Physician incivility in the health care workplace

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Transcript

Dr. Blair Bigham: I'm Blair Bigham.

Dr. Mojola Omole: I'm Majola Omole. This is the CMAJ podcast.

Dr. Blair Bigham: Jola, today we are getting into some dangerous territory here talking about incivility in medicine, which I don't know, I don't think there's any incivility where I work. Do you think there's incivility where you work?

Dr. Mojola Omole: I'm a surgeon. There's no such thing as incivility.

Dr. Blair Bigham: Of course not. Surgeons are perfect.

Dr. Mojola Omole: Just everybody else is just too sensitive. That was a joke everybody.

Dr. Blair Bigham: Before either of us get into trouble, there is an article in CMAJ entitled, �Five things to know about physician incivility in healthcare.� We are both very interested in this topic and to bring in a plurality of perspectives, we're going to speak not only with one of the authors, but also have an international panel afterwards.

Dr. Mojola Omole: So let's start. The article in CMAJ is titled, �Five things to know about physician incivility in the healthcare workplace.� Dr. Armand Aalamian is one of the authors. He's a Family Physician Educator and the Executive Director of Learning at the Canadian Medical Protective Association, which we're very grateful for CMPA's work. Armand, thank you so much for joining us today,

Dr. Armand Aalamian: Jola, it's a pleasure to be here. Thanks for having me.

Dr. Mojola Omole: So let's just start off, how big is this problem of incivility in the field of medicine?

Dr. Armand Aalamian: It's a great question. I think when you speak to any physician or any healthcare worker, they'll tell you that they've come across this issue during their career. So it's a problem that is persistent. We don't have a lot of statistics in terms of exactly how big the problem is, but we do know that it's prevalent and it is found in any healthcare institution, any healthcare context.

Dr. Mojola Omole: So I guess my first thing is just I'm a surgeon and so what other people might consider uncivil might be different. What exactly do we mean when we use that term incivility?

Dr. Armand Aalamian: I love that question. When we look at the literature, we look at a lot of studies and look at the literature, trying to figure out if there's anything in common in terms of definition. And the most common thing that came up were words, actions or inactions that degrade working relationships. So that's one definition, but I think the definition that I've always used in my own mind and career is being nice and professional. When I wrote a code of conduct many years ago when I was working at McGill University, I listed a whole bunch of behaviors that are okay and behaviors that are not okay. And I think that's how we can get to what is uncivil and what is not.

Dr. Mojola Omole: So just going deeper and talking about incivility, is it equal across populations in medicine or also even specialties or are there certain groups that report more exposure to it and also different specialties have that experience?

Dr. Armand Aalamian: Yeah, it's interesting. Again, the studies are quite varied and these are not randomized clinical trials. So these are studies, a lot of them are observational studies, a lot of them are folks reporting on their experiences. And I would say that there are certain contexts that would rise and promote potential uncivil behaviors. So we're in centers where resources are more scarce. We are in centers where there is a much larger patient volume and challenges is where you would see incivility more occurring. And that would also go within, I would say, specialties. So we haven't really been able to find data in terms of specialties versus each other, but we can make some inferences where there are higher stress situations. When you're in a situation where it's much more acute, much more stressful, when you have to make decisions quickly and under pressure, the chances are that there might be more incivil behavioral issues that come up.

Dr. Blair Bigham: That's an interesting observation because in the emergency department, which must be one of the most ubiquitous examples of a pressure cooker, I find that our camaraderie is actually quite protective, maybe amongst my peer emergency doctors and amongst other emergency team members like respiratory therapists or nurses, but it can sometimes be the consultants who are removed from the emergency department. Maybe I'm talking to them on the phone, maybe they're not typically providing-

Dr. Mojola Omole: Are you talking about surgeons?

Dr. Blair Bigham: No, not necessarily.

Dr. Mojola Omole: Name and shame.

Dr. Blair Bigham: Try waking up an endocrinologist at 3:00 in the morning.

Dr. Mojola Omole: The question is, should you wake up an endocrinologist at 3:00 in the morning?

Dr. Blair Bigham: There's a couple times when I've had to, but I'm just wondering what does that say about civility when teams, even in high pressure situations, know each other and perhaps view themselves as civil?

Dr. Armand Aalamian: Blair, you've raised multiple excellent points there and like Jola is saying, shall we call anybody in the middle of the night or not? I think-

Dr. Mojola Omole: Oh I can believe that. Without question.

