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Explore the critical role of civility in health care with insights from Matthew Sherrer, associate professor and director of care team collaboration at the University of Alabama at Birmingham, and Chris Turner, an emergency physician. Together, they discuss how workplace behaviors impact team dynamics, patient safety, and overall performance in health care settings. From reducing errors through quality improvement initiatives to fostering collaborative cultures that save lives, this episode uncovers the power of respect and teamwork in medicine.
Matthew Sherrer is an associate professor and director of care team collaboration at the University of Alabama at Birmingham Marnix E. Heersink School of Medicine, Department of Anesthesiology and Perioperative Medicine. He can be reached on X @MattSherrerMD and LinkedIn. He is also the co-host of the Fresh Flow podcast and has publications on PubMed.
Chris Turner is an emergency physician.
They discuss the KevinMD article, “The shocking impact of incivility in health care: Are your team’s behaviors putting patients at risk?”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com slash podcast. Today, we welcome back Matthew Sherrer. He’s an anesthesiologist, and we introduce Chris Turner. He’s an emergency physician. They both wrote a KevinMD article, “The Shocking Impact of Incivility in Health Care: Are Your Team’s Behaviors Putting Patients at Risk?” Matthew and Chris, welcome to the show.
Kevin Pho: All right, so Matthew, tell us what this article is about for those who didn’t get a chance to read it.
Matthew Sherrer: Yeah, so this article is about incivility in health care. I got introduced to Chris, gosh, a year plus, maybe a couple years ago. He runs a platform called Civility Saves Lives. I’ve become just a huge fan of his work and what he does. We’ve kind of struck up a friendship over the years, and his website is just resource on resource on resource. Full transparency, those are the resources that I used to kind of frame out this article that he and I wrote together. I’ve become a big fan of his work. I would consider him to be the expert in this field, and me to be more of a fan boy at this point in time of Chris Turner and his work.
Kevin Pho: So, Matthew, what’s the article about?
Matthew Sherrer: So, it’s about incivility in health care, the data behind it. There’s tons of data. Christine Porath brought a lot of the initial shock around some of the data on incivility in the workplace to light in 2013 with an HBR article, followed it up with a book called Mastering Civility in 2016, which is a fantastic read. Then we looked at it from a health care perspective. This is not just a business thing; this is a health care thing. We’ve all experienced incivility in health care, and I think we might not fully appreciate its impact. There’s an impact that we can talk about, and we’ll break that down over the course of the next few minutes, I’m sure. But it is a huge impact on the people that we work with, and the take-home message is that the way we treat each other at work matters tremendously.
Kevin Pho: All right, Chris. As Matthew said, you have an organization dedicated to looking at incivility in health care. Tell me how this organization came to be and what were some of the reasons why you started something like this.
Chris Turner: OK, so we’re not really an organization—we’re more of a grassroots health care social movement. I have lots of different people who move in and out of it. It came about because about seven or eight years ago, I became aware of the demonstrable impact that poor behaviors have on our ability to perform at work. I decided to give one little talk about it—just one talk. But after I gave that talk, three people in the audience asked me to give it in their departments, and so on and so forth. Literally, it was like a viral thing.
The reason we started talking about it was because a whole bunch of us recognized that our performance plummeted when we felt we’d been treated in a way that didn’t respect us. There wasn’t really evidence out there, but then, as Matt said, Christine Porath, Amir Erez, and a bunch of other people started to look at this. It became clear this isn’t a me problem; this is an us issue, and we can do something about it. So that’s how it came about. People got on board, and there are people all around the world who are really interested in this, because it’s like a hidden facet of both safety and excellence.
Kevin Pho: Chris, when we talk about incivility, what exactly are we talking about? Maybe you could give us some examples from, say, an emergency department setting.
Chris Turner: OK, well, emergency departments are fairly extreme settings for the sort of incivility you might see. Generally, the research is done on what’s regarded as low-level or moderate-level incivility: behaviors that you’re not quite sure if they’re meant to be offensive, but they make you feel uncomfortable anyway. So somebody who rolls their eyes when you start speaking in a meeting, somebody who tuts when you speak, somebody who speaks over you. It feels a little bit like you’re thinking, “Do they mean to be offensive?” The thing about it is that it still has an impact on the person on the receiving end, and that impact is significant.
Matt alluded to this, but in the moment, if I were to treat you in a way that made you feel disrespected, there’s a 61 percent reduction in your cognitive ability. Your bandwidth shrinks right down; you can’t think as well. In our health care environment, that’s a disaster because we’re all relying on everybody else performing at their best. It’s not good enough just to have one person who’s an absolute rock star. You need a whole team working well together. That’s how we started getting into this stuff and why it feels so important.
Kevin Pho: So, Chris, to clarify, an episode of incivility results in a demonstrable impact on a clinician’s performance—is that what you’re saying?
