Published ahead of print on August 20, 2008
Clin J Am Soc Nephrol 3: 1884-1886, 2008
© 2008 American Society of Nephrology
doi: 10.2215/CJN.01750408
Moving Points in Nephrology
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Academic Etiquette for the Nephrologist
Suzanne Watnick
Portland VA Medical Center, Portland, Oregon
Correspondence: Dr. Suzanne Watnick, 3710 SW US Veterans’ Hospital Road, P3NEPH, Portland VA Medical Center, Portland, OR 97239. Phone: 503-220-3450; Fax: 503-721-7810; E-mail: watnicks{at}ohsu.edu
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Abstract
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Academic etiquette is an underexplored and underemphasized topic. Yet, a collegial atmosphere is essential to accomplish the missions of an academic medical center. Appropriate social, personal, and cultural behaviors are not only desirable, but they are also necessary to practice and emulate. As faculty in an academic center, one may want to share these thoughts with peers, students, and other healthcare providers. As a trainee, one may want dedicated lectures on this topic and to observe the behaviors modeled by mentors. This article attempts to outline principles of appropriate etiquette in the academic workplace. These include issues of loyalty, collegiality, and collaboration in daily activities from research to clinical care. Approaching personal interactions with grace and integrity can be an essential tool in the pursuit of academic excellence and success.
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Introduction
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Previous articles about training the academic nephrologist have focused on fundamental issues, such as mentorship to funding strategies and critical thinking to institutional support. Rarely is there peer-reviewed advice on social, personal, and cultural behavior. As a trainee, I received dedicated lectures on this topic and saw the behaviors modeled by my mentors, specifically Alvan Feinstein, to whom this article is dedicated.*
Now I discuss these "principles" with our current fellows. This oral tradition deserves a wider audience; thus the background for this article.
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First Principles
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Do not surprise anyone; this seems a fitting first principle. It was introduced to me as "do not surprise your friends," but I have found it essential not to surprise your enemies, either. This recollection has saved me innumerable misunderstandings that would otherwise have taken up misspent time and energy. If you become aware of something important to your colleagues, don’t let them find out from another source. This includes informing people in advance of unpopular upcoming activities. Do not surprise past or present mentors either. Let mentors hear directly from you that your new grant will explore something that they believe unorthodox. You can best explain your case. Or, if you cannot, at least you’ll know how your case was presented.
Any large institution may seem daunting, but the rules of hospitality still apply. The more congenial we are, the better we will be treated. Sending thank you notes, even via email, is often appreciated. If you play well, people will want you on their team (1). Basically, professional hospitality should not be considered differently from social hospitality. Loyalty goes in all directions (up, down, and laterally) if it is going to work.
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Collegiality
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Collaboration, and collegiality, is a basic workplace standard that most professionals desire and expect in the academic environment. Occasionally, this is not strictly adhered to, and academicians need to learn how to deal with difficult situations. The analogy of learning to "swim with sharks" is poignant and adds humor to those difficult situations (2). Typically, no one wants to swim with sharks, but some find that they must swim. This is like any other skill: it cannot be learned from books alone, and the novice must practice to develop skills. Some rules include: 1) assume unidentified fish are sharks, implying that not all colleagues have your greatest needs in mind; 2) do not bleed, implying that a display of weakness to the aggressor is not helpful; 3) counter any aggression promptly and use anticipatory retaliation so not to let others think you are easily pushed around; and 4) disorganize an organized attack. The proper strategy may be diversion, as sharks can be prone to internal dissension, even by something minor or trivial. Luckily, in a communicative and appreciative environment where support is not difficult to find, standing your ground in such a manner is rarely needed.
Given the potential difficulties of the workplace, disputes may arise. Arguments might be avoided if the involved parties at least understand the topic of dispute. The first and second parties should be enticed to state the other’s position. Many arguments have vanished after realizing an initial misunderstanding occurred. Once the argument begins, the protagonist and antagonist should feel free to dispute. If the antagonist’s concern is contradictory to the establishment, ensure that the dissenter is reporting, not editorializing, the topic. "Purple prose" should be avoided, and the reader or listener should decide on the merits of a new idea. Judging or moralizing against the opposing side is inappropriate. Just because they may be wrong doesn’t mean they are evil! Let your adversaries know in advance that you are attacking their ideas. In fact, let your peers and/or supervisors know about the dispute if worthy of notice. This comes full circle back to the "don’t surprise anyone" principle.
Try to give a hearty congratulations or appropriate condolences to colleagues. Tell people that you appreciate them when the opportunity arises. Let others know about your colleagues’ accomplishments. Think of how much this means to you when it happens.
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Daily Activities
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Mail, electronic or otherwise, should be gone through once and disposed of immediately if possible. Less drudgery will be appreciated the most by you! Proofreading items and returning requests expediently may seem like minor details, but this demonstrates your professionalism. For meetings, silence pagers and cell phones. Be prompt, prepared, and to the point. Understand the constituencies represented. This will serve everyone well. Always ask the question, "What’s in it for me?" If you do not ask, others with whom you associate will ask this question. Thus, you must also ask, "What is in it for the other person?"
