By Dr. Micheal Kaufmann
OMA Physician Health Program
Words are powerful. They can flay like whips. When hastily chosen and self-serving, they can unnecessarily hurt and discourage. On the other hand, words that are well chosen, considerate and timely can lift spirits, motivate, heal, and connect us.
When we communicate with someone, be it face-to-face, by phone, online, or by any other means, we must remember that w are interacting with a living, breathing, vulnerable human being – just like us.
At its core, civil communication is courteous and respectful. I wonder why this can be forgotten during the course of medical training and practice?
We live in a time and place where such things as rules of etiquette, dress codes and dining manners, just to name a few social conventions, are relaxed, even disappearing. It’s possible that rules for everyday, well-mannered conversation are overly relaxed as well.
Here are some common sense considerations for civil conversation:
- Greet others warmly. Gently push vital preoccupations to the side, just for a moment.
- Engage in conversation genuinely when the opportunity arises. Consider what has been said, turn it over in your mind for a moment or two, and reply in a thoughtful manner.
- Be inclusive. When others approach, invite them to join the conversation.
- Thinking the best of others is a decent thing to do. Draw upon your respect for others, as discussed in “Fundamental #1: Respect Others and Yourself.”1
- Maintain your integrity. Share to the extent that you are comfortable without being dishonest or misleading.
Two Kinds Of Silence
Silence can help or hinder civility in communication. Active listening is the first kind of silence. If communication is sending and receiving information, then listening is as important as speaking.
Not talking in key situations is the other, unhelpful, form of silence. Communication withheld when it is expected, needed, or would be
appreciated, is a pernicious choice, even when harm is unintended.
Imagine a time when you had a good conversation with a colleague or friend. You know it was good because you came away feeling positive, buoyed up, heard. Your partner really listened. But how did you know that?
Well, they probably didn’t talk that much. And they certainly didn’t talk over you, or appear to be eagerly waiting for an opening in your narrative so they could punch through with their own ideas. You were sure they were paying attention to what you were saying, taking everything in. They faced you and didn’t fidget. They set their smartphone aside. Pauses in the conversation were comfortable spaces that invited you to share more detail. And when they did speak, it was to ask a question that really confirmed they were trying to understand what you were saying, and, perhaps, feeling. Or maybe they had helpful and relevant comments to offer. They didn’t hurry away.
In Choosing Civility, Forni says: “plan your listening, show that you are listening and be a co-operative listener.”2
Planning to listen is a conscious choice and a deliberate act. Silence is your tool. Head nodding and similar gestures at the right time demonstrate active listening. Clarifying questions in order to understand the other’s perspectives are signs of co-operative listening. So are offering your opinions and advice, but only if that is what your partner in conversation is seeking.
Listen also to your inner voice busily reviewing, comparing, identifying, maybe judging, planning your next words, tempting you to interrupt.
But silence it as well — until the right moment. Good listening is purposeful work and a great measure of civility.
Now let’s consider the other form of silence: absence of communication.
I think that many physicians find it difficult to offer praise. We might think that there is only one way to perform
— to the best of our ability. We expect that from others almost as much as we do from ourselves. So why compliment someone for simply performing as
we expect? The answer is that a well deserved compliment is a considerate act of support. It is capital deposited into the interpersonal emotional bank of good will. Genuine praise strengthens relationships now, thus facilitating more difficult conversations later, should they be needed. It is an act of civility.
Here’s a suggestion: if it crosses your mind that someone has done a good job, achieved an important goal, gone the extra mile, then tell them so. And if someone kindly does the same for you, then the gracious thing to do is to accept the compliment.
Giving Constructive Feedback
If it is a challenge to offer praise, then it’s really tough to provide feedback and guidance when someone we work with needs it. Rather than criticism, think
of this as constructive feedback. When someone around us is under-performing, struggling, distressed, distressing others and/or behaving in an unprofessional manner, approaching them as a friend, colleague or leader is a responsible thing to do. There are many frameworks to consider when the time is right to give constructive feedback and how to do it. Motivational interviewing (MI) is one of them.
MI is a strategy described by Miller and Rollnick that offers sound principles for effective communication with someone who is resistant to, or ambivalent about, change.3 A motivational conversation is embedded in a collaborative and supportive relationship. The physician leader, or speaker, is a guide who helps
to clarify a colleague’s goals and explore effective behavioural strategies to move toward achieving them.