Chris Turner: Absolutely, and even when we don’t think it does. Dan Katz did work on this—he’s an anesthesiologist in New York State. Even when we don’t think it has an impact on us, it still does. We think we compensate, and we just simply don’t.
Kevin Pho: Matthew, give us examples of incivility that you may have observed in your own setting or that you’ve heard about other physicians talk about.
Matthew Sherrer: Yeah, I’ve certainly experienced it, and to be perfectly honest, if I’m fully transparent, I’ve probably been uncivil in my career at some point. The operating room is a high-stakes, high-volume environment. We’re doing really big, sometimes dangerous stuff. There’s a huge volume pressure. Just as Chris said, it’s not overt violence or overt acts, but simply the eye roll or a snide comment. We see those frequently. As pressure builds on the health care system more and more, we just continue to see it over and over.
One of the things that Chris has pointed out in his work, which I’ll add here, is that it not only makes us less capable, but simply witnessing incivility makes people less likely to help others. The OR is a team environment, and when you simply witness incivility, if you’re less likely to help others, not only, as Chris says, are you less capable, but you’ve made your team less capable. That’s what we pointed out in the article: it inhibits both those individual factors that contribute to team success and the team factors. As Chris has said in his TED Talk and other places, that is a toxic combination that we wanted to bring to light.
Kevin Pho: Chris, what are some of the approaches to address incivility in the health care workspace? I can imagine if someone observes an episode of incivility, they may be hesitant to speak up, or there’s no recourse or no organized recourse. What are the options, as Matthew said, if one witnesses incivility or is the recipient of incivility?
Chris Turner: OK, Kevin, if you don’t mind, I’m going to go back a step and say that the first thing that’s been shown to have an impact is simply talking about it like we are now. People are good; people want to have the best outcomes for their patients. How we behave is like a drug, and it’s like a new drug because we didn’t know it made a big difference. Once we start talking about this, once we start recognizing it, there’s a whole bunch of people who just change their behavior because they were never behaving negatively to diminish others. They did it because it was role-modeled to us.
So, the starting point is talking about it as a proven intervention for getting people to change their behavior. That’s work by a woman called Anna Baverstock, who’s a pediatrician in Somerset. Beyond that, how do you go about challenging it? That’s much harder. There are really good ways of challenging uncivil behavior, and most of them are born from the work of Jerry Hickson at Vanderbilt and the “cup of coffee conversation” and getting a second messenger to speak to somebody. Not challenging back yourself, because actually we’re so diminished that we’re not good at doing that. Getting somebody else to have the chat. So if Kevin and Chris have a bad interaction and Kevin feels lousy, I know you want to be able to tell me I made you feel lousy, but that’s really difficult for people and they don’t do it well. It turns out that getting Matt to come and talk to me about my behavior is much more effective, because Matt, in a conversation with me, can take the judgment out of it. He can assume that I meant it in a positive way, and he can be compassionate to me—and that’s almost impossible for you to do. When he does that, there’s a chance I can hear it, and I will then go and change my behavior.
Kevin Pho: Matt, give us an example of some changes that you’ve seen departments make to address this, maybe utilizing some of Chris’s techniques. What are some ways, from perhaps a systems level, that can approach this?
Matthew Sherrer: Yeah, kind of one of the things Chris alluded to is I think a lot of people just don’t know about this. We are evidence-based clinicians, right? We certainly understand the evidence behind what I do in the operating room and what Chris does in the emergency room. But we also have to acknowledge that we work in a team environment, and so, to be evidence-based practitioners, we also have to understand the evidence behind civility, right? Behind teamwork. I think going out and educating on this is really the intervention that I’ve seen. And again, I haven’t seen it a lot. I know at my institution I have a talk on incivility, a talk on teaming, a talk on humility, and these topics. Really, I think we’re at the education stage right now. I’d love to say we’re further down the line, but I can’t really say that for the institutions that I’ve been in. As Chris said, somebody has to take the ball and run with it and be the one to bring this information to the forefront.
Kevin Pho: Matthew, talk to us about some of the external pressures, like you mentioned before, that can lead to incivility—whether it’s the electronic medical records, the time pressure, all the administrative burdens that can negatively impact physicians and perhaps affect their behavior.
Matthew Sherrer: Yeah, gosh, you named a few of them. You named quite a few. I would say our professional politics is a factor as well. We’re primed to walk into the operating room in a tense environment. Our politics, professional politics, can be very tense; my daily inbox is inundated with that stuff. We prime our brains to walk in, and the people we need to collaborate with are sometimes portrayed as people we’re fighting against. I think that’s a big one.