When requesting anything, either from a colleague or supervisor, consider advanced logical and organized preparation. Perhaps practicing the request aloud or in front of a friend can improve the chances of success.
For oral presentations, always stick to your point. Slide and text dissociation is befuddling to the observer. Say "thank you" at the end so the audience knows you’re done. Then they know to (wake up and) applaud. When critiquing reports and reviewing manuscripts, brevity is appreciated, objectivity is essential (3). Remember not to destroy that which you cannot create, implying that overly harsh criticisms may not aid the presenter or reviewer in pursuit of excellence.
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Research
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Much of the wisdom that I observed regarding research had more to do with the quality of studies than with the behavior that others should display. Thus, the contents of this section contain more about content than conduct. Perhaps this is appropriate, as the best ideas do not always arise out of the "status quo."
Of the many quotes I have heard about research, one was most memorable: "Research is 99% drudgery and 1% ecstasy." The modicum of ecstasy could be due to poor quality studies, or those "not in pursuit of truth." Other quotables have included, "The first prerequisite for a lot of writing, of course, is to have a lot to write about," and "forget statistics, return to common sense." A major criticism that I often heard concerned the manipulation of data: "Torture the data until they confess!" Also, cynicism or "skepticemia"
might assist one’s noble pursuit of research. "Since few human ideas are truly original, a scientist’s creative thoughts generally represent the conquest of his own ignorance."
To some degree, research represents a search for truth. "I would simply urge you to try to recognize truth, to stick to it when you think you’ve found it, to give objective news... avoid ad personam (that’s the politically correct way of saying ad hominem) attacks. Your adversaries may be deluded or ignorant fools, but they are not necessarily knaves. The hope is always to find open-minded, rational people. They are not abundant, but they exist, and they will sustain you if your ideas and evidence have merit" (Feinstein A, personal communication).
People may strongly disagree with all of this advice. If so, I suggest referring to the section regarding disputes, and act accordingly.
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Clinical Care
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The care of patients is integral to the mission of most academic medical centers. Serving as attending on the nephrology consultative service can be a very public role; in essence, we become the ambassador for the clinical inpatient service. Consultation etiquette entails collegial and collaborative interactions, whether or not we agree with the consultative questions being asked (4). The "Ten Commandments" of consultation are an excellent source of instruction, which keep the consultation focused and pragmatic (5). The first commandment is to determine the question; this sets the rules for the interaction. Other commandments include honoring turf, teaching with tact, and maintaining personal contact, which both help the requesting service and keep them coming back for help in the future.
Rules of etiquette apply to patient interactions, too. Professional behavior toward patients can be an external manifestation of good intent or merely a social practice (6). Either way, a simple etiquette-based approach can provide the patient with respect and attention (7). Simply asking the patient permission to enter the room, with appropriate introductions and explanations, keeps the patient at the center of the interaction and maintains a foundation of professionalism.
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The Need for Humility
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Most individuals in medical academe are highly educated, intelligent people who can be effusively praised for what they do. This can lead to unnecessary overconfidence. Other dynamics of physician overconfidence have recently been explored, such as attitudinal aspects (the concept of knowing all one needs to know), cognitive dissonance (not knowing what one doesn’t know), and complacency (8). Often those at more novice levels overrate their skills the most (9–11). Recalling a greater purpose can be somewhat humbling, perhaps healing to self, and often for the greater good. Some core principles are the following: 1) unswerving allegiance to always doing what’s best for the patient; 2) continuing support for the basic biomedical research that produces new accomplishments; 3) vigorous development of the basic clinical-care research that produces a humanistic science for evaluating the accomplishments; and 4) restoration of the charitable caring that Alvan Feinstein named "caritas."
Most importantly, never take yourself too seriously, but always take what you do seriously.
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Conclusion
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In daily personal interactions, integrity above all is at the core of mutual respect with others. Etiquette, as an instrument to open up a social space, helps to emphasize the importance of social integrity. In this way, etiquette plays a central role in the success of any individual or group within the setting of the academic medical center.
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Disclosures
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None.
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Footnotes
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Published online ahead of print. Publication date available at www.cjasn.org.
* All of the commentary and witticisms in this article, except for those cited, are based upon the writings of Dr. Alvan Feinstein (1925–2001), distinguished Sterling Professor of Medicine and Epidemiology at Yale University. In addition to being the "father of clinical epidemiology," and the author of over 400 original peer-reviewed articles, he was the mentor of many other distinguished Professors of Medicine throughout the world; in essence, a teacher’s teacher. 
Prior lectures coined the term "academic toilet training," rather than "academic etiquette," for this subject.
Skepticemia—of or pertaining to a state of constant skepticism. I first heard this term coined by Ralph Horwitz, Chairman of Medicine, Stanford University, and an early mentee of Alvan Feinstein.
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Abstract
Introduction