Dr. Armand Aalamian: But I think what you're highlighted is really the importance of communications and teamwork. I think that's one of the, I would say, secret sauces in terms of how to work better together. It's getting to know each other as people, getting to know each other as equal contributors as we're working together within the healthcare environment and what you described almost sounds like a really functional family. You work well together, you talk to each other, you're communicating well together. You get to know how each other functions and what are the strengths and what are the challenges. I say everybody has superpowers and everybody has kryptonites. So when we get to know those pieces is where we can actually work better together.

Now when you are interacting with others outside of your family, that's when it can get tricky. You have to be thinking about, "Do I know what the rules of the game are? Do I know how it works elsewhere? Do I understand the culture within the other specialty with which I'm interacting?" I think those are going to be key as well. How are we going to be interacting because we make assumptions. We make lots of assumptions. I make assumptions every day. So it's keeping those assumptions in check and always being curious. To me, it's about again, the curiosity piece. Are we curious? Do we understand? Did that person stay up all night? Are they exhausted? How tired are they when I'm calling them at 4:00 in the morning? How am I approaching that situation? So those are the pieces. And I would say there are emergency rooms where things are working fantastic. There are emergency rooms where they may not be working so great. And it's really about even the best practices. If we can share those practices, what is working great in Blair's emergency department, that would be great to figure those pieces out.

Dr. Mojola Omole: So in your paper you described that incivility has an impact on a patients� outcomes. How did that show up in the research? How was that measured?

Dr. Armand Aalamian: So in about 24 of the studies that we looked at, there was a correlation between patient safety and that could be from a procedure going wrong or it can be from a safety checklist not being properly followed. So those are some of the things that can go wrong and that really boils down to how are the teams functioning, how are they communicating? And if there's incivil behavior, and then put yourself in a situation when you're working in a team, and if somebody is behaving in an incivil way, I think it's intuitive to understand, that does not promote communication and people coming forward and pointing out things. So if they notice something, if there is an issue, they would be much less likely to speak up than if there was an environment of psychological safety where they could bring up issues where we could actually discuss it and that would be encouraged. So those are the kinds of correlations that we saw within the studies that we looked at that looked at patient safety.

Dr. Blair Bigham: Armand, you work for the CMPA, is there some connection to medical-legal risk? Is there connection to burnout? Personal health? What are the stakes here if we don't fix this?

Dr. Armand Aalamian: So our mission is to support physicians. That is really core. The work that we do, everything we do at the CMPA is about supporting physicians and promote safe care. So those are the two pillars of the work that we do at the CMPA. So we are so acutely aware of the needs across Canada for healthcare resources and physicians and physician burnout and the challenges that are there all across Canada. We need to give physicians the tools and also raise the awareness within healthcare systems of the challenges that physicians are facing because we want physicians to do what they do, care for patients. That's at that core piece.

And also the patient safety issues that I was making reference to before. We know that there are connections between effective teamwork and team interactions and patient safety. We know there are challenges potentially when interactions are not going well between physicians and patients in terms of communication issues and professionalism issues. So we want to make sure that we support everyone in that process. And I think this is not a simple issue, there are no simple answers, but there are answers, there are tools, there are very concrete tools that we can put in place, systems can put in place. Cultures do and can evolve. So that's how we're looking at it and I think there's some good work that we can all do.

Dr. Blair Bigham: Thank you.

Dr. Mojola Omole: That's great. Dr. Armand Aalamian is a family physician and executive director at the Canadian Medical Protective Association.

Dr. Blair Bigham: Let's dive a little deeper into what's driving incivility in medicine and some of the ways we can address it with a panel. We've got two guests with us now, Dr. Eve Purdy is an Emergency Medicine Physician and Applied Anthropologist at Gold Coast Hospital and Health Service in Australia. She focuses on helping healthcare teams perform at their best. And Dr. Sarah Kim is a Family Physician and an Assistant Professor in the Department of Family and Community Medicine at the University of Toronto. We saw each other just the other night, Sarah. Nice to see you again. She's also the Medical Education Health Humanities Lead at Temerty Medicine and she researches the intersection of high performance and hierarchical systems. Welcome to both of you.

Dr. Eve Purdy: Hi Blair, great to be here.

Dr. Sarah Kim: Hi Blair, thanks for having us.

Dr. Blair Bigham: Eve, Dr. Aalamian says we need to work on building community to improve civility. You've been working on helping teams build community and build respect for each other for a long time now so that you can, I guess, reduce incivility by being more community minded. What's your take on all of this?

