Civility and Academic Advancement: Evaluating Its Roles in United States Medical School Appointment,Promotion,and Tenure Policies

Abstract

Civility, encompassing respect and courtesy, is fundamental to healthy workplace environments but remains inconsistently addressed in academic medicine. This study investigates whether United States (U.S.) medical schools include civility as a criterion in Appointment, Promotion, and Tenure (APT) policies. From August to October 2024, we reviewed publicly accessible APT documents from 143 U.S. medical schools and identified 103 eligible schools. We conducted a keyword-based content analysis using 21 civility-related terms grounded in peer-reviewed literature. While 58.3% of documents referenced professionalism and 23.3% referenced respect or collegiality, only 4.9% mentioned terms like “civil,” “bully,” or “mistreat.” Although 26.2% of APT documents referenced codes of conduct, none included accessible links or consequences for uncivil behavior. Our findings align with the American Association of University Professors’ (AAUP) position that discourages civility as a promotion criterion. However, excluding civility from APT policies may allow incivility to persist unchecked, which can ultimately negatively impact patient care and the healthcare environment. These results suggest the need for standardized institutional processes to report and address incivility, supporting a safe academic environment.

Keywords

civility promotion academic advancement policy

Introduction

Civility is an essential feature of daily human interactions and involves basic courtesy and respect toward other people.^1,2 Incivility includes behaviors such as microaggressions, verbal abuse, racism, sexual harassment, bullying, gossiping, intimidation and exclusion.³ Incivility impacts both individuals and the overall workplace culture. On a personal level, those subjected to uncivil behavior may be excluded from organizational processes, representation, and the collaborative efforts essential to daily work.⁴ Others may experience rejection of their contributions such as having one’s expertise, knowledge, suggestions, or practical work dismissed from patients, colleagues and superiors. Moreover, some individuals may experience disempowerment via negative talk such as yelling, berating, belittling, or being scrutinized by colleagues.⁵

At the organizational level, incivility is associated with lower job satisfaction, reduced commitment and engagement, and higher turnover.⁶ In healthcare, however, incivility is often rationalized or dismissed. Bar-David describes common justifications, including “in a high-pressure environment, it’s okay to skip the niceties;” “people shouldn’t be so sensitive—if you want to enter the kitchen, you have to tolerate the heat;” and “physicians can’t be held accountable for abrasive behavior,” “we’re like a family—we don’t have to monitor everything we say to one another.”⁷ These beliefs create blind spots that obscure the problem of incivility among faculty. Moreover, exposure to and experience of uncivil behaviors can perpetuate a cycle of further incivility.⁴

Evidence suggest that faculty experienced incivility directly extends to patient care. Freedman et al found that experiencing or witnessing incivility was associated with a 19-75% reduction in the odds of key safety behaviors including teamwork, reporting patient safety events, organizational learning/improvements, management support for safety, and communication openness.⁸ Higher rates of reported incivility are also associated with increased risk for near misses, medication errors, nosocomial infections, falls, post-operative complications, and poorer procedural and diagnostic clinical performance.^8-14 Collectively, incivility undermines concentration, communication, ability to learn, confidence, interpersonal trust, and workplace psychological safety.¹⁵ Therefore, given these negative impacts on healthcare providers and their patients, addressing incivility in academic medicine is imperative.

Unfortunately, uncivil behaviors are rampant in healthcare, with nearly 90% of health-care workers reporting frequent exposure to incivility.^1,16,17 Healthcare providers frequently experience incivilities within their own professional discipline, such as nurse to nurse, instead of across disciplines such as physician to nurse.¹⁸ For academic medical faculty, perpetrators of incivility most commonly are first superiors and colleagues, followed by nurses and patients.^19,20 In fact, a mere 5% of faculty and administrators perceive that faculty members work well together.²¹ Almost one-third of physicians report receiving weekly or daily rude, dismissive or aggressive communication from other doctors.²² This is especially relevant in academic medicine since faculty not only educate the future healthcare workforce but also simultaneously provide patient care. While medical and allied health professional leaners, students, residents, and fellows are technically protected from incivilities by policies of training governing bodies, similar protection policies for practicing physicians are institution-dependent and lack standardization.^23,24 Additionally, implementing consequences for perpetrated incivility depends on leaders being and feeling empowered by their institutions. These data underscore a pressing need for institutional and national standards that promote civility, explicitly prohibit discourteous and egregious behavior, and foster a psychological safe environment that supports all members of the healthcare team in delivering high-quality patient care.

