While in traffic last month, a man noticed my failed attempts to reach the exit ramp and began to motion other drivers to let me by. His random kindness got me to the airport on time. At the grocery store, a teenager sprinted over to hold the door open for me. I praised him for being so polite and considerate. In my neighborhood, a six year-old boy fell off his bike, so I washed his skinned knee, put a bandage on it, and helped him fix the chain that came off his bike gear. His sweet smile was my reward.

These stories exemplify the backbone of a healthy society: civility. The very word evokes what it represents: courtesy, respect, kindness, good manners, politeness, and considerate actions toward others. You know it when you see it, and its absence can leave you empty, anxious, or even afraid. Civility entails a certain yielding, a voluntary submitting to one another with the understanding that we're all sharing this human experience, together.

WHY SPEAK OF CIVILITY IN HEALTH CARE?

Perhaps mirroring trends in our nation, rudeness, anger, and toxicity are becoming all too common in health care settings. In a 2017 survey of more than 800 U.S. physicians, six in 10 reported absorbing “offensive remarks about a personal characteristic in the past five years,” including comments about the physician's race, gender, ethnicity, age, and weight.¹ According to the survey, and perhaps not surprising, female physicians face bias more often than males.

A 2015 study of 5,385 hospital workers found 5,576 incidents of verbal abuse by patients or visitors over a 12-month period in addition to 2,260 physical threats and 1,180 instances of physical assault.²

Studies also reveal a lack of resources for physicians to handle prejudice or abuse. Only 24 percent of physicians state they document such interactions in the medical record, and only 10 percent report such incidents to an administrator. Alarmingly, 60 percent of physicians reported not even knowing whether their institutions had a “formal process to initiate when patients discriminate” against a member of the medical team, and 49 percent said their organization lacked any training in managing patient bias. ³

Of course, patients are not the only ones who display incivility. Tired or stressed-out physicians and staff can be rude, or worse, to patients and colleagues as well. We have all likely observed this at some point in our careers.

Incivility in the workplace has several detrimental effects on workers. In one study, 48 percent of workers who had been on the receiving end of incivility cut back their work efforts, 66 percent said their performance declined, 80 percent lost work time worrying about the incident, and 12 percent left their jobs.⁴ Interestingly, a separate study found that those who display civility — by thanking people, sharing credit, listening attentively, acknowledging others, etc. — are more likely to be viewed by their colleagues as warm and competent and as leaders.⁵

Having a plan for handling situations in which incivility arises is a necessity in today's practice environment, and it will help keep us safe — physically, emotionally, and spiritually. This plan should include the following:

• Having a set of de-escalation strategies,

• Knowing what to do when incivility crosses the line,

• Knowing what help is available at our institutions,

• Setting healthy boundaries that prioritize our well-being.

INCIVILITY MANAGEMENT 101: DE-ESCALATION STRATEGIES

Knowing that medical professionals commonly face abusive interactions in the workplace, what strategies should we have at the ready to help us handle these stressful or demeaning exchanges? Here are four techniques to try when you encounter incivility:

1. Don't take it personally. Hurting people hurt people. Their incivility may stem from stress, fear, fatigue, illness, or ignorance. Or it may stem from trauma, abuse, or an unfortunate start in life that leaves them judging others through mistaken filters or harming others as they were harmed. Acknowledging their hurt does not justify or excuse their behavior, but it can help reset your perspective and remind you that this isn't really about you. You can then enter the situation with objectivity and be better able handle it with professionalism, wisdom, humility, and emotional agility.

2. Take a timeout. Years ago, I treated a patient who had a mass in the perirectal region. As soon as I entered the exam room, he told me what I must do and what he would do if I didn't. When foul language started flying out of his mouth, I said, “Timeout!” I calmly acknowledged his feelings, asked if we could start over, and left the exam room for a few minutes. When I returned, he was sitting down, calmly reading the newspaper. I looked him in the eye, shook his hand, introduced myself again, and reminded him that I was there to help him.

Giving this patient a second chance to act in a civil manner changed the interaction for both of us. Although he was rude, condescending, and disrespectful at the outset, I knew these behaviors stemmed from fear, and I chose to practice patience and kindness. As he left that day, the man apologized for his foul language and meanness and thanked me for a second chance. He had tears in his eyes, and so did I. Although this approach may not be appropriate or effective in every situation, it produced a good ending for this visit and set the tone for a meaningful relationship.

3. Respond, don't react. Once, a man in his 60s came in for a medication refill and quickly interrupted me to ask where I'm from. Being from Puerto Rico and having lived in the United States since age 18, I can spot whether someone asks this seemingly innocent question from simple curiosity or judgment. Always mindful that some people were immersed in prejudice since childhood, I strive not to react defensively and have disciplined myself to give people the benefit of the doubt. His tone and demeanor alerted me to keep my answers brief and move on — a plan that typically works, but not this time. About two minutes into the appointment, he began to mock my accent.

Instead of reacting from a place of hurt and offense, I took a deep breath. I chose to respond calmly and meet his disrespect with creative confidence. Proudly, I explained my accent reflects the fact that I speak more than one language — a gift that allows me to connect with people of many backgrounds, enriching my life. “I love my accent,” I added, refusing to be diminished while remaining respectful, and I went on with his exam. He countered with a disarmed, “Oh, I guess you're right. I never thought of it that way.”

This approach helped to diffuse the situation and redirect the conversation. The next time I saw the patient, he was on his best behavior.