Dr. Eve Purdy: Look, I think he's totally right. If we can focus on relationships in healthcare and getting those relationships right, the rest will follow. There's some structural ways that we can do that. Finding ways to spend more time with each other away from the hot, sharp end of clinical care is certainly one of those ways. And also just building structures that really make us think about the relational aspects of medicine. I think one of the challenges that we've found ourselves with in modern day healthcare is a really transactional approach. So we ask colleagues for procedures to get done instead of asking for their opinion on a challenging problem and valuing what they're bringing to the table. So I think if we can find ways to value each other's expertise, spend time understanding what other people's roles are, then really that will go a long ways.

Dr. Blair Bigham: To build that value, to build that respect for each other, is there a magic formula that you use?

Dr. Eve Purdy: There's not a magic formula. I would say one thing that we focus on is small moments though. So in every single team across healthcare, there's a series of small moments for those teams every single day that we can pay close attention to. So I'll give you one example. When we have spent time with our intensive care unit here really trying to understand how we can help them perform better, we identified their morning handover as this small moment that really matters and sets up the day for the team. What we noticed was that the doctors and nursing team leaders were going into the patient's room at the bedside and the bedside nurse was often in the corner, not really invited into that conversation.

And you can imagine that if we've not introduced each other at the beginning of the day, that bedside nurse who's spending 12 hours with the patient might be less inclined to come to that team leader or consultant later in the day with a good idea that they have. Maybe we can actually start trying to wean this patient from a ventilator earlier, but unless we've set up that relationship early in the day, those good things are much less likely to happen.

So where are the places that we can inject moments of mutual respect and civility, actually very purposeful civility, so that the rest of the day goes better? And I think that resonates with teams because we're not asking them to find more time to do this. We're trying to think about where is this already happening and already important and how can we just do it a little bit better?

Dr. Blair Bigham: What did you do to incorporate the bedside nurse into those rounds?

Dr. Eve Purdy: Well, I wish I could say that we're completely winning here, Blair. We're not. It was quite interesting. So with this group, we actually took a really deep dive into morning handover rounds and we interrogated this process with some bedside observation actually of what's happening. We asked people who are involved in this process, "What makes this go well and what makes this go better?" And what we really got was some fairly stark data from the nurses and residents that the consultants just needed to be a bit more civil in these rounds. And not because anybody wanted to feel better, but because this was what was going to be best for patients. And we actually presented that data back to the intensive care consultant group and said, "Hey, look, this is what your team is saying and we're not asking you to be nice just to be nice, we're asking you to be civil so that things can go better for your patients."

And if people can't get on board with that, that's actually an easier thing for an organization to have a problem with. But we've learned along the way in different groups where there's been similar problems that sometimes people that are in leadership positions, they actually need some coaching around this. They're not trying to be bad, they're not trying to be rude, they just actually are unaware of what the issue is and what are some of the conversational skills, what are some of the things that they can do that might really work? So pairing them with people who do it really well, actually getting them to observe the round of a colleague who's been identified as maybe a really positive deviant. And then I think actually just assessing whether teamwork is a value for everybody. For some people it's not, and those people are a problem.

Dr. Blair Bigham: I want to bring Sarah into this part of the conversation. Sarah, when we're talking about incivility and the need for people like Eve who come in and help teams build themselves up. We can also take a step back and look historically at how we've gotten here. Why do we need civility consultants to begin with?

Dr. Sarah Kim: Well, what I think is easier for people to understand is that these moments of incivility are not necessarily individual failures, it's a system design failure. So it's reflective of things that have continued to be pervasive in our education systems and institutions that allow for these behaviors to persist. And so giving people context of when we talk about, for example, what are some of these historically embedded systemic biases and prejudices from which people have learned to internalize what is acceptable behavior or not. And there's behaviors that get modeled for medical learners in subtle and not so subtle ways. The way team members are addressed, the way in which comments like, "Ugh, they forgot to do this again. Don't they know what I need available for me to do my job?"

So all these, basically these moments of contempt where off-handed comments are made, but that then also signals non-verbally to trainees coming through that somehow we are superior as physicians. We're the ones that are being inconvenienced. We're the ones that are actually doing things right and it's everyone else that are working against us or doing it wrong and that are failing in what they do. But then it also happens physician to physician where a call might arrive to a specialist and they're like, "Why are you bothering me with this question? Why are you wasting my time?"

