This is the first of two articles introducing five fundamentals of civility for physicians. Incivility in the health care system can have an enormous negative impact and consequences. In contrast, civil behaviour promotes positive social interactions and effective workplace functioning. This article focuses on the first two fundamentals: respect and self-awareness.

 

KEY WORDS: civility, definitions, awareness, respect, humility, CanMEDS roles

 

A medical student on a surgical rotation walks into the emergency department of a teaching hospital in response to a page for a consult from the attending ER physician. Seeing the student approach, the ER doc rolls his eyes and says, “If your resident isn’t right behind you, turn around and leave now.” Top

 

A busy surgeon, intent on his case in the OR, is frustrated when the nurse hands him the wrong instrument. He reaches across and snatches the correct instrument off the tray, pushing the nurse back as he does so.

 

A senior physician, convinced of his own good ideas and certainty of perspective, talks over his colleagues at a departmental meeting, diminishing their contributions.

 

Are these examples of disruptive behaviour? Possibly. Unprofessional behaviour? That might be a stretch, but it’s easy to identify these behaviours as lacking in civility. Top

 

Definitions of civility

 

The dictionary defines civility simply as polite or courteous behaviour. However, civility is more than that. Perhaps civility is most easily recognized by its absence. Everyday incivility has been described as seemingly insignificant behaviour that is rude, disrespectful, discourteous, or insensitive, where the intent to harm is ambiguous or unclear.1,2 An interaction characterized by uncivil behaviour leaves one feeling uncomfortable, fundamentally disrespected, diminished, and ostracized. Civility, then, achieves the opposite effect.

 

Civility has many dimensions that involve the individual, as well as the communities and culture we share. According to Forni3: “Although we can describe the civil as courteous, polite and well-mannered, etymology reminds us that they are also supposed to be good citizens and good neighbors.”

 

Davetian4 says that civility is characterized by: “The extent to which citizens of a given culture speak and act in ways that demonstrate a caring for the welfare of others as well as the welfare of the culture they share in common.” Top

 

A robust and useful definition of civility comes from the United States’ Institute for Civility in Government5:

 

Civility is about more than just politeness, although politeness is a necessary first step. It is about disagreeing without disrespect, seeking common ground as a starting point for dialogue about differences, listening past one’s preconceptions, and teaching others to do the same. Civility is the hard work of staying present even with those with whom we have deep-rooted and fierce disagreements. It is political in the sense that it is a necessary prerequisite for civic action. But it is political, too, in the sense that it is about negotiating interpersonal power such that everyone’s voice is heard, and nobody’s is ignored.

 

From the same source comes a reminder that civility is about respect and self-care as well: “Civility is claiming and caring for one’s identity, needs and beliefs without degrading someone else’s in the process.”5 Top

 

For the purpose of discussion in this and a subsequent article, an uncivil behaviour is one that lacks the attributes of civility, and incivility refers to a condition characterized by the absence of civility in social interactions.

 

The consequences of incivility

 

Incivility has a negative impact on the delivery of health care services at all levels: the worker, the health care team, organizations, and even patients and their families.6,7

Individuals experience incivility as personal stress, distress, anxiety, depression, psychosomatic disorders, and burnout. Naturally, these people are hard pressed to live up to their productivity potential. Some people experiencing uncivil behaviour may, in turn, retaliate by directing unwanted and unhelpful behaviour toward co-workers and the organization itself. Top

 

Organizations pay a price for incivility, too. Persistent incivility in the workplace creates an environment that is psychologically unsafe and difficult to endure — one that creates worker unhappiness and under-performance, at the least, and drives people away, at the worst. Along with the psychological costs, incivility can also inflict striking fiscal costs on the organization, although precise calculations can be difficult to obtain.

 

Even small acts of everyday incivility can contaminate the culture of a workplace. Unaddressed and uncorrected, this can lead to an insidious infusion of risk and insecurity into the social environment at work creating a spiral of uncivil behaviours, reactions, and retaliations. The unstated, but actual, code of conduct becomes a code of incivility. If this condition is repeated in a sufficient number of related workplaces, such as health care institutions, entire professions can be culturally “tarred” as uncivil. Top

 

The impact of civility

 

Positive social interactions allow the development of strong and effective connections with others. Civil interactions at work identify co-workers and leaders as supportive and are, therefore, associated with enhanced seeking and exchanging of advice, increased professional efficacy, and effort.8 Civility among colleagues is associated with lower rates of professional burnout.6 Civil collegial relationships foster inclusivity and cooperation and can be energizing and empowering. Health care workers and patients alike perceive a higher quality of care in a climate of civility.9