Unhelpful strategies are also identified — often by the colleague. This is known as developing discrepancy, or, as a popular television counselor might say, “How’s that working for you?” Learning how to roll with resistance is vital: a bloody- minded response to a bloody-minded stance calcifies obstinacy. Ultimately, an effective motivational approach supports the other’s self-efficacy in finding ways to make necessary change.
While it is beyond the scope of this article to go into MI strategy in depth (or other effective communication paradigms), here are some tips that can provide helpful structure to difficult conversations:
- Plan and rehearse your conversation ahead of time.
- Choose a place and time that is private and unhurried.
- Engage using empathy and open reflection upon what you are hearing (e.g., “I imagine you found yourself in a difficult position…”).
- Seek to genuinely understand and support the other person’s goals whenever possible.
- Use open-ended questions without judgment (e.g., “Tell me more about that” or “Help me understand”).
- Focus on accepted facts and behavioural observations, not the person (e.g., “I’d like to discuss an incident that arose in the OR last week” rather than, “How can you have been so thoughtless?”).
- Monitor your own internal state, including emotional reactions, biases and “stories” you are telling yourself about the other person and their circumstances.
- Clarify expectations and preferred outcomes objectively, without “taking sides.”
- Clarify consequences/contingencies that are relevant to the circumstances.
Support positive behavioural choices and outcomes. And watch out for these common conversation stoppers:
- “You always…” (exaggerated overstatement)
- “You never…” (exaggerated understatement)
- “Don’t take this personally, but…” (it is personal)
- “With all due respect…” (it is not respectful)
- “I shouldn’t have to tell you this, but…” (inappropriate assumptions)
Just as giving feedback requires skill, so does receiving it. Not one of us can judge ourselves perfectly. Forni advises that if we can see the person giving us constructive criticism as our friend (and that might require an active imagination) then we can open ourselves up to quietly considering the feedback as helpful.4 If it rings true, gracious acceptance is certainly appropriate. If you’re not sure, then offer a thoughtful response, perhaps “You’ve given me something to consider. Thank you for that.” And if you just can’t accept the feedback as valid, then a civil response might be, “I appreciate that’s how you see things, but that just doesn’t make sense to me.” Counterattack — adopting an aggressive stance — will quash any hope of useful dialogue, blocking positive outcomes and the promotion of respectful workplace relationships.
I’ve heard it said many times about doctors referred for assessment and support that they “lack insight,” that is, they don’t understand or appreciate the impact that their behavioural choices have had upon others. “Have you explained that to the doctor?” I’ll ask. “No” or “Not recently” is often the response.
I’ve also heard it said that we judge ourselves by our intentions while others judge us by our impact upon them.5
Even good intentions can result in negative impacts. To the extent that there is a gap between those perspectives, there is a gap in insight — a civility gap. Closing this gap enhances civility and is entirely dependent upon effective communication, both sending and receiving.
In any civilized culture there are rules, written and not, that guide comportment in the company of others. By age 16, George Washington, the first American president, had collected 110 Rules
of Civility and Decent Behaviour in Company and Conversation.6 Rule number 12 states: “Shake not the head, feet, or legs; roll not the eyes; lift not one eyebrow higher than the other; wry not the mouth; and bedew no mans face with your spittle by approaching too near him
when you speak.”
Clearly, the important messages of non- verbal communication have long been known. Eye contact, facial expression and body positioning all require conscious attention in order to facilitate effective communication.
Smile a little when appropriate; adjust your facial expression and posture to demonstrate attentiveness and concern about what is being said; unfold your arms into a more relaxed posture; and George Washington reminds us to sit back and give our colleague enough physical space to feel comfortable.
When The Situation Is Urgent
The pressure of a health care emergency is not a rudeness rationale. The ABCs of communication in urgent situations (Awareness, Breathe, Communicate Civilly) were described in the last
“Fundamentals” article (#2: Be Aware).7
Civil communication in this setting involves directive, but respectful, language designed to motivate appropriate responses from colleagues and co-workers in the most efficient and timely manner possible. Skillfully done, everyone wins: doctor, colleagues, co-workers, patients. Here are some suggestions to enhance effective communication in the heat of the moment:
- Speak in a firm, but unhurried manner.
- Be clear, concise and crisp in your directions and choice of words.
- Use sufficient volume to be easily heard by everyone present, without shouting or yelling.
- Repeat yourself, if necessary, using the same approach.
- Choose a tone that conveys a sense of support. Do your best to filter out any anger or frustration you may be feeling.
- If some of those emotions do assert themselves, explain them rationally and sedately as soon as possible.
- Avoid using profanity.
- Never embarrass, humiliate or belittle anyone — ever — regardless of their role and status.