I think advocacy is 100 percent necessary. I have to advocate for my specialty, and so do others in their specialties. Advocacy is our responsibility to our profession. But at the same time, we have to be able to take a breath when we walk into that collaborative environment and say, “OK, these people aren’t against me. These people are good people who came to work today wanting to do a good job, wanting to be fulfilled in their work, wanting to go home satisfied, and wanting to come back excited to do it again tomorrow.” I think that pause before walking into clinical spaces is incredibly important.
Kevin Pho: And Chris, let me ask you the same question. You practice across the Atlantic Ocean. Tell me about some of the external pressures that physicians there face that can negatively impact their behavior.
Chris Turner: The same things you mentioned previously: the time pressure, the volume of patients coming through the door, the fact that everyone’s being pulled in lots of different directions. It can be overwhelming. What happens when we get overwhelmed is that bits of niceness drift off at the sides. We forget little bits of the interaction, and we do something else: we start to judge other people. We look at someone else’s behavior and think, “Oh, you did that because you’re a bad person, or you did that to make my day harder.” The truth is, people generally don’t do that. There’s a small number who do, but most people don’t. Most people are doing what they think is right within the system.
If we can step away from judgment a bit and step toward curiosity—step toward trying to understand people rather than fighting them—then we start to open the door to behaviors where we understand our environment better. That means stepping away from the desire to be right all the time, and there ain’t no doctor on this planet who doesn’t want to be right all the time, because we do. Stepping away from wanting to be right and stepping toward trying to do the right thing, which is collaborative and requires a lot of understanding of each other. For me, that’s been the big thing that’s helped me move into a slightly different space when I’m in disagreement, when I could be in conflict with somebody: going, “Hang on a second, they know something I don’t know,” and maybe I can listen to understand rather than listening and then fighting to win.
Kevin Pho: Chris, do you have a story that can illustrate that? An example from yourself or one of your colleagues where they’ve implemented some of these techniques and demonstrably moved the needle when it came to their incivility?
Chris Turner: Yeah, well, I think it’s important—it’s the perception of incivility as well. This might sound like a weird little story, but one day one of my colleagues came up to me and said, “What happened? What did you do? I’m going to call this person Margaret. She’s really upset.” I didn’t think I’d done anything with Margaret, and he said, “Well, she said that you…” And this was really difficult for me to hear: “She said you touched her inappropriately.”
In my head, I couldn’t think what it was, and then I realized, in a meeting previously, she’d been really angry about something—legitimately angry, but there was nothing she could do about it—and I gave her what I give my nieces, which is a sideways hug. When they’re in their teens, I don’t hug them straight on; I give them a sideways hug, a little squeeze across the shoulders, shoulder to shoulder. That’s it. And I said, “It’s OK,” to this person. “This is just going to settle down.” She found this horrible—that I had touched her, that I’d done this. Now, I work in emergency medicine. We’re rubbing up against each other all the time. I’m not the sort of person who likes a lot of physical contact, but I’m so used to it that I thought that was normal.
When this person told me, I realized that caused her tremendous offense. I went and spoke to her, and I apologized, because that wasn’t my intention. She forgave me for it. Later, I found out she was going through a really terrible time at home, and there were a lot of difficult things happening. I had effectively triggered her. But we trigger people without knowing it. If nobody comes and tells us, we can’t do anything to fix it. I’ve said this before: Most people are good. If we give them the chance to make amends, they will. If we don’t get that chance, that becomes our reputation. We’re someone who does these bad things, and I like to think of reputation as your theme tune—the music that plays in other people’s heads when you walk in the room. Your theme tune gets darker and darker until it’s the theme tune to Jaws when you walk in the room, and everybody just goes, “Oh, good grief, it’s him.” But you can’t fix that if nobody tells you, because so much of this stuff just isn’t obvious that we’ve caused offense.
Kevin Pho: We’re talking to Matthew Sherrer and Chris Turner. Matthew is an anesthesiologist; Chris is an emergency physician. Their KevinMD article is “The Shocking Impact of Incivility in Health Care: Are Your Team’s Behaviors Putting Patients at Risk?” Now I’m going to ask each of you to share some take-home messages with the KevinMD audience. Matthew, why don’t we start with you?
Matthew Sherrer: Yeah, Chris said a minute ago the idea of curiosity—just assuming positive intent when somebody says something. Don’t assume they’re a horrible person right off the bat. People come to work wanting to do a good job. Listen, try to understand, and then maintain that curious attitude because they do know something that you don’t. Everybody out there knows something that we don’t, right? So try to create an environment where you can bring that thing to the surface, because in our world, information is the currency of safety.
Kevin Pho: And Chris, we’ll end with you. Your take-home messages to the KevinMD audience?
Chris Turner: So my take-home message is this, Kevin: behavior matters. It matters in a demonstrable, measurable, material way, and how we treat each other can be the difference between poor performance and excellence.
Kevin Pho: Matthew and Chris, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.
Matthew Sherrer: Thanks, man. Thanks for having me.
Chris Turner: Lovely to be here.
