Friday, June 17, 2016


      Over the past few months I have conversed with several experts on their views regarding leadership attributes that either facilitate or impede teamwork as well as the affective component in learning and teamwork (see links below).  Needless to say, after talking recently with Coach McCoy regarding the need to focus on one’s behavior in response to stressful encounters, I have been more cognizant of my interactions with fellow teammates over the past few months.  With this awareness I attempt to override my typical terseness in the midst of difficult situations and view events with empathy (I don’t hear “you don’t have to be sarcastic!” as much anymore). On the same note, Dr. Sotile and Dr. Schoomaker reminded us at the Faegin Leadership conference that as we allow ourselves to become stressed and don’t find a release outlet, our mental capacity is reduced and we become angry (then everyone hates us). Modification of one’s innate behavior is by no means an easy journey but a worthy one. While I am certain I have not been hospitable in all circumstances over the past several months, I do feel less stressed which in turn has clearly reduced my potential for an inhospitable encounter (at least it appears that way to me). With that in mind, it was perfect timing that Medscape recently highlighted a 2015 paper titled “THE IMPACT OF RUDENESS ON MEDICAL TEAM PERFORMANCE”. It seems that the old adage, “You catch more flies with honey than vinegar” may run true.

            The study was performed amongst 72 NICU professionals recruited from four Israeli Hospitals, who were organized into teams of one physician and 2 nurses from the same unit. Each team was asked to participate in a 1-hour simulation in their own hospital’s NICU. The teams were randomized into teams with moderators who were either civil or mildly rude. Diagnostic skill and procedural performance were compared between the two groups.  The authors reported that the majority of individual performance items as well as overall diagnostic and procedural performances were negatively affected by exposure to rudeness during their simulation. Overall, they discovered that model explained 52% of the variance in diagnostic performance and 43% in variance in procedural performance.  The team pointed out that this study only assesses the effect of rudeness in very short duration and was not target-specific, therefore the effect of more intense or longer duration or specifically pointed incivility could be associated with an even more significant deterioration of performance.

         After reading this report, I contacted the authors to see if they could provide more information on their research.  Dr. Amir Erez, PhD (AE) was kind enough to send me another summary publication on their quest to understand the impact of an uncivil incident and agreed to chat about this topic. Our conversation regarding this subject is as follows:

--Just how serious are the consequences of incivility on the team?
AE. Rudeness can reduce performance by a significant amount. As we noted in the study, an uncivil encounter can cause an immediate reduction in people's performance. Our studies have shown that even a single and brief incident of incivility can hinder performance. Even worse, a single uncivil event can prime the witness / victim to severe dysfunctional behavior / thoughts. This can become very contagious. Knowing that just imagine the effects on highly complex patient care if a member or the team losses the ability to concentrate or becomes dysfunctional. The results can be deadly or at a minimum catastrophic (read their summary paper for examples of how this can be extremely dangerous). We have another study that is ongoing looking at rudeness during pediatric care that shows that incivility is damaging by reducing production by 35% leading to serious mistakes. We have an anesthesia study assessing if rudeness can affect a provider by causing them to focus on the wrong diagnosis. They miss serious problems that led to death. They could not switch their diagnosis. This even affected the witnesses.

--Is the effect brief (temporary) or long term?
AE. Rudeness can impact motivation and well-being but the effect goes way beyond that. Those exposed to incivility have attention deficit, memory malfunction, and a reduced ability to participate in teamwork, all of which reduce performance. For example, our new study assesses the effect of rudeness in the morning over the entire day. The effect is over the entire day. A second study tests rudeness in the morning on the effect on executives. We found that this also affects the exposed study participants all day. Another study assessing the ability to negotiate, looking at contagiousness showed that the effect on the group lasted over SEVEN days.

--Does this affect the recipient of the rudeness alone or does the team suffer?
AE. One of the first studies we published on testing witnesses showed the same issues. The effect can be widespread such that witnesses to an uncivil incident (not even directed at them) suffer a reduction in their capacity to solve complex problems and diminished creativity. As we discussed, the effects can become infective in the organization. Teams will always be prone to negative performance and unrest, but they typically band together. Not true when they are victimized by uncivil behavior. Incivility breeds aggression and then the teammates take out their frustration on each other. To make matters worse they then fail to share information or workload. Surprisingly this is regardless of whether or not the rudeness originated from a teammate or from someone outside the team.

--Your 2015 study notes a diminished cognitive and procedural ability, any clue what component of our processes is negatively affected?
AE. we have a study using Randy Engle’s measure of working memory and spatial memory and found that working memory is greatly affected. The most impacted was goal aspects and attention and problem solving.
Me: I talked with Randy Engle last year about his research on working memory but can you expand?
AE.. Working memory is where we store visual and verbal information used for decision making and goal management. Witnesses to rudeness have an impact in all those areas. For instance, they do worse with verbal tasks, become less creative, recall less, and miss visual cues directly in front of them (see Simon and Chabri Harvard invisible gorilla). The misinformation even in the center of their visual fields for 30 seconds is affected. This can be a real problem with surgeons. Simply having this uncivil event on one’s mind can affect all components of working memory.

