CREOG Education Committee
Social Etiquette Work Group
This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Council on Resident Education in Obstetrics and Gynecology (CREOG) Education Committee and the Social Etiquette Work Group in collaboration with committee members Mark B. Woodland, MS, MD; Amanda B. Murchison, MD; Rebecca P. McAlister, MD; Karen Adams, MD; Erica E. Taylor, MD; and Expert Work Group member Lee Learman, MD.
ABSTRACT: Educators in obstetrics and gynecology work within a changing clinical learning environment. Ethnic, cultural, and social diversity among colleagues and learners have increased, and methods of communication have expanded in ever more novel ways. Clerkship, residency, and fellowship directors, in partnership with chairs and senior faculty, are urged to take the lead in setting the tone for workplace etiquette, communication, and social behavior of faculty and trainees to promote a high standard of civility and citizenship. The Council on Resident Education in Obstetrics and Gynecology (CREOG) Education Committee has promulgated recommendations that can be used to help address professional relationships, professional appearance, and social media usage. These recommendations also address communications pertinent to educational processes such as interviewing, teaching, evaluation, and mentoring.
The American College of Obstetricians and Gynecologists (ACOG) Council on Residency Education in Obstetrics and Gynecology (CREOG) Education Committee makes the following recommendations regarding social etiquette in interactions involving residents or prospective residents:
Program directors can help ensure that faculty members have the tools they need to be successful mentors. Program directors are encouraged to discuss with their institutions specific needs for faculty development by doing the following:
Provide education for residents and fellows regarding institutional dress codes or policies applicable to professional appearance.
Educate learners about policies to ensure professionalism.
As part of the standard curriculum in a new digital age, faculty are encouraged to model professionalism and decorum, teach learners about potential pitfalls, and facilitate and maintain professional relationships by doing the following:
Remind faculty and residents that their digital footprint represents not only themselves, but also their institutions, specialty, and the obstetrics and gynecology profession at large.
Educate participants in the student, residency, and fellowship interview process regarding potentially biased or discriminatory remarks or questions and encourage the interviewer to focus on determining the applicant’s ability to successfully complete residency training.
Program directors can help educators become more effective teachers by making them aware of the following specific characteristics of adult learners:
Many of today’s learners prefer information to be delivered individually, or through available technology as well as group discussions. Program directors may need to look at creative ways to provide their curriculum to today’s learner.
Today’s learners are typically positive about their careers and respectful of authority. They desire frequent, personal, and focused feedback.
When interacting with learners in a social environment, faculty members still are seen as role models—and to a certain extent, professionalism must follow them into their private lives. Program directors and other faculty who mentor residents are advised to involve their graduate medical education (GME) office for advice and support if the mentoring relationship extends beyond career advising.
Today’s educators in obstetrics and gynecology work within a changing clinical learning environment. Ethnic, cultural, and social diversity among colleagues and have increased, and methods of communication with those groups have expanded in ever more novel ways. The ever-changing face of obstetrics and gynecology faculty and residents, mixed with the advent of expanded methods of communication, has opened the door for the CREOG Education Committee to address the nature of communication and provide a framework for social etiquette. Social etiquette is now more complicated than following the “golden rule” and remembering to say “please” and “thank you.” Clerkship, residency, and fellowship directors, in partnership with chairs and senior faculty, are urged to take the lead in setting the tone for workplace etiquette, communication, and social behavior of faculty and trainees to promote a high standard of civility and citizenship.
Definitions of specific terms used in defining parameters of social etiquette are listed as follows 1.
Etiquette: A code of behavior that delineates expectations for social behavior according to conventional norms within a society, social class, or group.
Social Behavior: A behavior directed toward society or that takes place between the same species.
Social Etiquette: A code of behavior within an institution, community, or family.
Manner: A way of doing something or the way in which a thing is done or happens. Manners reflect the prevailing customs, social conduct, and norms of a specific society or group.
Decorum: Behavior in keeping with civility and propriety.
Scenario: As program director, you placed a second-year resident on probation at the recommendation of your Clinical Competency Committee for academic and professionalism issues. The resident appealed this decision to GME. The GME office held a hearing, and the decision was overturned with a recommendation of remediation. You are meeting with the resident for the first time since this hearing.
The resident–program director relationship requires self-disclosure by the resident. For example, program directors have access to the trainee’s academic record and are responsible for reviewing this record with the trainee and potentially implementing remediation or probation plans. This characteristic of self-disclosure results in a more intimate relationship than perhaps the resident has with other faculty members 2, which can put the trainee in a vulnerable position, especially because the disclosure of information is one sided. Residents often benefit from having access to mentoring relationships with faculty during their training and should maintain a certain level of decorum. Program directors can help ensure that faculty members have the tools they need to be successful mentors and, when needs are identified, faculty members may want to reach out to their institution for faculty development support.
