Cultivating civility and collegiality in medical training and practice

Sir,

With ever-increasing pressures on public healthcare systems and an increasingly aggressive medicolegal environment that creates a defensive culture, civility and collegiality have unfortunately become increasingly eroded over time.

Recently, some authors have called for a re-look into how we can enhance collegiality and civility as professional or moral imperatives of medical training and practice,^1,2 especially given their effects on physician well-being, patient care, as well as junior trainees’ personal and professional development and sense of belonging to the medical collegium.^2,3

A wide spectrum of uncivil and uncollegial behaviour in clinical medicine, including rudeness (being dismissive in verbal interactions or by non-verbal body language), gossiping, back-stabbing, arguments, aggression, humiliation, power struggles, and various forms of bullying, harassment and discrimination. ³ In a highly hierarchical practice environment, junior trainees and residents are often caught in the intra- and inter-disciplinary conflicts and cross-fire, either as a primary target or secondary bystander.^3,4

We therefore suggest practical ways to cultivate higher levels of collegiality and civility in medical training and practice. In our view, within a hierarchical medical system, constant re-calibration and evolution of institutional culture, set by senior management and leaders of healthcare teams, is ever more crucial. At the same time, individual trainees must also be given the necessary tools to navigate the inherent challenges in the social realm of clinical practice environments.

Firstly, we suggest that collegiality should be one of the core values of healthcare institutions where healthcare workers, who serve patients, should not be antagonistic or demonstrate uncivil behaviour towards one another. Interventions to promote collegiality should aim to target its three constituent components of culture (shared professional purpose), behaviour (interpersonal and professional relationships) and structure (organisational governance).^2,5

To promote cultural collegiality, multidisciplinary events should be held to showcase the work and recognise the efforts of various clinical, para-clinical and allied health disciplines and individuals at different levels of the hierarchical ladder (even junior medical trainees or students) in impacting patient care and clinical outcomes. This will not only create greater awareness of their important healthcare roles, but also nurture a deeper sense of belonging and shared purpose. Innovative ideas such as experiential learning, for example, “a day in the life of (another professional)” may engender greater professional empathy and understanding towards one another. Behavioural collegiality can be enhanced through shared spaces for organic workplace interactions, empathy exercises through simulation practices or case discussions of workplace conflicts, ² and incorporating collegial language into everyday communication/handover frameworks (e.g., K-ISBAR model ⁶ ).

Organisational collegiality is enhanced when senior staff or leaders of healthcare teams role model expected professional behaviour in both public and personal spaces so as to set the tone for what is acceptable or unacceptable professional conduct. Selection of leaders would therefore be predicated not only on clinical or academic excellence, but also multi-source anonymous feedback on their character and espoused values. Bad practices such as specialty disrespect or undermining of colleagues,^6,7 malignant pimping ⁸ and abuse of power ³ must be disavowed, with such unacceptable conduct spelt out, if necessary by role play, for action to be taken against offending individuals. On the flipside, clinical preceptors must be equipped with the skills to provide constructive or corrective feedback in a palatable and non-judgmental manner. For example, a statement, such as asking a junior physician who performed suboptimally in a clinical task if he/she “has ever been to medical school”, is both hurtful and constitutes a personal attack. Instead, constructive, objective feedback should be directed at the deficiencies displayed in a particular task, with the intention of improving subsequent performance. Moreover, unequal power structures within the healthcare system can be mitigated through role rotations and adoption of transformational healthcare leadership models. ² Importantly, individuals who continue behaving in an uncivil manner should be identified through anonymised channels or multisource feedback in order to provide counselling, and meting out of necessary disciplinary action.

Medical students or juniors should be provided with the relevant communication and interpersonal skills-based training to learn about conflict management in inter-professional practice, setting of professional boundaries, and assertiveness in context of power differentials. ⁹ This could be done through case-based simulation.

Lastly, as the maxim goes: ‘hurt people hurt people’; it is therefore imperative to perform root-cause analyses of uncivil behaviour within healthcare organisations, in order to implement targeted interventions. For example, unkind interactions tend to be common within a medical workforce with high rates of burnout and stress, or amidst a work environment that is harsh and unforgiving.^4,6 Simple measures include duty hour restrictions, improving night call work schedules, opportunity for undisturbed sleep, and provision of adequate staffing, clinical, administrative or technological support. ⁴