(For those interested, I received a copy of EXECUTIVE ATTENTION, WORKING MEMORY CAPACITY, AND A TWO-FACTOR THEORY OF COGNITIVE CONTROL from Randall Engle whereby they describe working memory components – See down below for their description)
--Is incivility an individual problem or a sign of systemic issues? That is how far reaching can it become. “This person is a disruptive physician” is commonly what we hear.
AE. In of itself an uncivil culture can likely impact the entire organization. It makes staff sad, mad, fearful and unmotivated. Whether this starts with a single person or not it is typically very contagious and becomes cultural. This affects everyone, doctors, nurses AND patients. Patients themselves can create this distraction.

--Can you narrow down why humans are so negatively impacted? Why can’t we just shake it off?
AE. Incivility becomes a major social threat. Under attack by any threat our nature is to go into self-preservation mode. Then, that is all we think about. We may not realize it but we become primed to respond to this negative social issue. People ruminate about this and think on and on “what should I have done? why did I not do that?” It becomes very disturbing to us.
Of note, their 2015 paper goes into detail about the amygdala response to threat described by Joseph Ledoux and Antonio Damasio. This response to any catastrophic event was described by Sweeney et al in LEADERSHIP IN DANGEROUS SITUATIONS. In that book, the authors estimate that these events require one to wait at least a day prior to returning to usual activities. The event clearly overshadows all other thought processes.

--Can an organization do anything to curtail incivility? You mention the following in your summary: 

  • Recruitment: the recruitment process can identify those who have had excessive issues with incivility especially those who foster a hostile environment.
  • Set expectations and norms for civility- civility should be held as an organizational mission and value.
  • Recognition and awards.
  • Coaching- organizations must provide interpersonal skill development amongst its staff.
  • Intolerance of incivility.
i. Aside from that, in many organizations rudeness seems to originate from the top. That is, employees identify that the leadership of the organization does not take the staff seriously and has been known to be rude to its employees. Does the organization owe it to its staff to do a self-assessment first before it blames its employees?
AE. We have a study on 90 schools in Israel. When the Principals are rude to teachers then the teachers are rude then the students misbehave. It’s the domino effect. People tend to try to downplay rudeness.
ii. Doesn’t the organization owe it to the staff to look internally in the facility to ask the question “why does incivility still exist in healthcare when we are supposed to be nurturers and providers?” That is- why are these people being rude in the first place? Are they rude to everyone about everything or are there events that trigger these episodes? Is anyone asking -what was that event that triggered the inhospitable response? And- is it actually a serious event that was overshadowed by a person’s outburst? It seems that most of what we read regarding the disruptive physician centers around the person and the uncivil event and not on the question as to why the event happened in the first place. As a Chief, I had a recurring warning to staff to avoid their personally becoming the focus of a negative event. That is, after something occurred during their care of a patient, any outburst by them will overshadow the negative event (or sequence of events) that caused them to become angry in the first place. They always related to me that they felt someone was being irresponsible, neglectful or just plain dangerous and no one seemed to care. My response was for them to come find me and release their anger with me rather than in public. Once they felt better we would outline the problem. As Chief, if a recurring hindrance to effective care was causing them to lose their focus and their temper, then that was my responsibility to find the team who would work with me to make the situation better.  It is clear that the person with the personality drive that steers one towards complex patient care is highly likely to take these events personally. The staff will have spent an inordinate amount of time preparing the patient and themselves for that care episode, so naturally when the results are suboptimal, they perceive this as a personal failure (see Bosk, Forgive and Remember) and a reflection on their personal performance. This research on rudeness reinforces that an uncivil outburst can easily overshadow substandard care making any resolution difficult if not impossible. It is now obvious to me that victims or witnesses of incivility focus on the inhospitable encounter itself and are unable to move beyond that instead of focusing on whatever situation triggered the event in the first place. Everyone will lose the ability to reason and plan. With that in mind after all this research what is your advice to the staff who feel the need to express their exasperation in public when they feel that no one is listening? As leaders, what do we do about that?
AE. “This is the question of -why do people behave this way? We do interview people and ask them why they behave this way. The first reason is that someone was rude to me. The second was that they reacted to an incompetent person. THERE ARE REASONS, we just need to understand it. Something you may be able to control by making them aware of the cognitive consequences, but we cannot control the patients. These can be just as dramatic in the creation of mistakes.”

--What can an individual do? Has this research lead to potential intervention that looks to be successful?
AE. Take care of yourself by being aware of the problems that incivility poses on the team and organization and taking time for stress reduction. Reduce your potential for incivility when possible by steering clear of those who have a propensity of being uncivil. Engage in mindfulness and meditation- we do not have any evidence of this but it is highly probable that it is effective. (see my recent post on an interview with Dr. Schoomaker on meditation and mindfulness).
AE. People who are perspective taking seem to be more resistant, but training people to take the perspective of the person who was rude, did not work. Same methods used in PTSD may work.  Inoculation may work. Using cognitive behaviorally intervention for phobia treatment to raise the threshold to hostility, seemed to work for Yair Bar Hain.  It is clear it works short term but no assessment if this works more than throughout the day.