So it's really interesting what learners will hear and then begin to take on these behaviors and slowly through what we call the hidden curriculum as it relates to civility or incivility in the workplace, it becomes internalized and then it's blamed on, "Oh, they're overworked." "They're just having a bad day. There's a lot going on." But you know what? People who work cleaning jobs, they're working very hard, they're tired, they'll get fired if they speak like this. So it's about protected privilege of who gets to continue to be allowed to act with incivility towards others. And that's also what becomes problematic about it.

Dr. Blair Bigham: Eve, the way Sarah describes this, it sounds like incivility is deeply ingrained in medical education. How much of this problem is ubiquitous and we've just all grown up with it versus how much of it is just there's a few bad apples, just one or two people, you just need to fire.

Dr. Eve Purdy: Blair, you're a man after my own heart. Look, I think certainly with all the teams that we work in, there is bad behavior on show across the board. And some of that I think just is not coming from bad people is either from a lack of civility, maybe sometimes some direct incivility, but I think about myself. I'd say at least once a shift, I behave in a way that doesn't really align with my values. Maybe the 10th time I'm getting asked for an order and I don't have any brain capacity to deal with it, I might roll my eyes or I might dismiss somebody. I like to think that I've put enough in the bank throughout the rest of my shift. I might get away with it, but perhaps more importantly, somebody might point that out to me and I can go and I can repair it.

So I think there's a lot of people who maybe don't behave well all the time, but can repair it and can still be a really functional part of a team. But look, Blair with a number of teams that we work with, there are just some people that are sucking the energy from these teams, that are sucking the energy from their ability to continue to try to improve, to continue to try to do good work. And they do this again and again and again, every day they show up to work and the entire team knows who they are. We have not sorted out how to deal with that in healthcare, and it is ruining some of our teams.

Dr. Blair Bigham: Let me put Sarah on the spot here. Sarah, is there a solution to those bad apples? What can institutions do to help teams when there's extremely disruptive and egregious behavior?

Dr. Sarah Kim: I often think about how ineffective sometimes it is to call people out, but rather you want to figure out a way to call them into dialogue around their behavior. I think Eve would agree. The vast majority of people who go into healthcare and healthcare professions are good people. They're well-meaning. Many get in who have had a lifetime of existence where incivility was somehow acceptable, but that doesn't mean that they are lost causes. And it's interesting that sometimes where change can happen is when they are approached more one-on-one rather than in front of a team because usually people who are demonstrating incivility are also holding themselves in an extreme amount of contempt.

Dr. Blair Bigham: Can you explain that for me? What do you mean by that?

Dr. Sarah Kim: Oh, so I'll give a stereotypical example of in medicine and in healthcare in general, emotions are a place of shame. That is something that was historically embedded very early on, especially when science became the idea as the gold standard of being completely objective. That is an impossibility in healthcare to be completely objective because we are dealing with human beings and it's inherently relational and therefore emotional. Now we can deny that we are experiencing emotions or suppress them, and that is what is modeled and taught. And so individuals, in particular classically men, are not allowed to admit that they are emotional beings. And so they themselves carry a huge amount of shame around emotions in general, but the one emotion that is often allowed is anger. It's the one thing, that's all they had. If they're sad, they get angry. If they're feeling shame, they get angry. That seems to be the only possible expression. And in that sense, when they feel something coming up and then it's pointed out, it's just going to come out as incivility.

Dr. Mojola Omole: What comes to my mind as we're talking, as someone who sits on MD admissions, is that by valuing certain benchmarks, we are picking people at the age of 22 to come into medicine. And I would argue that the 22-year-old of 2024 is vastly different than the 22-year-old of 1965, for example. And so we are picking young people whose brain and frontal cortex has not developed, and we're picking them based on their academic rigor, not on necessarily emotional maturity because A, they haven't emotionally matured, B, that is very hard to assess in a 20 minute interview. And in a way, it almost feels as if we create a system by picking people based on academic rigor, who part of surviving and to be in the top 1% of your class is to actually block out your emotions. Because if you cry all the time, you're not going to get that far in life. And so we're picking them to become physicians.

Dr. Blair Bigham: And then we take them and they're in complete frontal cortexes and we drop them in this culture cesspool where they just soak up all of this historical contempt and negativity and incivility. It sounds so pessimistic.

Dr. Sarah Kim: It's also though too, it's really interesting and I'm glad you brought that up, Jola, that is what I mean when I talk about system design failure. And that's what I mean when we talk about just re-envisioning what it is about. We know this is a problem and taking a design approach. If we know this is a problem, and this is often what I try to say to medical students is that you do have a certain degree of control over who you can choose to be by demonstrating to them what it is that you do. Because again, there's a lot of literature about how students come in quite civil and compassionate, and by the time they leave, something happens.

