When doctors behave badly: a call for civility

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acp new logoA guest column by the American College of Physicians, exclusive to KevinMD.com.

It can be as blatant as a public argument between a hospitalist and emergency medicine physician about whether a patient requires admission.  But most commonly it is more nuanced and subtle.  Such as members of one speciality “bad-mouthing” another or a subspecialist criticizing a generalist for asking for a consult they don’t think is appropriate.  Not to mention the day-to-day interactions we have with other health care professionals in which we ignore, disregard, disparage, or otherwise fail to appreciate the work they do in caring for patients.

I’m talking about incivility – not treating each other with mutual respect and courtesy.

The word civility derives from civilis, the Latin term for “of a citizen.”  While it is easy to think of civility simply as having manners and not being rude to others, in its truest definition it is much more than that.  Civility refers to the action of being able to work together to reach a mutual goal, often one with an intended beneficent purpose.  It means acting in ways that demonstrate a caring for the welfare of others in the context of a common, shared mission.  This is why civility is a crucial aspect of a well-functioning society.  But civility also applies to our other human endeavors, including medicine.

Incivility reflects a failure to appreciate this commonality of purpose that results in negativity in the way we treat each other.  It doesn’t need to be illegal or clearly unethical behavior, but may be manifest in a variety of ways ranging from outright conflict and rudeness, to insulting and degrading verbal and nonverbal conduct.

There’s not a single one of us who has not experienced this many times throughout our careers.  And learning incivility begins early. For example, data from the Association of American Medical College’s annual Medical School Graduation Questionnaire reveals that over 40 percent of newly-minted doctors experienced at least one episode of public embarrassment during medical school and over 20 percent were publicly humiliated at least once, numbers that have been alarmingly consistent over years.  And most of these episodes occur during clinical training when they are interacting with other medical professionals.

What has always struck me is the paradox that those of us who have dedicated ourselves to the healing arts can treat others who share our same mission and goals so poorly.

Where does our propensity to act in uncivil ways toward each other come from?  I’m sure the reasons are many and likely include the personal issues that confront each of us – people unhappy in their personal lives are typically unhappy in the clinic or hospital, and this may be revealed by uncivil behavior.  Plus, medicine is hard work.  The stress of dealing with patients and working within suboptimal systems can easily lead us to lose focus on our mission to the point where we stop thinking about how our words and actions impact others.

But the costs of incivility are high.  It exacts a high personal price on us as individuals.  When we act negatively toward our colleagues and coworkers, we compromise our integrity as medical professionals, both in the eyes of others but also to ourselves.   And when we are on the receiving end of uncivil behavior, the results can be just as damaging.   Although experiencing periodic episodes of rude, demanding, or demeaning behavior is tolerable by most of us, repeated exposure can progressively wear us down, erode satisfaction in the work we do, and risks killing the sensitivity and compassion we need to be good doctors.  There is little question that Incivility between medical professionals is a contributor to the current high rates of physician burnout.

But another mostly unrecognized implication of incivility is its effect on patient care.  Despite its personal impact, there is evidence that the quality of care provided by clinical teams is dramatically affected by the relationships and interactions between team members, with uncivil behavior being associated with declines in both diagnostic and procedural performance.   In fact, a number of studies have shown that poor communication and deficient teamwork adversely affected patient outcomes more frequently than lack of knowledge or clinical skills.

So how can we help practice and promote civility in our daily lives?

The first step is to take care of ourselves.  Civility and self-care are clearly linked to each other as it can be difficult to respond to others in a respectful and courteous way when we are overly challenged by life and professional pressures.  Although how achieve personal well-being differs for each of us, attending to our basic needs provides us the strength and “bandwidth” to allow us to genuinely connect to those we work with, along with the benefit of improving our relationships with patients.

A second is making a concerted effort to be self-aware and mindful of our interactions with others.  Just as we try to view patients in an objective, accepting, and understanding way, approaching our colleagues and co-workers in a similar way is vital.  By focusing on the fact that we share core values and are all working toward the same goal – improving the health of our patients – we can work from a base of trust and mutual respect, and examine our behaviors and those of others from this perspective.

Fortunately, increasing efforts are being made to take on the issue of medical incivility.  Dr. Chris Turner, an emergency medicine physician in the UK and several of his colleagues have started a project titled Civility Saves Lives to raise awareness of the power of civility in medicine, emphasizing that civil work environments reduce errors and stress, while fostering excellence in clinical care.

The solution to doctors behaving badly is for us as physicians to take responsibility, both individually and collectively, to promote a culture of civility in our professional relationships and in the care of our patients.

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Image credit: Shutterstock.com

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