Since academic medical institutions rely on policies to shape the cultural norms within which faculty work, it follows that these same policies could articulate expectations for civility. One powerful governance mechanism with the potential to function as an upstream determinant of the healthcare environment are Appointment, Promotion and Tenure (APT) policies. Advancement in academic medicine is marked by a sustained record of excellence and impact across clinical care, teaching, research, and service. These same domains are the very categories that affect patient care. Since promotion serves as a major incentive, one potential strategy for addressing incivility is to incorporate expectations for civility into promotion criteria, or, conversely, to prohibit academic advancement when such behavior is absent. Notably, the American Association of University Professors (AAUP) argues that civility should not factor into promotion decisions,²⁵ yet the well-documented consequences of incivility in academic medicine suggest that APT policies could play a foundational role in shaping faculty culture, and by extension, the conditions under which clinical teams collaborate.

The central aim of this study was to determine whether United States (U.S.) medical schools assess civility within their APT documents. By systematically examining these documents for the presence—or absence—of civility as a criterion for academic advancement, we sought to understand if these powerful documents play a role in articulating expectations for professional conduct.

Methods

From August-October 2024, we used publicly available websites to access APT governance documents from 143 U.S. accredited M.D-granting medical schools. If website searches did not yield results or required an institutional login access, that school was excluded.

Two reviewers conducted independent searches of keywords associated with civility within each of the accessible APT documents and any discrepancies were resolved though discussions and cross referencing to consensus definitions established through a comprehensive analysis of peer-reviewed literature (Table). Although concepts such as civility, professionalism, collegiality, and mistreatment are often described together, each represents a distinct construct with partially overlapping boundaries. Civility refers to behaviors that promote respect and considerate interpersonal interactions.^1,2 Professionalism encompasses the broader ethical and behavioral standard expected of clinicians and faculty, including accountability, integrity, and commitment to excellence.²⁶ Collegiality reflects behaviors that facilitate effective collaborations, shared decision making and mutual support among peers.²⁷ In contrast, mistreatment includes behaviors that violate professional norms such as harassment or bullying.²⁸ We included these constructs, along with 17 additional keywords (accept, behavior, bully, conduct/code of conduct, consequences/repercussions, considerate, courtesy, decorum, defend, discrimination, genial, harass, hostile, integrity, polite, respect, and tact) because they are often referenced when interpreting workplace behaviors, suggesting that they function as an interconnected but not interchangeable framework. This also reduced the risk of overgeneralizing any single construct to all forms of interpersonal or organizational behavior. We used descriptive statistics to analyze the data. This study was approved by Nationwide Children’s Hospital Institutional Review Board.

Results

Among the 143 U.S. medical schools, we obtained APT documents from 103 schools (72%). The following base key words occurred most frequently: professionalism (58.3%, n=60), respect (23.3%, n=24), collegial (23.3%, 24), integrity (20.3%, n=21), harass (11.7%, n=12), civil (4.9%, n=5), bully (4.9%, n=5), mistreat (4.9%, n=5), and consequences (2.9%, n=3). Examples of each of these frequently appearing terms can be found in the Table 1. The following terms were mentioned least frequently among the APT documents: courtesy (2.9%, n=3), considerate (2.0%, n=2), and tact (0.9%, n=1). The terms “decorum,” “genial,” and “polite” were not found in any of the documents. Codes of conduct were referred to in 26.2% (n=28) of APT documents; however, none of these documents had accessible links to the referred codes. None of the APT documents described consequences of uncivil behavior.

Table 1.

