The 5 Fundamentals of Civility for Physicians:

#5 Be Responsible

By Micheal Kaufmann, MD
OMA Physician Health Program

Perhaps the best way to bring this phase of the conversation to a close is to circle back to the starting point of this series, and reflect again upon some concepts captured by the various definitions of civility.1

Civility begins with a fundamental courtesy based upon respect — for ourselves as well as others. Naturally, if we are to make civil behavioural choices, conscious effort based upon self awareness and effective communication skills is required.

Even in the face of conflict and disagreement, civility leaves us, and others, feeling intact and safe. Civility empowers us to take responsibility for our own well-being which, in turn, enables us to do and be our best under all conditions. Individually and collectively, we bear responsibility to inject civility into our professional relationships, communities and culture.

Being Responsible For Ourselves

The way we treat people matters — always and in any situation. For that we are responsible. Extraordinary accomplishment and exemplary behaviour in some circumstances does not permit or forgive belittling, shaming, or any other such treatment of colleagues, coworkers, learners or patients at other times. I have interviewed many amazing doctors and learners who easily and readily dismiss their incivility by pointing out their achievements and positive evaluations — as if these have the power to negate their (even occasional) transgressions.

Our primary mission can also obscure personal responsibility. “I do what I do in the name of quality patient care,” some doctors proclaim, justifying troubling behaviour, oblivious to the paradox. When others on the healthcare team feel the hurtful impact of a doctor’s incivility, they aren’t able to work well with that individual. Patient care can be compromised as a result.

Even more likely to deflect introspection and personal responsibility is the often irresistible urge to blame contextual elements for one’s behavioural choices. Most, if not all, doctors I have interviewed regarding behavioural concerns point toward people, places and things around them which have caused their problems. Certainly, context matters.

Of course there are a myriad of tensions, troubling circumstances, leadership challenges, personality conflicts, even outright injustice that bear down upon us and affect behaviour. Some of those things we can influence, quickly or slowly, but most we can’t.

But, recognizing our internal locus of control, we can take responsibility for our own choices, and civil choices are the ones most likely to have a positive impact on everything and everyone around us.

Being Responsible For Others

Even considering a medical tradition of rugged individualism, there are times when we are “our brothers’ keepers.” Sometimes there are witnesses when a doctor behaves in a manner that is disruptive or hurtful toward others. Maybe we have seen an instance of incivility ourselves. What then? Should we say something? Do something? An observer to an episode of incivility who chooses not to react in any way is a bystander. That form of silence adds to the problem.

Remember, incivility involves at least two individuals who need help: the one whose behaviour is objectionable (who might be unaware, or worse, troubled in some way) and the other who is suffering the impact, often unable to protect themselves. But “stepping up,” seeing a need and deciding to do something about it, is often difficult, especially when considering how to approach the colleague whose behaviour is problematic.

Clarkson talks about the “bystanding slogans” that readily come into our thoughts.2 These are the ones that can block a helpful response. Here are a few of them:

  • “It’s none of my business.”
  • “Someone else will take care of this.”
  • “I don’t want to be hurt myself.”
  • “I don’t know what to do.”

And there are many more. The responsible thing to do is to become aware of these and counter them with more rational and helpful thoughts. Here are some suggestions, considering the examples listed above:

  • “It is incumbent upon me to help — we are all in this together.”
  • “If I don’t say something, it’s likely no one else will and the problem will persist, maybe worsen.”
  • “That person might be suffering in some way and helping them is worth the risk that they might lash out at me.”
  • “I’ll get some advice about what to do next.”

Then the next right thing, as Izzo says, is to “do something, anything.”3

Armed with a sense of responsibility, a little courage, good timing and some practical advice about how to offer constructive feedback, anyone can approach the individual whose behaviour must be challenged. It’s surprising how a particular and simple initial question signals compassion and invites engaging conversation. That question is “Are you OK?” Many times that opening will be enough to help a colleague voice their concerns (usually quite legitimate) and also begin to gain insight into the nature of their behaviour. If nothing else, the individual now becomes aware that their behaviour has been the cause of some upset, and he or she is afforded the opportunity to reflect upon that. They have received the gift of feedback.

And, of course, reaching out to any recipient of hurtful or problematic behaviour is a caring and responsible thing to do as well. The same opening question works very well!