Dr. Eve Purdy: I feel strongly that this doesn't start with the students.

Dr. Mojola Omole: So I would actually have to disagree with you because I feel-

Dr. Eve Purdy: Yeah, I'd love to disagree with-

Dr. Mojola Omole: Well, no, because I actually think that spending enough time with them is that they're so singularly focused and get into medical school because I've mentored them since high school and this is all their world. And I also do think there's a difference between those who are privileged who are on medicine because let's be frank, the majority of people who are in medical school have a family member in medicine. So that is also part of it in the sense of you have these young people who they have great ideas, but they haven't fully formed yet. And to get into medical school is really hard. I don't think it was that hard for me.

Dr. Eve Purdy: Yeah, but we have this opportunity to form them, so I see medical students that come into the workplace, they behave one way on one team, and then they go to a different team and they behave another way.

Dr. Mojola Omole: 100%.

Dr. Eve Purdy: It's the same person and put them in an environment to thrive in one team. And if we put them in a team that is uncivil, they behave a different way, they answer the phone differently. And so I feel like we actually have this opportunity-

Dr. Mojola Omole: But to me, that actually speaks to maturity.

Dr. Eve Purdy: Yeah, but we have this opportunity to shape them. But if we're putting them in a group that is uncivil, we can pick the best people and they're still going to be inculturated. The lowest people with the least amount of power are-

Dr. Mojola Omole: I guess the way I view it is that because our selection bias is so heavily weighted on academics and not actually on the part that is the most important in being civil, which is are you a person who can relate with other people? Are you a person who can work well in teams? Because we actually are missing out on some of the best physicians, so that's more my argument is that we're missing out on people who actually would be great physicians, but they just don't have 99%. They have 96.%

Dr. Eve Purdy: But we're going to take those nice people and put them into a place that then makes them really sad.

Dr. Blair Bigham: So I think it'd be helpful to summarize where we're at and then maybe move into another chapter. It sounds like we have a chicken or the egg scenario here. We have this culture, this giant soup of incivility through these historical ways that medicine has been valued. And then we have a flawed admissions process, and even when we find the perfect candidate, they then get dropped into the soup and are easily indoctrinated. So let's talk about leadership. When we bring leaders into this conversation, I imagine that a lot of them probably hear excuses like, "Well, the system's too busy. My workload is too high. I don't have enough resources. There's too many patients." All of those things that we know are just bubbling to the surface in Canadian healthcare. How can leaders refute some of those very solid arguments and help their teams become more civil?

Dr. Eve Purdy: Look, it's very simple. Incivility kills patients, and that needs to be the single line of every healthcare leader that is responsible for managing and leading teams. And the evidence is clear enough that's the case. And so once we accept the fact that incivility kills patients, then we can get somewhere with our teams. I think there's also the reality that there's a lot of people that face these same constraints and are civil, so this is not a one or the other. There are actually a lot of people doing this hard work, exposed to the same trauma that managed to get it together. We've got to, I guess, set the very clear expectation that that is how we work in this place. And certainly I've been involved in some personal circumstances where it's very clear to me that there's not an organizational interest or approach to engaging in people who are demonstrating repeated uncivil behaviors.

Dr. Blair Bigham: Sarah, let's end on how we can all individually take responsibility for our own behavior. I feel like we all have moments. I was incivil the other day, people were incivil to me the other day. What can we do when we're in the moment and incivility is raging? What's the best way to address it?

Dr. Sarah Kim: These are moments where some learn, what is it I need in order to start to feel my feet on the ground again? Is it that I need to take a moment and a timeout, or is it another team member says, "Maybe you just need a few moments just to gather yourself and then come back"? And that's also another thing about the team building is that when you make it more relational, when people are picking up on other people's blood starting to boil, because I don't think what works is to shame them. It's actually to name it and say, "You seem very upset. Maybe we need to take a pause here before we continue the conversation."

Dr. Eve Purdy: Yeah, I think I would add we're all very finely tuned social animals that are very good at identifying what risk is worth it and what risk is not. And there's some people on our teams who taking this risk is just not going to be possible. And so I think one of the most important things is recognizing when you are in a position with maybe a little bit more power and a little bit of positioning to shield or to pipe in with Sarah's comment of, "You look upset." So for me, maybe that looks like if I see another consultant treating their resident on a different service poorly, or an example was a registrar called our ED team leader and she was in tears after the conversation, my position in that is to provide some feedback on the impact of that behavior and set some expectations around how we treat people. But that comes because I've got a little bit of power as the consultant on the team. So I think not feeling bad if you don't actually have the power in this moment.

