Nurses, doctors, and everyone else near the nursing station looked up suddenly when they all heard a loud male voice booming from the nearby staff room.

I heard this story later, one of the tales that is increasingly and disappointingly more frequent in this hospital. The speaker in the next room was telling an RN that his patients were receiving substandard care on that unit. As reconstructed from the speaker himself, from the victim of his wrath, and from witnesses, the criticisms were general and not related to points that could be addressed by anyone who heard them. The remarks were, however, rude, unprofessional, and arguably illegal, if placed under scrutiny of the rules governing sexual or employee harassment. The tone of anger clearly mitigated against any constructive response that the nurse, supervisors or the physician's colleagues might otherwise have mustered in support. And patients in nearby rooms or passing by on gurneys surely heard this unsettling and inappropriate outburst.

It would be a cliché for me to say that in the past year as chief of staff I've seen lapses in civility and therefore perceive the need for all of us to hone our interpersonal skills in this realm.

But I've seen how this issue goes far beyond the need for manners that we learned as children.

First, I am now scrupulously aware that these lapses do not fit stereotypes. Doctors, nurses, housestaff administrators; young, old, male, female; and even patients, land on both sides of the civility ledger.

Second, not all lack of civility is equal, at least in the eyes of the law. Interactions between an authority figure and a subordinate or employee may raise specific concerns. That form of incivility doesn't make a clash between two equal colleagues any less uncivil, or, in some cases, any less damaging. But in the 1990s, we must be mindful that a clash of persons in unequal positions of authority may trigger a new set of rules. If it's unacceptable to be uncivil, it's obviously even worse to cross that second line into libel, harassment or other forms of behavior which are now illegal.

Third, I think a perceived increase in incivility is intertwined with a general increase in stress. The lack of time and the weight of the pressures on all of us obviously mitigate against traditions of courtly, polite social discourse. All of us in health care are increasingly on the firing line as we cope with the economic evolution in health care and an escalation in the litigiousness of our society.

Each of us has a different capacity to handle stress and we each react differently to it. How do physicians (or for that matter, anyone else) develop the requisite social skills that enable us to be courteous and perhaps even supportive - without wasting the increasingly scarce resource of time? For example, what do we do when the patient with a newly diagnosed terminal illness wants to talk with us for 30 minutes rather than the 10 minutes our schedulers have allocated? This is a dilemma, certainly, but one that we each must address individually. It is also a very personal matter and one that we should be motivated to solve. Can we use what little time we have more effectively? Can our support people play a larger role in these sensitive moments, saving us time but giving the patients the human contact they need? We cannot solve this dilemma here, but we can recognize that civility is at the core of our behavior in these matters. When we find solutions in our own ways, patient care will benefit and those of us who learn these "patient sensitive" skills will become better, more successful caregivers by every measure.

Courses, programs, counseling sessions are all ways to improve sensitivity and skills. Balance in our personal lives is, of course, another way to cultivate the personal resources we need to conduct our affairs in a healthy, productive, civil manner.

Right here at SHS, there are mechanisms and forums to deal with conflicts that we may have with our associates or fellow health care workers. The place to start is at departmental or service meetings or, if the issue involves patient matters, at mortality and morbidity conferences. In these settings you are working with the colleagues you know best. My office is available for counsel if for some reason a medical staff member, house staff, nurse or patient would like help in resolving a conflict. My office number is (415) 723-5371. The Medical School ombudsperson, Martha McKee, is more than willing to be an impartial facilitator in such issues. She can be reached at (415) 498-5744.

Effective communication is a necessary tool in patient care and in a teaching environment. Civility promotes communication whereas the opposite behavior blocks or destroys it. We need to resort to the Old West protective behavior in time of danger and stress. The settlers venturing into new frontiers would "circle the wagons." We must make sure that when we do form the circle we are protecting our values, not pointing our guns or directing our vitriol at our allies.