Scenario:Your hospital has a policy of not wearing scrubs to and from work. Hospital-laundered scrubs should be worn at work when appropriate. You are sent a picture of one of your residents wearing scrubs while grocery shopping after work.
Medical professionalism had originally been defined from a physician’s perspective, but since the 1980s, there has been a public-centered shift that has changed the social contract between physicians and society. The public recognizes doctors as professionals and has expectations of good behavior, high values, positive attitudes, citizenship, decorum, and sound clinical care 3. Physician attire influences the patient–physician relationship. A study in the inpatient setting showed that patients’ family members reported the following physician factors as most valued: easy-to-read name tag, neat grooming, and professional dress. When shown pictures of health care providers, the same study participants preferred physicians in traditional dress with a white coat 4. A recent study of a surgical subspecialty showed that compassion, politeness, and knowledge are the physician characteristics most valued by patients. The impression of cleanliness and good hygiene was more important than the style of dress 5. Professional appearance reduces the risk of unintentional communication or provocation based on popular trends or culture that may be construed as sloppy, dirty, or sexually inappropriate for the nature of the interaction (such as short skirts, open shirts, or low-riding pants). Residents should be made aware of institutional dress codes or policies. Providing education as to why policies are in place may help with compliance with the policy. For example, some policies ensure a level of professionalism while others may be in place to improve infection control. Faculty members can serve as role models; thus, an understanding of institutional standards and policies will help them to appropriately hold residents accountable to set standards.
Scenario:You become aware that your resident posted a picture on Facebook with a caption “Isn’t she so cute? I delivered her today and she is up for adoption.”
Current trainees are usually comfortable using the latest technology, which may or may not cross boundaries of privacy and Health Insurance Portability and Accountability Act regulations. As educators, obstetrician–gynecologists need to familiarize them-selves with technology so that they can incorporate the potential benefits into their teaching programs, but also to be able to educate learners about the potential limitations and downfalls, such as breaches in privacy and maintaining confidentiality. As faculty, obstetrician–gynecologists strive to model professionalism in a new digital age, and the way they go about doing this serves as a model for physicians in training 6. With the availability of social media, the boundary of personal and professional lives can be blurred. Residents may not realize that as physicians in training, their digital footprint now represents their institutions, specialty, and the obstetrics and gynecology profession at large. Residents who display a high ethical standard offline may fall into the trap of disinhibition during online actions. It is equally important that obstetrics and gynecology residents are taught that patients, in addition to colleagues, employers, and other staff, are using social media to judge a physician’s common sense and trustworthiness to handle patient care while maintaining privacy 7.
As faculty, obstetrician–gynecologists can encourage residents to maintain a professional image by educating them on the following 6 7:
Using strict privacy settings on social media sites
Thinking carefully before posting and communicating
Having discussions about appropriateness of “friending” on social media sites
Protecting patient privacy and personal and professional integrity
Maintaining compliance with institutional privacy regulations and Health Insurance Portability and Accountability Act standards
Scenario:While interviewing a female applicant for a position in your residency program, you notice that she appears to be in her third trimester of pregnancy.
It is important to keep in mind federal and state discrimination regulations in the residency applicant interview process. Applicants are protected against discriminatory employment practices by the Title VII Civil Rights Act of 1964, state and local laws, and associated regulations. Hospital and university policy also may address employment discrimination. Interviewers must avoid questions that may be construed as discriminatory. This would include questions on such topics as marital status, family planning, national origin, religion, age, sexual orientation, and race. A small, but alarming, study showed that 90% of medical students reported they had been asked at least one potentially discriminatory question during their residency interview process. Residency interviews are a high-stakes process and program directors are looking for students who will best fit their programs. Consider educating all members of the interview team on potentially biased or discriminatory questions, maintaining the decorum of the program and institution, and providing instruction on how to keep the interview focused on determining applicants’ ability to successfully complete residency training and their fit into the program 8.
Curriculum Development and Teaching
Scenario:As the program director, you notice that your residents seem to be disengaged during their weekly didactic sessions with faculty. The faculty has been delivering the same lecture format for the past 10 years, but recently the resident feedback is less favorable.