Highest Frequency Base Search Terms, Definitions and Examples in APT Documents

Search Term	# APT documents with search term present	Definition	Definition best reference	Example
Bully	5	Offenders abusing positions of authority and intentionally targeting individuals through persistent negative behaviors to impede education or career growth.	Iyer MS, Way DP, MacDowell DJ, Overholser BM, Spector ND, Jagsi R. Bullying in Academic Medicine: Experiences of Women Physician Leaders. Acad Med. 2023;98(2):255-263.	“Intimidation includes but is not limited to stalking, bullying, or engaging in verbal, written, expressive, or physical actions that intentionally or recklessly frighten or coerce an individual, or that would be viewed by a reasonable person as such.” (University of Oklahoma Health Sciences Center)
Civility/Civil	5	Civil behavior involves treating others with dignity, acting with regard to others’ feelings, and preserving the social norms for mutual respect.	McCullough LB, Coverdale J, Chervenak FA. Professional virtue of civility and the responsibilities of medical educators and academic leaders. J Med Ethics. 2023;49(10):674-678.	“Because of their roles within the School of Medicine, faculty members, in particular, are expected to treat all members of the Stanford Community with civility, respect and courtesy and with an awareness of the potential impact of their behavior on staff, students, patients and other faculty members.” (Stanford University)
Collegial	24	Collegiality is instantiated in the relationships that emerge…and in the manner in which members …interact with and show respect for one another, work collaboratively in order to achieve common purposes, and assume equitable responsibilities for the good of the unit as a whole.	Dawson DD, Morales E, McKiernan EC, Schimanski LA, Niles MT, Alperin JP. The role of collegiality in academic review, promotion, and tenure. PLoS One. 2022 Apr 6;17(4):e0265506	“Further, Jefferson’s appointment, promotion and tenure systems are aligned with the university’s desire to provide a culture that promotes excellence in achievement and the life-long professional growth and personal wellness of its TJU Faculty Handbook students and faculty. The university achieves this culture by setting clear expectations for achievement, providing timely, relevant feedback, and by fostering a collegial, supportive environment.” (Thomas Jefferson University)
Consequences	3	Effect (change or non-change), usually associated with an event or condition or with the system and usually allowed, facilitated, caused, prevented, changed, or contributed to by the event, condition, or system.	Consequences. National Institute of Standards and Technology. https://csrc.nist.gov/glossary/term/consequence.	“Faculty members must be sensitive to the harmful consequences of professorial or student conduct that perpetuates stereotypes or prejudices. Failure to abide by and uphold these specific responsibilities may result in disciplinary action including, but not limited to, suspension or termination.” (Howard University)
Harass/ harassment	12	Repeated and persistent behaviors towards another with the intent to torment, undermine, frustrate or provoke a reaction.	Siad FM, Rabi DM. Harassment in the Field of Medicine: Cultural Barriers to Psychological Safety. CJC Open. 2021;3(12 Suppl):S174-S179.	“UCSF is committed to maintaining a community in which all individuals, including faculty, can work in an atmosphere free of harassment, exploitation, and intimidation. ‘Quid pro quo’ sexual harassment occurs when an individual in authority or power jeopardizes another individual’s future academic career through job discrimination, demotion, withheld promotion, or a decreased grade unless sexual favors are granted. A second form of sexual harassment is often subtle and involves a ‘hostile environment’ in which an individual engages in unwelcome sexual behavior that creates an offensive work or learning environment.” (University of California, San Francisco)
Integrity	21	Integrity is the bedrock virtue, and it is defined by a commitment to practice medicine in accord with the standards of intellectual and moral excellence.	Coverdale JH, Roberts LW, Balon R, Beresin EV, Louie AK, Guerrero AP, Brenner AM, McCullough LB. Professional Integrity and the Role of Medical Students in Professional Self-Regulation. Acad Psychiatry. 2016 Jun;40(3):525-9.	“Faculty members are expected to be role models of collegiality, integrity, scholarship, and excellence in their professions.” (University of Michigan)
Mistreat	5	Mistreatment includes offensive, harsh, or insulting speech as well as threats of physical contact, inappropriate physical contact, sexual harassment, humiliation of learners, and discrimination.	Lind KT, Osborne CM, Badesch B, Blood A, Lowenstein SR. Ending student mistreatment: early successes and continuing challenges. Med Educ Online. 2020;25(1):1690846.	“Professionalism is defined as conduct in the work environment, which includes creating an environment free from mistreatment or inappropriate behavior; working respectfully with others; maintaining morality and ethics in dealing with colleagues, learners, and patients; maintaining confidentiality, and acting with integrity, honesty, and trustworthiness.” (University of North Carolina)
Professional	60	Habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served.	Epstein RM, Hundert EM. Defining and assessing professional competence. JAMA. 2002 Jan 9;287(2):226-35.	“Faculty members on all tracks are expected to exhibit professionalism in all aspects of their work. Faculty who conduct research or investigations should carry out their investigations with professional and courteous interaction with colleagues in Department, School, University, and the field. With respect to their teaching responsibilities, faculty should behave courteously and professionally with trainees, students, and colleagues.” (Rutgers Health New Jersey Medical School)
Respect	24	In the literature, manifesting ‘respect’ is related to positive attitudes toward human worth and the dignity of every individual; maintaining non-judgmental attitudes toward human diversity and uniqueness among patients; support for patient autonomy (including shared decision-making with patients and listening); suitable attention to privileges and codes of conduct; and maintaining privacy and confidentiality. Other definitions include respectful interactions with family members and colleagues.	Karnieli-Miller O, Taylor AC, Cottingham AH, Inui TS, Vu TR, Frankel RM. Exploring the meaning of respect in medical student education: an analysis of student narratives. J Gen Intern Med. 2010;25(12):1309-1314.	“All faculty members, regardless of rank or pathway, are expected to conduct themselves professionally at all times and to promote the institutional core values of integrity, respect, diversity and inclusion, teamwork, creativity, excellence, and safety.” (University of Arkansas for Medical Sciences)

Discussion

The majority of U.S. medical schools do not consider civility as a category for promotion and tenure. While less than one-third of U.S. medical schools refer to codes of conduct to help guide proceedings regarding civility in the workplace, these codes exist separately from the APT guidelines, further suggesting that there is not a standardized set of criteria for incivility in promotion and tenure evaluations.