4. Check your feelings. Being able to de-escalate a situation and rise above a patient's rudeness or other toxic behavior requires tapping into your inner strength, emotional intelligence, and self-control, which may not be possible if you're feeling exhausted, hurt, or defensive. Self-awareness is vital. Take note of your feelings before you respond. For example, in the above situation, had I felt more upset, I could have chosen to leave the room for a moment (giving myself time to regroup) or asked the patient if he'd like to see a different physician. Such actions could help stop the hostility by exposing it, since people who are stressed can be oblivious to their own behavior. However, if you begin to feel unsafe at any point, it's time to move beyond these basic de-escalation strategies.

WHEN INCIVILITY CROSSES THE LINE

Over the course of my career in family medicine, I have had a number of patient interactions that were not just uncivil or disappointing but plain scary, such as caring for combative intoxicated patients, having patients yell threats directly at my face, or examining an aggressive patient in the emergency department with a police officer standing next to me. In these instances, our best attempts at diffusing difficult interactions will probably not be effective, so we must discern when it is time to get help or remove ourselves from the situation.

If your instincts ever make you feel unsafe, do not ignore them; act immediately to ensure your safety. For example, if someone makes you feel uneasy or has behaved inappropriately in the past, you can leave the exam room door ajar and ensure another person is always in the room with you for the interaction. Sit or stand near the door with nothing obstructing your path to a swift exit, and have a solid emergency plan. You may even need a colleague or security person, if one is available, to step in and interrupt the person's behavior (or perhaps you can be the person who steps in on another colleague's behalf).

Years ago, I needed to examine a young man to rule out a sexually transmitted infection. I put on gloves while instructing him where to stand for the exam, and he remarked he'd prefer if I didn't wear gloves. I asked whether he was allergic to latex, and when he added it was simply a preference, I excused myself from the room and told a male physician what happened. My colleague finished the exam and took care of the man's medical needs, and he was promptly discharged from our practice. We never saw him again.

Knowing we have the unswerving support of colleagues in such instances, particularly those involving sexual harassment, is invaluable and necessary for physicians in training and in practice. And now that more than 50 percent of medical students are women, “systematic approaches are needed to ensure that female clinicians can safely treat patients.”⁶

THE INSTITUTION'S ROLE

Health care organizations have an obligation to protect their staff from unsafe and abusive interactions with patients, family members, and the public as well as coworkers. Although not everything can be anticipated, steps must be in place to keep employees safe, both physically and emotionally. This begins with having and practicing emergency procedures (see “How to Prepare for and Survive a Violent Patient Encounter,” FPM, November/December 2018), but it does not end there.

Medical institutions should also adopt policies to address harassment — and enforce them consistently. For example, Penn State's Hershey Medical Center, my alma mater, recently conducted an internal study of discriminatory behavior by patients directed at staff, resulting in a change in its policy. It will now not honor patients' requests for a new physician based on prejudices.¹ This will help educate the public while reassuring physicians their well-being is a priority.

Institutions also have a responsibility to create a culture in which physicians feel comfortable, not judged, when reporting instances of bigotry, rudeness, harassment, or any scenario that causes anxiety or fear. Kimani Paul-Emile, JD, PhD, associate professor of law at the Stein Center for Law & Ethics, has studied the legal, clinical, and ethical implications of racist behaviors by patients toward clinical staff. “Even if you have the best possible policies,” she explains, “if you have a culture or norm of nonreporting because physicians are afraid of being ignored or accused of being overly sensitive, then people won't report.”³ Physicians must trust that their concerns will be taken seriously without negative repercussions. A system-wide overhaul of the culture may be needed in some institutions.

Shame keeps many of us from reporting these embarrassing and demeaning encounters, but it is important to talk about them. Discussing these experiences begins to remove their power and erase the shame that contributes to burnout, anxiety, and disengagement and leads some physicians to leave medicine altogether. If your institution does not provide a venue for this type of dialogue, I urge physicians to seek out mentors or colleagues they can confide in and trust.

THE LIMITS OF EMPATHY, AND THE NEED FOR HEALTHY BOUNDARIES

Empathy can only go so far. Caring for people well includes enforcing healthy boundaries, which has two aspects.

Protecting our safety. First, we must learn to recognize people who are unsafe or inappropriately needy and establish safe and healthy boundaries. Setting limits shows we are caring and wise, not mean, but physicians often feel guilty, as if prioritizing their safety and expecting to be treated with dignity is selfish. At times, we may need to reassign patients to a different physician or even discharge patients. In my experience, physician colleagues recognize these situations more readily while nonclinical administrators are slower to see these unhealthy dynamics or their dangers, sometimes becoming obstacles in the process. Physicians must stand their ground to ensure their safety.

Protecting our hearts. Second, we must not be afraid to say “no” when needed and prioritize self-care and our well-being. Healthy boundaries are an essential component of nurturing a heart of service. Knowing that our needs as human beings will not be neglected is essential to our ability to provide compassionate care. If we allow these negative experiences to harden our hearts or make us cynical or emotionally detached, we've paid too high a price for the privilege of being physicians.

With health care undergoing tumultuous change, physician burnout at an all-time high, and incivility on the rise, we must be alert and discerning. Our institutions have a responsibility to address this issue pro-actively, take reports seriously, and create a culture in which physicians feel both protected and free to report every instance of inappropriate behavior or abuse. Those of us who care for patients must do so with excellence and compassion and set the tone for civility with intention, keeping our teams and ourselves safe while remembering to guard our hearts.