Program directors are responsible for developing and carrying out the educational and clinical curriculum for their residency program. They typically will rely on their faculty to successfully complete this task. In doing so, the program director may periodically monitor the product provided. This may be done through such avenues as resident evaluations of the faculty, annual program evaluations and review, internal program evaluations, and Accreditation Council for Graduate Medical Education annual evaluations by the residents and faculty. When areas could benefit from improvement, the Program Evaluation Committee may be helpful in discussion, problem solving, and identifying areas for faculty development.
When teaching in a group setting, it is important to recognize that generational differences can affect learning, and teachers should adapt their methods to best suit the learners’ needs. Many of today’s learners appreciate structured learning with clear expectations and prefer the information to be delivered individually, or through available technology as well as group discussions. Program directors may need to look at creative ways to provide their curriculum to today’s learner.
When working with residents in an individual setting, it is important to remember that residents are historically very positive and enthusiastic about their career and education, and respectful of authority and the inherent hierarchy of the educational process. Having said this, frequent, personal, and focused feedback is essential to this process 9.
Scenario:You receive an event report that was submitted by a scrub nurse describing a resident who became very frustrated with the nurse when she had difficulty loading left-handed needles. She reports that the resident commented, “nobody around here can load a left-handed needle.”
When giving feedback and evaluating individuals or groups, faculty are encouraged to focus on specific behaviors, including manner and decorum or knowledge gaps, and avoid general, less-specific comments such as, “good job” or “needs to read more.” Evaluation should be clear, expected, and based on the established learning goals. Avoid labels such as “unprofessional” and focus on the effect of undesirable behavior, decorum, and manner on patient care or the team functions or process. Learners often have difficulty accepting negative feedback, however constructively it is intended. It is best to discuss receiving criticism with them and identify how their interpretation of criticism and feedback may be an obstacle to achieving their goals. Find opportunities to praise in a supportive manner, but be careful to criticize in a private and confidential manner. Assume the intent of a learner was to do his or her best work. When areas needing remediation are identified, work with learners to build a learning plan to achieve the stated goals within the clinical learning environment. Discuss specific expectations and arrange for follow-up in a timely fashion.
Scenario:You have a mentor–mentee relationship with a second-year resident. During a meeting, your mentee divulges that she is struggling with the pressures of residency and the additional stressors of trying to maintain a work–life balance.
Program directors are expected to informally mentor all trainees and may be asked to formally mentor trainees and colleagues. When developing a mentoring partnership, it is important to set clear boundaries of what can and cannot be done for the mentee. Considering specifics regarding how often to meet, the method of meeting (in person or by telephone), the duration and scope of the mentoring relationship, specific skills and expertise to be shared, and how to handle confidential information will allow the mentor and the mentee to achieve clarity about what is to be accomplished. Keeping these factors in mind will allow mentors to better understand their mentoring framework, what areas they are interested in covering, and what they will and will not attempt to do. If anything is beyond the mentor’s skills and abilities, the mentee may benefit from referral to another expert.
For example, if a discussion raises a human resource issue, a resident mentee can be referred to the institutional GME office. Faculty colleagues also may need referral to an institutional expert, counselor, coach, or attorney. If conversations about work problems lead into personal or family problems, the mentee may need more focused professional help from a resident wellness program, psychologist, or therapist, and reaching out to program leadership or institutional resources may become necessary. A mentor can provide support and advice to the mentee, but must know when to involve others. He or she may be called upon to be a sounding board for all sorts of issues and concerns. It is advisable for mentors to know in advance how they are going to deal with difficult situations and how to maintain a professional decorum consistent with their institutional standards. Program directors, and other faculty who mentor residents, are advised to involve their GME offices for advice and support if the mentoring relationship extends beyond career advising.
Social Interactions Outside the Workplace
Scenario:You are at a departmental holiday party and observe one of the faculty members drinking heavily.
Program directors and faculty members continue to represent their institutions and profession when interacting with residents outside of the clinical setting. Events such as departmental celebrations or professional meetings may allow for more casual dress and behavior than the daily workplace environment, but it is expected that faculty members project and maintain a professional decorum. When interacting with learners in a social environment, faculty members still are seen as role models—and to a certain extent, professionalism must follow them into their private lives as exhibited in manners and decorum.
“Etiquette, like our living language, is seemingly rigid but actually fluid. The time in which we live are constantly producing new, and therefore, puzzling situations” 10. As faculty members who are training the next generation of professionals, it is important that social etiquette is taught and role modeled. As in the modern interpretation of the Hippocratic Oath, “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm” 11. When it comes to social etiquette for physicians, the classics still apply with the addition of some 21st century applications to maintain a high standard of civility and citizenship in our professional lives.