- Check with the team member to whom responsibility has been directed to be sure they have received your directions properly.
- Be open to expressions of concern from any co-worker on the team.
- Debrief kindly with others after the event to explain your approach during the crisis.
Communication In The Digital Age
Electronic communication and social media have changed so much about the way professional communication takes place.
Like all innovation, electronic and online communication offers many benefits, but also pitfalls that open the door on new forms of incivility. Whether it’s an entry into an electronic medical record, email, tweet or blog, there appears to be something about sitting at one’s computer that permits unpleasant messaging of all forms. I have seen gratuitous comments slagging a colleague’s clinical skills; exhortation for open defiance of workplace administrative policy; criticism of hospital leaders in clinical records, blaming them for negative patient care outcomes; endless email harangues, one doctor in conflict with another; and so on. None of these forms of communication are helpful, effective or civil.
Our thinking and communication practices need to evolve along with the digital revolution in order to preserve personal and professional integrity and high-quality relationships in the workplace.
As the Canadian Medical Association Code of Conduct affirms: Treat your colleagues with dignity and as persons worthy of respect.8 This ought to be the case whether our communications are face to face, in writing, online, in social media, or in any other form of communication in the digital age.
Here are some thoughts about maintaining civility in electronic and online communication:
- Keep professional and personal communications separate. It’s so easy to blur the lines between our private lives and work lives and the sharing we choose for each.
- Email communication should be brief and respectful. Use face-to-face communication to resolve conflict.
- Consider all comments posted online to be public. Would you say them to, or about, someone in person, in front of others?
- Be mindful and respectful of local corporate/institutional social media policy when functioning as an advocate within the health care system. The necessary role of advocate and the right to free speech do not protect physicians from the consequences of libel and defamation. 9
- Remember that digital communication never goes away. Consider that the uncivil comment you make in a moment of pique often can’t be taken back, and the record is permanent!
- It is our ethical obligation not to impugn the reputation of col – leagues.8 Pause for a moment, especially if your emotions are high, before completing any digital entry or pressing “send.” Re-read the message later. Ask yourself: “Is there anything defamatory about this message? How would I feel if this were a message posted by someone else referring to me?”
Our professional goal is to heal whenever possible and to comfort always. We are honoured to work and connect closely with others on this mutual mission.
Civility is the vehicle we need to deliver our skill, knowledge and compassion to others.
Effective communication is at the heart of a caring and civilized profession. Choose civility
Previous articles in “The Five Fundamentals of Civility for Physicians” series are available on the Physician Health Program website at http://php.oma.org.
Dr. Michael Kaufmann is Medical Director of the OMA Physician Health Program (http://php.oma.org/) and Physician Workplace Support Program. Dr. Kaufmann would like to thank PHP and PWSP colleagues and staff for their suggestions and support in the preparation of this series of articles.
1. Kaufmann M. The five fundamentals of civility for physicians: #1 – respect others and yourself. Ont Med Rev. 2014 May;81(5):19-21.
2. Forni PM. Choosing Civility: The 25 Rules of Considerate Conduct. New York, NY: St. Martin’s Press; 2003, p. 51.
3. Miller WR, Rollnick S. (2002). Motivational interviewing (2nd ed). New York: Guilford Press).
4. Forni PM. Choosing Civility: The 25 Rules of Considerate Conduct. New York, NY: St. Martin’s Press; 2003, p. 144.
5. Stone D, Heen S, Thanks for the Feedback: The Science and Art of Receiving Feedback Well. New York, NY: viking; 2014, p.88
6. Foundations Magazine. George Washington’s rules of civility & decent behaviour in company and conversation. [Internet]. Pasadena, CA: Foundations Magazine; c1996-2012. [about 20 screens]. Available at: http://www. foundationsmag.com/civility.html. Accessed: 2015 Jan 7.
7. Kaufmann M. The five fundamentals of civility for physicians: #2 – be aware. Ont Med Rev. 2014 Sep;81(8):32-5.
8. Canadian Medical Association. CMA Code of Ethics. Ottawa, ON: Canadian Medical Association; 2004 [last reviewed 2012 Mar]. Available at: https://www.cma.ca/Assets/assets-library/document/en/ aboutus/PD04-06-e.pdf. Accessed: 2015 Jan 7.
9. Canadian Medical Association. Social media [guidelines]. Ottawa, ON: Canadian Medical Association; 2012. Available at: https://www.cma.ca/Assets/assets-library/document/en/advocacy/CMA_Social_Media-e.pdf. Accessed: 2015 Jan 7.