 

One might argue that there is no need to discuss the benefits of civil behaviour in the workplace, or anywhere, for that matter. Everyone wants to be treated well. No one wants to feel hurt by an interaction with a friend, colleague, or co-worker. We all appreciate a workplace that is comfortable and supportive. Yet many, if not most, medical workplaces include doctors whose behaviour has been identified as uncivil and labeled as “disruptive.” These cases occupy a disproportionate amount of time for physician leaders and often result in referrals to physician health programs and regulatory colleges. Top

 

Embracing civility

 

It appears, then, that a civil approach to relationships in the workplace has merit, but there are many questions to explore. Is there something different about the culture of medicine — something that justifies incivility? Should all doctors be expected to behave in a civil fashion all the time, even in tense situations or difficult work environments? Is civility being sufficiently modeled and taught in medical training programs and beyond, if it can be taught at all? Top

 

Most doctors interact with others in a civil manner most of the time. Does this come naturally to them, or have they been trained in civil conduct? It is no longer enough for doctors to have the clinical knowledge and skills once thought to be sufficient for the complete medical practitioner. The kind of person the doctor is, how he or she interacts with co-workers, and how, together, they bring their technical knowledge and skill to the patient matter equally.

 

The CanMEDS framework10 highlights a number of competencies required of the complete medical practitioner, including those of Communicator, Collaborator, Manager, Advocate, and Professional. Thus, when the many dimensions of civility are considered more closely, it appears that there are key competencies that can be learned and adopted to foster civil behaviour, even at times of risk. As such, the following are offered as “Five fundamentals of civility for physicians”: respect others, be aware, communicate effectively, take good care of yourself, be responsible. Top

 

Respect

 

Respect can mean many things, but here, respect is a consideration of the way we regard others and ourselves. To respect is to recognize a sense of worth, to hold in esteem desired or admired qualities, to accept and acknowledge the intrinsic value of oneself and others.

 

Respect and civility are intertwined. It’s easier to interact with others in a civil fashion when we view them with respect. And civil behaviour conveys our respect while fostering the same in those with whom we live and work. Civility, as a means of demonstrating respect, engages people in their work.6 Top

 

Respectful relationships are fundamental to worker engagement, high-quality job performance, and, therefore, in the health care sector, the highest quality of patient care.6,11 Thus, if respect is fundamental to civility, how can respect be kept foremost in our thinking? Is it possible to respect everyone, without exception? What is the role of self-respect?

In a good number of its practitioners, the culture of medicine has bred a style of aggressive self-assurance that can be interpreted as arrogance. Such doctors see themselves as heroic champions for patients and health care improvement. They launch themselves vociferously and belligerently against individuals and systems, speaking their “truth,” heedless of those they trample in the process. Convinced that their own system of values is unassailable, they judge the motives of others at suspect. Despite the positive intent of these usually amazing and accomplished individuals, their approach is seldom respectful of the needs, status, and opinions of others. Arrogance does not convey respect and is not civil. Top

 

Humility: Respect and humility are also intertwined. A humble person has an open mind, recognizes his or her own limitations and is willing to consider other ways of being, thinking, and behaving. A leader who is humble will understand the appropriate use of the power their status confers. Humility allows for apology when needed. Even a modicum of humility in our manner can convey respect for others, engage cooperation, and help us effectively reach the same goals that a more forceful approach demands but fails to achieve. Top

 

It’s easy to respect friends and colleagues we know well and, perhaps, admire. Still, a vigilant approach that considers etiquette and healthy interpersonal boundaries will promote acts of everyday civility. Here are some examples:

• Be present. When in conversation with others, pay attention. Consider putting the smart phone aside whenever possible.
• Everyone needs personal space, both physical and psychological. Keep an appropriate distance in conversation, and don’t pry or divulge too much about yourself uninvited. Make space for others to speak and contribute.
• Maintain professional dress and grooming.
• Be mindful of timeliness. Arriving and leaving meetings on time tells others that their time is as important as your own.

Showing respect toward colleagues we don’t know well offers them inclusivity — a civil thing to do:

• Acknowledge them. Make eye contact. Smile.
• Learn their names, and address them by name.
• Engage in friendly conversation from time to time.
• Learn more about their role and duties within the organization.
• Invite their opinions when appropriate, listen carefully, and express appreciation toward them.