Being Responsible For Workplace Culture

I have heard culture defined as “the way we do things around here.” Workplace cultures vary tremendously, described as collegial, respectful, fragmented, competitive, supportive, toxic, healthy, and so on. More and more doctors work in health care teams even though they may not be directly employed by their hospital or other health care institution. That can set the doctor apart from other co-workers, both practically (they don’t necessarily adhere to the usual local employment policies and procedures) and psychologically (they are health care providers and leaders who bear the brunt of patient care responsibility personally in a manner unlike that of others on the team).

And there are cultures within cultures where the social tone can vary widely and civility values seem to be at odds with one another. So often I have heard how the same doctor can be rude and intimidating in the operating room yet warm and supportive on the wards. Learners describe different cultures as well, experiencing respect in some environments and belittlement in others.

Leadership is key. All doctors are leaders by virtue of their professional standing and the patient care dynamic. But it is the special responsibility of our designated physician leaders, be they department heads, chiefs of staff, University chairs, residency program directors, political representatives and others to understand their role in shaping and guiding workplace and professional cultures. Thoughtful, well-trained and collaborative, these are colleagues entrusted with creating the safe and supportive professional environments where we want to be. In such a workplace, any one of us can lead by seizing the moment, stepping up and forward when our senses and intuition tell us the time is right.

In these complex and dynamic professional environments characterized by stressful political and economic changes, power imbalances, multiple agendas, technological evolution and revolution and so much more, civility as a shared responsibility might be the only way through.

Being Responsible For The Culture Of Medicine

The idea of memes as units of transmissible cultural information(like genes in a biological sense) is

intriguing.4 It can be argued that there are a number of medical memes contributing to the “incivility crisis” (if I can be so bold as to call it that) in the medical profession. Some examples include:

  • A doctor’s sacrifice of vital personal needs (e.g., sleep, nourishment, time with family) in the service of medical training and patient care is virtuous.
  • Superior knowledge and technical excellence permits and forgives rudeness and other forms of incivility.
  • The ultimate responsibility for patient outcomes lies solely with the doctor, thereby justifying any form of workplace behaviour no matter how it might affect co-workers.

I think of these as memes because I have heard about them, observed them and lived them, and others like them, throughout my career in medicine. They inform our attitudes and beliefs. They are modelled for us, overtly or implied, reinforced through training and practice, and passed along to each subsequent generation of doctors. But are they true? Unalterable? Which of our memes ought to be preserved and which ones require change? And continuing the metaphor, should the change be gradual and sporadic (as in genetic mutation) or sudden and deliberate (like infection or genetic engineering)? A culture of civility, like incivility, after all, can spread like contagion or be passed from one generation to the next.

Here, compassion, courage and humility are required. Do we care enough about ourselves, our colleagues, or co-workers (including health care managers and administrators), our workplaces and our profession to challenge our longheld beliefs that might not be serving us well? Our senior colleagues, seasoned by experience, may have a particular wisdom to offer.

The newest members of our profession carry with them modern personal and social values that might improve the humanity of our profession. I submit that opening our minds to these perspectives, or any others that challenge our long-held cultural beliefs, will add to the civility of our profession while simultaneously enhancing patient care.

Conclusion

And so this phase of the conversation, a consideration of Five Fundamentals of Civility for Physicians, comes to a close. We end as we began, by questioning:

  • Are we able to dig deep and find respect at the core of all of our professional behavioural choices?
  • Will we learn, practise and teach selfawareness skills that will enable us to choose civility deliberately?
  • How will we incorporate teaching of effective communication skills into all aspects of medical training and practice?
  • Will we be able to elevate the concept of self-care from a good idea to a cultural value and professional imperative? And finally, maybe most importantly, it is our responsibility to challenge ourselves:
  • Who are we at work and what kind of individuals do we aspire to be?
  • Can we improve relationships among colleagues and co-workers as members of our health care teams?
  • How do we come together to create the most grand medical profession imaginable?

Let’s keep this conversation going. Responsibility is at the heart of a caring and civilized profession. Choose Civility.


References

  1. Kaufmann M. Physician health: the five fundamentals of civility for physicians: initiating an important conversation — series introduction. Ont Med Rev. 2014 Mar;81(3):13-5.
  1. Clarkson P. The Bystander: An End to Innocence in Human Relationships? London, England: Whurr Publishers; 2006.
  1. Izzo JB. Stepping Up: How Taking Responsibility Changes Everything. San Francisco, CA: Berrett-Koehler Publishers; 2012.
  1. Harari YN. Sapiens: A Brief History of Humankind. Toronto, ON: Signal; 2014

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/). Dr. Kaufmann would like to thank PHP colleagues and staff for their suggestions and support in the preparation of this series of articles.