McCullough and colleagues draw an historical line from the writings of Percival, who found himself resolving arguments (sometimes violent) between physicians, surgeons and apothecaries, to the concept of civility as a professional virtue and duty. The authors show that civility is a prerequisite to effective cooperation, which itself underpins patient safety and positive clinical outcomes—desirable endpoints of any discussion about healthcare. They exhort academic leaders to teach, role model and reward correct behaviours.1 Why then, as a clinician manager with a (...) deep interest in fostering civility and psychological safety, am I not satisfied? Three reasons: the paper does not adequately explore the reasons why, its focus is largely restricted to academic institutions, and it does not encompass the non-clinical workforce; as a result, its proposed solutions appear ungrounded. Why are ‘good people’, who were attracted to careers that demand altruism and empathy, uncivil in the workplace? What are the competing goals that result in curt, disrespectful or downright rude exchanges? This has been studied. Leape et al concluded that endogenous factors such as personality, insecurity, anxiety, depression, narcissism and responses to prior …. (shrink)

McCullough et al 1 confront a challenge that no organisation has fully eradicated: incivility. They emphasise that civility is not merely a matter of common decency and good conduct but also a moral imperative, an aspirational value that should be promoted and modelled by all the members of the institutions and throughout all the stages of practitioners’ careers. In their fusion of ancient wisdom and philosophical classics with their own insights on contemporary workplaces, they forward a defensible case for why (...) civility matters and is worthy of continuous contemplation. Given the clarity and persuasion of their piece, I do not seek to challenge their claims. Instead, I will complement their argument with a perspective highlighting the difficulties of identifying low-level workplace mistreatments and responding to them impartially. While organisations should certainly not skimp on their efforts to promote civility and hold their transgressors accountable, there are nonetheless boundaries to good intentions.2 The unexamined pursuit of civility, if characterised by inconsistent definitions of harm and inappropriate allegations of uncivil acts, runs the risk of fostering its own toxicity spirals. With the hope of contributing to the exchange initiated by McCullough and colleagues, I briefly highlight …. (shrink)

In his feature article,1 McCullough LB et al highlights the importance of civility among medical educators and academic leaders in shaping the professional habits of junior doctors. He emphasises the role of medical educators in correcting unprofessional behaviour and emphasises the need for academic leaders to motivate junior doctors to develop virtuous professional habits. The relationship between junior doctors and medical educators can be likened to that between students and teachers. Through active or passive learning from medical educators, junior doctors (...) gain the necessary knowledge, experience and professional virtues. Academic leaders, as prominent experts in their field, play a guiding role in this process. Therefore, their relationship with junior doctors is akin to that between idols and fans. In this regard, academic leaders can serve as exceptional role models for guiding junior doctors to develop the inclination to …. (shrink)

McCullough et al have taken up an important issue that is highly interesting from a theoretical as well as from a practical standpoint in drawing attention to (in)civility as a matter of professional ethics: As a ‘low intensity deviant behaviour’1 p3 incivility seems to widely escape the scope of professional norms as well as legal regulation and jurisdiction. At the same time, empirical evidence suggests that incivility occurs frequently in healthcare and might have an enormous negative impact on the quality (...) of patient care. Against this background medical ethics should no longer hesitate conducting profound conceptual and empirical research on (in)civility as an ethical issue. The authors’ analysis sheds light on the different dimensions of practical rationality as involved clinical reasoning and behaviour. Whereas I agree with their idea of civility being a ‘professional virtue with cognitive, behavioural and social components’1 p2 I cannot fully support their claim of the cognitive component lasting on a ‘commitment to excellence in scientific and clinical reasoning’ (ibid.). Instead I would like to argue that professionalism comprises both, civility as …. (shrink)