And I guess the other challenge, the reason why we see this not happening all the time is to anybody, there is a high risk of some short-term harm. The benefit to the organization is a very long-term one. So there's this mismatch between what are the risks to us as individuals in that moment and what are the benefits to the organization in the long-term? And I think that's what gets in the way of actually dealing with this, and we've got to figure out a way for the organization to take on some of that risk away from individuals and actually maybe be proactive in how they're identifying these people and getting supports to people because relying on individuals to take what is a really big risk is just never really going to quite pan out, I don't think.

Dr. Blair Bigham: It absolutely pains me to have to bring this panel to a conclusion. I feel like we have so much more to talk about and could go all night and all day until it didn't matter what the time difference was between Australia and Canada, but we do have to wrap here. I want to thank you both so very much for bringing your minds and your hearts to this conversation.

Dr. Eve Purdy: Blair, pleasure to be here.

Dr. Sarah Kim: Thanks for having me, Blair.

Dr. Blair Bigham: Dr. Sarah Kim is a Family Physician and Assistant Professor in the Department of Family and Community Medicine at the University of Toronto and Eve Purdy, joining us from Australia is an Emergency Physician and Applied anthropologist at Gold Coast Hospital and Health Service. Well, Jola, do you stand by the comment that there is no incivility in the OR?

Dr. Mojola Omole: Well, so my controversial take is that because we, in the last few years, decades, we've moved to this view of trying to be sensitive and being culturally sensitive, politically sensitive, that people are no longer sharing what they mean. I believe in civil incivility, which means that you say what you mean. You don't have to berate someone for it.

Dr. Blair Bigham: I'm on the same page as you. I think that in healthcare sometimes because of competing demands, we do have to stand up and speak a little more loudly or a little more forceful. But I think what I'm taking away from what Sarah and Eve were talking about is that you just have to know where it's coming from inside yourself. If it's like, "Hang on, I just need to make sure everyone's being heard. I just need to make sure the patient is at the center of this conversation." Maybe it's okay to be a little bit boisterous, but if you're losing that focus and if it's becoming me versus you, then that's when I need to say, "Wait a minute, I'm not contributing my best self to this conversation."

Dr. Mojola Omole: I think for me, my lasting impression, similar to what you're saying, is actually about relationships, is that because we've moved so far away from centering care in healthcare, talk about a cliche, that we lose that connectedness. What makes work enjoyable is the people that we work with, and when we're spending so much time trying to be in an EMR and everything should just be on the computer and we just message each other instead of calling each other, we lose that connectedness, which helps us build relationships. Being able to know people.

This weekend I was talking to another surgeon who works in Cranbrook in the interior BC, and for them, the merge doc and her, their kids play hockey together. They go downhill skiing together. It's much harder to be uncivil to someone that you're going to see outside of work.

Dr. Blair Bigham: Definitely.

Dr. Mojola Omole: ...who you're going to be carpooling with. So I do think that part of creating community in our big centers is trying to replicate what we have in smaller communities across Canada where you are connected not just because of work, but because you have similar interests. Your children and other aspects of life are intertwined.

Dr. Blair Bigham: The other thing that we should cover, Jola is how we can individually contribute to that environment where everybody starts to feel that connectedness, and especially how we can model this to learners so that they leave our rotations feeling like they're part of that beneficial, positive environment instead of a more cantankerous one.

Dr. Mojola Omole: I think us, as the educators and as the adults in the room, need to understand our audience, they're always listening and if we have that in the back of our head, is that what would happen if someone in my family, my children, or my nieces or my nephews saw me behaving this way or saying these things, would I say it around them? If the answer is no, then don't say it around a medical learner or the staff that you're around.

Dr. Blair Bigham: Definitely. Lots for us to think about both in terms of how we own our own actions and posture towards our colleagues, and also how we model that desired behavior with those around us.

That's it for this week on the CMAJ Podcast. If you like what you heard, please give us a five star rating wherever you get your podcast. Share it with your networks, leave a comment, climb a mountain, and shout about us when you get to the top. It would go a long way to helping us get the message out. The CMAJ Podcast is produced for CMAJ by PodCraft Productions. Thanks so much for listening. I'm Blair Bigham.

Dr. Mojola Omole: I'm Majola Omole. Until next time, be well.