Special mention needs to be made of power imbalances and workplace relationships. Uncivil behaviour by those with higher status directed toward subordinates has a greater negative impact compared with such behaviour between peers.6 Even unintended slights can convey disrespect and cause harm. And if intended? There is no valid pedagogy that supports shaming as an effective teaching or workplace engagement strategy. Top

 

A further complexity arises when it comes to people with whom we don’t agree, or perhaps those whose opinions or values we don’t share. However, there are still ways to show respect. Here are some suggestions:

• Assume positive intent. Generally, in any medical workplace everyone is working toward the same goal: positive outcomes for patients and their families.
• Seek to understand other perspectives by finding common ground and identify with that. Remember that colleagues and co-workers from other cultures, generations, and even gender are inclined to see things differently.
• Value the fundamental humanity and worth these colleagues and co-workers possess as members of our community.
• Respect the established systems and roles that govern and guide our work and our profession. Disdain for health care administration or regulations and scorn for its leaders is uncivil and unhelpful. If change is the goal, healthy participation, strategic advocacy, and sound leadership are the routes to take.

Perhaps the greatest challenge arises when dealing with someone who has bullied us or hurt us in some way. Even in this situation, civility is preferred over incivility — even if not everyone agrees. Self-respect is an important component of civil interactions with others in all circumstances, but in this instance, it is key.

• At the end of the day, reflecting on your behaviour when interacting with these individuals, think about how you feel about yourself — especially if you chose incivility.
• Understand the useful steps that can be taken from a procedural perspective in dealing with someone whose behaviour toward you in the workplace is hurtful. Gossip, disparaging remarks in clinical notes, email, or the press, and threats of retribution are not among them.
• Show leadership by demonstrating the kind of assertive communication and regard for others that you wish to be modeled in your medical community and culture. Others will respect and emulate that.
• Demonstrate self-respect and compassion by seeking advice and personal support should you find yourself feeling distressed or victimized by the behaviour of others in the workplace.

Can respect and humility be taught and learned? That is a good question for discussion, but it is certain that the opportunities will keep on presenting themselves. Top

 

Awareness

 

A myriad of influences inform and shape our every thought, choice, and deed. Most are beyond our awareness, therefore, unconscious. They include our physical and emotional states, temperament, values, assumptions, beliefs, past experiences, attitudes, biases, cultural practices and prejudices, knowledge content and gaps, and much more.

 

Reflection and self-awareness help doctors examine many aspects of themselves that contribute to their thoughts, moods, and actions. Without this awareness, we function “mindlessly,” and mindless interactions with colleagues and co-workers can sometimes lead to uncivil behaviour. In fact, mindlessness accounts for many deviations from professionalism that seem to occur more often when doctors find themselves in pressured, emotionally charged situations.12 Top

 

Mindlessness can catch us up into negative emotional, cognitive, and behavioural patterns without our being able to intervene. Mindlessness also prompts shifting of blame and avoidance of personal responsibility. In short, when we are not sufficiently self-aware, choosing civil behaviour can be difficult; we might even do harm to ourselves and others.13

 

Mindful self-awareness: Hence, we see the connection to civility. Mindful self-awareness leads to accepting, non-striving, contented well-being — a “being mode” rather than a “doing mode.”13 Another description of mindfulness is a state of “could be,” welcoming uncertainty rather than trying to avoid it.12 Self-awareness is the moment-to-moment, non-judgemental recognition of what’s happening within us. The goals of mindful self-awareness include enhanced expression of core values, such as empathy and compassion; the courage and ability to see the world more as it is rather than as one would have it; and the humility to recognize, tolerate, and embrace our “blind spots,” or areas of weakness, while leveraging our strengths.6,12 Awareness practices also open the door on sensitivity to others. We might wonder about how they are interpreting their circumstances and understand that they might not react in the same way as us, even in the same situation. We can respect others’ feelings without taking them on to ourselves or automatically reacting emotionally to them. It is easier to understand how another might be challenged to behave in a civil manner if we accept that the same is often true of ourselves. Top

 

Cultural awareness: If the simple definition of culture is “the way things are done around here,” then we need to pay attention to that as well. Our behavioural choices are influenced broadly by external norms and expectations, just as they are by our internal status and the behaviours of others. Civility is easier to choose if one is aware of the cultural influences, positive and negative, all around us. Kindness is good, meanness is not. Directive communication is acceptable under certain circumstances, profanity is not. Teaching by asking tough questions is fine, shaming is not. Humour is fun, sexist jokes and other forms of harassment are not. Top

 

