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Mind Your Manners to Minimize Harm

Operating rooms are typically cold and uninviting on their own. Now add the stress of an emergency and a team of men and women camouflaged by caps, masks and scrubs who are unfamiliar with each other. That doesn't leave much room for civility, and when that leaves, the dangers for patients could escalate.

Cedars-SinaiWhen personalities collide in the operating room, and it does happen on occasion, according to research by Andrew Klein, MD, director of the Comprehensive Transplant Center at Cedars Sinai, patients can be at risk. Klein, who recently co-authored a commentary in the Archives of Surgery titled "Barbers of Civility," strongly believes civility in healthcare is greatly needed.

"When people realize what the potential is here, that it doesn't cost anything, and is the least expensive way to improve health care costs, they will catch on," Klein said. "I don't see a down side to it."

Klein co-authored the article with his colleague Pier M. Forni, co-founder of the Civility Institute at Johns Hopkins University, which assesses the significance of civility, manners and politeness in contemporary society.

In the commentary, Klein suggests civility often takes a back seat to self-interest, stress, anxiety, unhappiness and the desire for power and control. What's often left in the healthcare setting is rudeness, or disruptive behavior. In some instances, individuals have become violent, Klein said.

One of the studies Klein used to support his argument was a survey of 50 hospitals and more than 1,500 nurses and physicians. In that survey, 86 percent of the nurses said they had witnessed disruptive behavior by physicians, whereas 47 percent of the physicians made the same claim against nurses.

Studies also showed that young doctors are learning to be uncivil early in their career. According to data that Klein cites in his commentary, of 1,500 medical students evaluated at 16 U.S. medical schools, 42 percent claimed to have been harassed and 84 percent thought they had been belittled. The perpetrators were residents, fellows and clinical professors.

"Do you know the damage I could cause if I overreacted in the operating room? That action could linger throughout the entire case, and bring down the entire team," Klein said. "That negative reaction has the potential to cause harm to the patient."

Klein has introduced several concepts medical institutions could deploy to better civility.
Among them, he suggests that administrators should implement character criteria in the recruitment of staff, trainees and faculty. Hospitals, in particular, traditionally hire on the basis of accomplishment, knowledge, training and productivity. However, he said what should be taken into account is an individual's social skills as well as their productivity and technical abilities.

"There are many talented people out there who are civil," Klein said. "We should not be seduced by the wealth of talent, those who have accomplished a lot, but lack situational and personal awareness."

Klein also suggests surgical leadership provide model behavior for the team.

"We have an opportunity to improve," Klein said. "We work in stressful environments where things can invariably go wrong. Part of the reason we don't solve the problem better is because we are driven apart by our lack of civility and, adding to that is the fact we sometimes don't actually know the people we are working with."

In his own practice, Klein said staff has set up pot-luck lunches and after-hours gatherings as means of introduction. In the near future, Klein hopes to launch an Intranet site that would allow each of his staff members an opportunity to post a picture and other information about themselves.

"Familiarity allows you to fill the well of good will so that when things go wrong you are much more likely to react with understanding," he said.

Only a small percentage of people have this critical civility flaw, Klein said, but there's a large percentage of people who, if they thought about it, could improve their behavior.