We agree with McCullough, Coverdale and Chervenak1 that ‘medical educators and academic leaders are in a pivotal and powerful position to role model’ to counter ‘incivility’ in medicine, which can include ‘dismissing’ or ‘demeaning others’. They note that ‘women may be at greater risk for experiencing incivility compared with men’, as may other individuals who experience ‘patterns of disrespect based on minority status’. The authors promote ‘professionalism’ and ‘etiquette’ to foster civility within medicine. Yet theory and experience suggest that medical (...) educators and academic leaders are also in powerful positions to mobilise these concepts to perpetuate exclusions from, and biases within, medicine, upholding racist, sexist and ableist norms. Feminist methodology reveals how ethical theorising historically excluded views and experiences of marginalised individuals and groups and provides frameworks for interrogating supposedly universal norms. Presuming dominant values and experiences reflect universal ones can further marginalise already oppressed groups and individuals. A feminist analysis reveals how ‘professionalism’ or ‘etiquette’ are historically shaped by white or male identity and experience, including norms of attire, hair, accessories, speech or behaviour. Part of the hidden curriculum of medicine becomes intuiting how leaders implicitly or explicitly define ‘professionalism’. McCullough et al define ‘professionalism’ in medicine as ‘sustained commitments to scientific and clinical excellence… making the protection and promotion of health-related interest the physician’s primary concern …. (shrink)

Incivility poses a serious threat to any healthcare system striving for effectiveness without sacrificing the requirements of humanity. Threats to civility within healthcare not only come from individual ‘bad apples’ exhibiting borderline and inacceptable behaviour, as seen in many ‘high-tech, high-risk, high-responsibility’ environments such as operating or emergency rooms.1 They may also be facilitated by ‘bad trees’ or system-immanent, poor healthcare environments.2 This may be the case when healthcare administrations, facing the challenges of political austerity, set budgetary targets that cannot (...) be met without seriously compromising quality of care, patient safety, and the well-being of those professionals working at the ‘sharp end’. Both individual and systemic factors fuel the occurrence of incivility,3 and individuals—rather than institutions—are often held responsible for acts of incivility. Nevertheless, explaining what might trigger incivility can never serve as a justification for it, because ‘in-civility’ —in its literal sense—breaches basic rules of civic cooperation and goodwill, and thus grossly violates the social …. (shrink)

McCullough et al ’s article about the professional virtue of civility makes a persuasive case that civility should be a core value in medical education, and that civility facilitates the development of organisational cultures committed to excellence in clinical and scientific reasoning.1 In particular, the negative implications of incivility on the well-being of individuals, on team-working dynamics and on patient safety, creates a strong argument that incivility from healthcare professionals is entirely unacceptable. However, in terms of professional attitudes, civility is (...) the bare minimum that modern clinicians require. Modern healthcare involves complex systems in which patients are likely to encounter multiple different healthcare professionals in the course of their investigation and treatment.2 No one clinician has all of the skills or knowledge that patients need and so the practice of medicine is necessarily collaborative. However, civility can be achieved by individuals who are content to politely and respectfully coexist in …. (shrink)

In our ‘The Professional Virtue of Civility and the Responsibilities of Medical Educators and Academic Leaders’,1 we provided an historically based conceptual account of the professional virtue of civility and the role of leaders of academic health centres in creating and sustaining an organisational culture of professionalism that promotes civility among healthcare professionals and between medical educators and learners. We emphasised that any adequate understanding of the virtues, including professional virtues, has cognitive, affective, behavioural and social components. Some of the (...) commentators expand on these components in important ways. Xuhao et al emphasises the importance of role models, especially in the hierarchical context of medical education.2 The hierarchy of faculty in the senior position and junior doctors and other learners below them has characterised medical education for centuries. Xuhao et al rightly call for academic leaders to shape this hierarchy in a morally responsible way, by becoming ‘exemplary role models’.2 Berry, a clinician manager, in critiquing our account, calls for an increased appreciation for the psychological and environmental factors that might explain why uncivil behaviour occurs.3 …. (shrink)

Several months ago, an Israeli resident in emergency medicine engaged in a hunger strike to protest 26-hour shifts. His protest was part of a country-wide struggle of medical residents from all disciplines against such long shifts, arguing that they are a thing of the past, and that they harm patient care. While there is actually no evidence that long shifts harm patient outcomes, they very likely reduce civility among staff members and towards patients.1 Two kinds of strategies are possible to (...) address this likely source of incivility: expect and train residents to be kinder and more patient towards their peers and patients, or do away with long shifts. Therein lies the tension in implementing the case for civility made by McCollough et al 2 should we invest in agent-based or system-based interventions? Virtue ethics is prominent in discussions of the professional duties of healthcare providers (HCPs). A common theme that threads throughout these discussions is that HCPs ought to, or are expected to behave in a kind, patient and sensitive manner towards their peers and patients, …. (shrink)