hotdog, but dangerous if you’re a doctor, or a nurse, or a bomb disposal expert, lorry driver, hostage negotiator, crane operator, parachute packer, fireman, juror, or a cleaner in a nuclear bunker dusting the big red buttons.
‘We’re trying to find some ways to control it,’ he says, at one point. ‘To raise the threshold of people’s sensitivity to hostility.’
He throws this away, but it’s fascinating. We can’t do much about the rudeness that spreads like a cold. We’ll never stop it, because it’s already started, and it’s out there – waves of it, infecting new people every day and being passed on all the time, as unstoppable as the tide. But maybe the trick is to protect against it.
Erez and his team tried a new idea. A simple 15-minute videogame doctors could play at the very start of their day.
‘It reduced the effect of rudeness on their performance.’
I’ll let that sink in.
Erez is developing a rudeness vaccine.
‘It doesn’t change the perception of rudeness. They still perceive the person who was rude as rude. But the rudeness did not affect them. [But for] other people not inoculated … it affected their performance tremendously.’
The good doctor says the results of his experiments are the same in people all over the world. If nothing else, we can say rudeness unites us.
But if rudeness can lead to heart attacks, diseases, mistakes in the operating theatre, misdiagnosis, unnecessary deaths, cost hundreds of billions of dollars and pounds and euros and yen, and cause 40-ton trucks to miss stop signs, can we go on ignoring it?
If the world’s getting ruder, it’s getting more dangerous.
‘Most people think it’s not a big deal,’ says Erez. ‘Just like I thought.’
But it’s not overstating the case to call it a silent killer, I tell him. Yet people find rudeness amusing.
‘They find it amusing,’ says Erez, ‘until they’re on the operating table.’
CASE STUDY: SAY IT
I’m walking along a very long corridor in a very old building and there is a man walking very closely behind me.
We’ve been through one set of double doors already and I have done the polite thing and given them an extra little push so that he can get through right behind me with the minimum of effort.
You must not call me a hero for this. Plenty of other people have done far greater things – saving lives, curing things, etc. – but you are right if you say that this is just a different type of heroism.
The only problem is, the man didn’t say thank you.
Because that’s what you do, isn’t it? A stranger makes a small effort to make your life easier? You say thank you!
Not to worry, though, because we’re about to hit the second set of double doors and this will be his chance to redeem himself, and as we go through I give them that extra little push again but once more he says absolutely nothing.
Maybe I’m missing it. Maybe he’s saying ‘cheers’ or ‘thanks’ or ‘ta’ very quietly. How could you not say thank you? It’s a reflex, isn’t it? After all, I’m giving the doors an extra little push!
The third set of double doors is upon us. He must be going to the same place as I am. He must realise this too. Well, he has to say thank you now, doesn’t he, because we may end up in the same room? He will know he didn’t say thank you for my extra little pushes and he will be devastated.
And as we walk through them, I give them that extra little push, and I listen really closely, but the man does not say thank you!
Well, now I know exactly what I’m going to do.
When we get to the end of this corridor, I’m going to say, ‘Pfft, don’t worry about it.’ But I’m going to say it in a really cutting way. It will be loaded with contempt, and dripping with sarcasm. ‘Don’t worry about it’ will become all he can think about, all day. He will lie in bed tonight staring at the ceiling thinking about ‘Don’t worry about it’. ‘Don’t worry about it’ will cause him radically to reassess his life. He will come to question his every decision he has ever made, and perhaps start to reflect on how he treats people. In time, he will realise he has been taking his wife for granted and neglecting his children. His work will begin to suffer. He will be overcome by an overwhelming sense of ennui. He will resign from his job, citing emotional distress, and spend his afternoons sitting at home in his pants wondering how he ever came to be this way. ‘Where is the bright-eyed young kid?’ he will ask himself, wailing at his bathroom sink, staring into his own cold, empty eyes in the mirror, his mascara running down his face, even though he doesn’t wear mascara, it just helps the image.
‘Where is the young man setting out in the world, so full of hope and optimism?’ he will scream as he bangs his fists against the mirror – shattering it, each shard now a grim taunt, each one reflecting the men he could have been.
Then his wife will leave him, taking the kids, because now she realises that without his job, she never really liked who he’d become anyway. Theirs was a cold and lifeless marriage, fuelled only by habit, she will tell him. When had they stopped talking to each other the way they used to? When had they stopped listening?
‘WHYYYYY?’ he will scream, as he drives his car aimlessly around in the dead of night – this ‘man’, if you can call him that – searching for forgiveness the way he always used to search out the dollar, prepared to do anything to get ahead, no matter who he let down or what he sacrificed.
And he will know that all he had to do was say thank you to me as I pushed open some double doors for him that day and he could have continued living that lie.
‘Don’t worry about it’ will be all he can hear, as he spirals down into the depths of his own self-loathing, a washed-up has-been living rough on a beach, forced to hang around hospital entrances so he might dash in and squirt some more alcohol gel onto his hands to lick off later, before the security guards, who would once have respected him, chase him away, the way they always do. ‘Don’t worry about iiiiit …’
On reflection, maybe I shouldn’t say it.
But I know I’m going to. He needs to realise. He can’t go on this way.
And as we reach the final set of double doors, this is my moment. I am going to absolutely relish this.
I give the doors an extra little push, sending them swinging wildly open, and as I begin to peel off to the room I’m going to, I half-turn my head and sneer, ‘Pfft, don’t worry about it’ …
At exactly the same time as the man says, ‘Thanks, mate!’
I look like a terrible, sneering sarcastic person asking far too much of my fellow man! What – did I expect him to say ‘thanks’ each and every time?
Well – yes, of course I did.
‘Don’t worry about it!’ I quickly say, again, turning round and beaming, but this time in a panic and trying to erase all sense of sarcasm.
‘Cheers,’ he says again.
‘Don’t worry about it!’ I say, giving him a big thumbs-up.
I feel such incredible warmth towards him for the simple fact that he wasn’t horrible.
‘Okay,’ he mumbles. ‘Bye.’
I love that guy!