Barriers to awareness: Barriers to self-awareness are numerous in medical training and practice.12 Fatigue, dogmatism, emphasis on an overly “algorithmic” and literal-minded approach to clinical choices and behaviours (rather than on conscious, non-judgemental awareness and reflection) close the mind to relevant feelings and options. These practices in senior physicians may be emulated by learners and junior colleagues, who then become unconsciously incompetent with respect to self-awareness, even as they develop exquisite competencies with respect to the clinical knowledge and skills of their specialties. In essence, learners are trained to behave in an uncivil manner. Top

 

Self-awareness strategies: Here are a few recommendations designed to help improve self-awareness:

• Keep a journal of reflective writing. Record thoughts and ideas, without censorship or judgement, about your reactions to events of the day, reflecting on what went well, or not, and how your personal realities influenced your choices.
• Learn and practise meditative techniques.
• Seek out trusted friends and peers with whom you can discuss your thoughts, feelings, behavioural choices, and reactions. Invite their honest feedback.
• Seek behavioural feedback at work in the form of regular supervision (from a department chief or other physician leader) or by using a 360° multi-rater survey tool specifically designed for this purpose.
• Seek out opportunities for group education and discussion that focus on relevant leadership, problem solving, and ethical practice.
• Mentor and be mentored by others who value self-awareness practices.
• Employ the services of a suitable professional coach. Coaching is an increasingly available tool to help define one’s personal and professional goals, enhance motivation, and reinforce positive choices to attain those goals.
• Sometimes professional counseling is a good way to enhance self-awareness in a more clinical and in-depth way. Top

 

In the heat of the moment: Is it ever acceptable, as a physician, to be uncivil toward colleagues or co-workers? Some say it is, especially when the physician is in charge of a patient’s care in a life-and-death situation. They are usually referring to a communication style that is firm, even forceful — not necessarily a bad thing. However, few condone the use of profanity in that situation. Moments of high tension can generate feelings of frustration, anger, or fear that can place civility at risk. Once aware of these reactions, the doctor can pause, then choose an assertive, directive, yet respectful, stance designed to bring out the best action from others on behalf of a patient in dire need and still leave co-workers feeling intact.

 

The goal of awareness, as it pertains to civility, is to render informed and conscious behavioural choice readily available. Then, an interesting thing can happen: when any one of us accesses civility, others seem to do the same! Top

 

References

1.Bar-David S. Trust your canary: every leader’s guide to taming workplace incivility. Toronto: Fairleigh Press; 2015. p. 3.

2.Andersson LM, Pearson CM. Tit for tat? The spiralling effect of incivility in the workplace. Acad Manage Rev 1999;24:452-71.

3.Forni PM. Choosing civility: the 25 rules of considerate conduct. New York: St. Martin’s Press; 2002. p. 12.

4.Davetian B. Civility: a cultural history. Toronto: University of Toronto Press; 2009. p. 9.

5.What is civility? Houston: Institute for Civility in Government; n.d. Available: https://tinyurl.com/no8o43w

6.Leiter M. Analyzing and theorizing the dynamics of the workplace incivility crisis. New York: Springer; 2013. Chapter 3.

7.Van Aerde J. Rudeness in health care is harmful. Can J Physician Leadersh 2017;3(4):123-8. Available: https://tinyurl.com/va2ugcr

8.Porath CL, Gerbasi A, Schorch SL. The effects of civility on advice, leadership and performance. J Appl Psychol 2015;100(5):1527-41. doi: 10.1037/apl0000016

9.Oppel EM, Mohr DC, Benzer JK. Let’s be civil: elaborating the link between civility climate and hospital performance. Health Care Manage Rev 2017;44(3). doi: 10.1097/HMR.0000000000000178

10.The CanMEDS framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2017. Available: https://tinyurl.com/j5fcykv

11.Klein AS, Forni PM. Barbers of civility. Arch Surg 2011;146(7):774-7. doi: 10.1001/archsurg.2011.150

12.Epstein RM. Mindful practice. JAMA 1999;282(9):833-9.

13.Gilbert P. The origins and nature of compassion focussed therapy. Br J Clin Psychol 2014;53(1):6-41. doi: 10.1111/bjc.12043.

 

Author

Michael Kaufmann, MD, a family physician and addiction medicine physician, is the founding medical director and now medical director emeritus of the Ontario Medical Association’s Physician Health Program.

 

Correspondence to: dr.i.michael.kaufmann@gmail.com

 

This article has been peer reviewed.

 

Note: This article is based on a series, “The five fundamentals of civility for physicians,” which first appeared in the Ontario Medical Review from March 2014 to December 2015.

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