These data align with the AAUP’s stance that civility should not be included in the criteria for academic advancement.²⁵ The AAUP also argues that collegiality—a term we searched for in APT documents—should not be used as a standalone metric for promotion. They caution that “the current tendency to isolate collegiality as a distinct dimension of evaluation…poses several dangers…[including] threaten[ing] academic freedom…and invit[ing] the suppression of dissent…when even the occasional malcontent [has] been known to play an invaluable and constructive role in the life of academic departments and institutions.”²⁹ However, in the same statement, the AAUP also asserts that “professional misconduct or malfeasance should constitute an independently relevant matter for faculty evaluation…so, too, should efforts to obstruct the ability of colleagues to carry out their normal functions, to engage in personal attacks, or to violate ethical standards.”²⁹ Taken together, these statements suggest that faculty unprofessionalism and perpetrated mistreatment should be evaluated but only outside of the confines of academic advancement. This raises the question-- what national standard then, since one currently does not exist, could be implemented to dissuade uncivil behavior?

Because promotion is a highly valued individual incentive in academic medicine, APT policies inherently exert great influence on faculty and institutional leaders. In practice, faculty tend to a hierarchy of documents: first APT documents; then faculty bylaws and governance procedures (typically when navigating authority or decision making conflicts); followed by clinical protocols; compensation and effort policies; teaching and training policies; and less frequently, codes of conduct and/or professionalism policies—usually only when conflict arises.^30,31 This pattern suggests that faculty selectively attend to policies tied to meaningful incentives or consequences.

APT documents are uniquely powerful because they determine career advancement, making them stronger drivers of behavior than stand-alone codes of conduct. When civility is not embedded in APT criteria, there is little formal incentive to prioritize it. Reevaluating APT content--and at minimum linking these documents to codes of conduct--could better align institutional expectations with professional behavior and shape upstream conditions in the clinical environment.

Given the current absence of a unified national standard for civility in academic medicine and while simultaneously upholding academic freedom without compromising the core values of academic discourse, U.S. medical schools may consider delineating other pathways to foster civility.^25,29 Such efforts may be framed and grounded in the principles of humanism in medicine, including human interests, values, dignity, empathy, and compassionate care. Humanism-aligned professionalism emphasizes that relational behaviors, such as respect, trustworthiness, and ethical engagement, are essential to high quality medical education and clinical care.^1,32-34 For example, recognizing that uncivil behaviors undermine the moral goals of healthcare and erodes the humanistic foundation of medicine, institutions could develop zero-tolerance and zero retaliation policies for reporting incivility through confidential mechanisms.^23,24,35,36 Given incivility’s documented harms, institutions should also empower leaders to have crucial conversations about lapses in civility and support them in delivering consequences for continued egregious behavior.³⁷ Finally, beyond linking codes of conduct within APT documents, institutions could foster civility by developing programs that provide restorative support for affected individuals, thereby aligning institutional expectations with the humanistic ideals essential to the practice of medicine.

Implications for Patient Experience

Patient experience was not measured in this study. Nevertheless, these findings informs the understanding of upstream structural conditions, including the inherent hierarchy in academic medicine that shape clinical environments. Future research could use other evaluative methods such as 360-degree evaluations, workforce engagement/pulse surveys, psychological safety reports to determine whether civility is being cultivated through institutionally established mechanisms.

Limitations

While we successfully obtained and evaluated APT documents from over 70% of U.S. M.D.-granting medical schools, we did not include similar documents from D.O.-granting institutions, potentially missing references to civility and consequences for uncivil behavior. Additionally, we did not conduct a separate review of the referenced codes of conduct to determine whether incivility could affect a faculty member’s academic advancement or evaluate if these codes had a minimal set of criteria that would raise concern for incivility. Finally, we did not triangulate the APT documents with institutional governance policies to assess whether consequences for incivility might be enforced through mechanisms other than promotion.

Conclusions

Our study highlights that most U.S. medical schools do not use civility as a criterion for promotion and tenure. Since incivility is prevalent in academic medicine, institutions may consider developing standardized processes that allow faculty to report incivility and also creating programs that support leaders in addressing uncivil behaviors. The impact of incivility cannot be overstated, as it adversely affects faculty members, their teaching, scholarship, and service—core tenets emphasized by both the AAUP and medical schools in consideration for promotion. More importantly, incivility carries significant negative consequences for targeted individuals, affecting their well-being, performance, and professional engagement, the workplace culture, and above all, the quality of care that they provide to patients.

Footnotes

ORCID iD

Maya S. Iyer

Ethical Considerations

This study (STUDY00003551) was approved by Nationwide Children’s Hospital.

Consent to Participate

Patient consent is not required or applicable for this study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data is available and can be shared.*

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