--Why are people rude?
AE. We do not know. We are having issues recreating this to make people become rude. We have a study looking at this but have not replicated it. We should know the benefits of this behavior- what are the gains for acting this way? I am actually a positive moodness researcher. When I was introduced to this, I did not believe this- I quickly learned people were slower in their reactions after a negative encounter.

--How has this affected you personally? Do you act different?
AE. I am more aware and more concerned. In social sciences something that explains 5-10% of variation is huge but this effects 43%. For example, resident sleep only effects 23% of production and this is twice a bad”.

--Is there a regional cultural variation on the effect of rudeness? Ie Northeast vs South vs Midwest Vs Pacific Coast vs Caribbean?
AE. I thought that there would be a variation on tolerance to rudeness. We did this in California, Florida, Washington, UK, Israel, New York. We FOUND NO difference except for perspective taking. We thought people in Israel would be immune to this. We found the exact same response. I did not believe it would affect everyone the same way but right now it is the same everywhere.

--This study is from 2015. Where have you gone from there? I.e. Have you reversed the groups without their knowing it to see if the performance significantly changed when the groups were exposed to the opposite style of moderation?
AE. Don’t know if we can pull it off. The study participants were very upset and we told them all that this was a study and not real. We are going to do a study to survey people about rude experiences and relate them to medical errors.

EXECUTIVE ATTENTION, WORKING MEMORY CAPACITY, AND A TWO-FACTOR THEORY OF COGNITIVE CONTROL – WITH PERMISSION OF Randall Engle & Michael J. KaneAs developed by Baddeley (1986, 1996, 2000), the working memory model now arguably emphasizes structure over function. It consists of both speech based and visual/spatial-based temporary storage systems (the phonological loop and visuo-spatial sketchpad), with associated rehearsal buffers, as well as an "episodic buffer" thought to maintain episodic information using integrated, multi-modal codes. Finally, a central executive component, analogous to Norman and Shallice's (1986) supervisory attention system, regulates the flow of thought and is responsible for implementing task goals.

By our view, then, working memory is a system of: (a) short-term "stores," consisting of LTM traces in a variety of representational formats active above a threshold; (b) rehearsal processes and strategies for achieving and maintaining that activation; and (c) executive attention. However, when

we refer to individual differences in WMC, we really mean the capability of just one element of the system: executive-attention. Thus, we assume that individual differences in WMC are not really about memory storage per se, but about executive control in maintaining goal-relevant information in a highly active, accessible state under conditions of interference or competition. In other words, we believe that WMC is critical for dealing with the effects of interference and in avoiding the effects of distraction that would capture attention away from maintenance of stimulus representations, novel productions, or less habitual response tendencies.  We also believe that WMC is a domain general construct, important to complex cognitive function across all stimulus and processing domains.

     To better illustrate our view, let us place WMC in a context of general cognition. We believe that much of what we need to know to function, even in the modern world, can be derived from retrieval of L TM-retrieval that is largely automatic and cue-driven in nature. Under those circumstances, WMC is not very important. Even in some putatively complex tasks such as reading, WMC is not required in all circumstances (Caplan & Waters, 1999; Engle & Conway, 1998). However, as we see in the following example, proactive interference can lead to problems from automatic retrieval. When the present context leads to the automatic retrieval of information, which in turn leads to an incorrect or inappropriate response in a task currently being performed, a conflict occurs between the automatically

retrieved response tendency and the response tendency necessary for the current task. That conflict must often be resolved rather quickly, and so we need to have some way to keep new, novel, and important task-relevant information easily accessible.

Take a simple example obvious to every American walking the streets of London for the first time. While driving in a country such as England can lead to potentially dangerous effects of proactive interference, there are numerous cues such as the location of the steering wheel, the cars on your side of the road, etc., prompting the maintenance of the proper task goals. However, in walking the streets of England, the cues are much like those present when walking the streets of any large American city and the temptation-shall we say prepotent behavior-is to look to the left when crossing the street. This can be disastrous. So much so that London places a warning, written on the sidewalk itself, on many busy crosswalks used by tourists. This is a situation in which the highly-learned production, "if crossing street then look left," must be countered by a new production system leading to looking to the right when crossing streets. This task seems particularly problematic when operating under a load such as reading a map or maintaining a conversation. For individuals that travel back and forth between England and America, they must keep the relevant production in active memory to avoid disaster. ” Approved by Randall W Engle)



Porath CL, Foulk T, Erez A. How incivility hijacks performance: It robs cognitive resources, increases dysfunctional behavior, and infects team dynamics and functioning. Organizational Dynamics 2015;44:258—265.

 A, Erez A, Foulk TA, Kugelman A, Gover A, Shoris I, Riskine K, Bamberger PA. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015;136(3):487:495.

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