How to practice civility in medicine

“Labour to keep alive in your heart that little spark of celestial fire called conscience.”
– Rule 110 from Rules of Civility, copied by George Washington as a teenager

The most consequential gesture in a clinic visit is sometimes the smallest one: a hand resting on the door handle. The visit seems over. The plan has been explained, the orders are in, and the day is already running late. Then, as you turn toward the hallway, the patient says, “One more thing.” In that pause, whether you turn back, whether your expression remains receptive, an entire moral weather system reveals itself. The patient may not remember lab values, but they will remember that moment.

As a young man, George Washington copied, by hand, a list of 110 “Rules of Civility in Conversation and Behavior.” The maxims were not his. They are commonly traced to a sixteenth-century Jesuit manual, later circulated through English schools before arriving in colonial Virginia. Washington transcribed them as an exercise in discipline. He did not compose the rules; he practiced them.

These were sentences meant to shape a person from the inside: to cultivate restraint, humility, and attentiveness. Long before Washington held authority, he was training himself in the manners by which authority can remain human.

Medicine unfolds in a similar landscape. Each clinical encounter is shaped by asymmetry: knowledge and uncertainty, authority and vulnerability. Illness disrupts not only physiology but identity, time, and agency. The clinician enters as one whose words and decisions carry consequence. How that presence is enacted is often remembered long after the diagnosis is forgotten.

Civility, in this sense, is not polish. It is an ethical posture: a disciplined way of inhabiting authority in the presence of another person’s exposure. Like Washington’s copybook, it is a practice, repeated, imperfect, and formative. Washington’s example is useful not because he authored those rules, but because he practiced them.

What follows is my own attempt to articulate a similar ethic for medicine.

Ten rules of civility in medicine

• Listen before speaking: Listening is an act of respect before it is a method of diagnosis. To listen before speaking is to delay premature certainty long enough for the meaning of illness, not only its mechanism, to emerge. In this brief pause, thirty seconds can be the difference between being managed and being understood.
• Apologize when appropriate: An apology acknowledges harm at the level of experience, not merely outcome. It says, “I recognize what this has been like for you.” In moments of error, delay, or misunderstanding, an apology restores equilibrium without surrendering competence. It reminds us that authority does not confer exemption from accountability.
• Receive every question with seriousness: Questions are often made of fear. They arrive as repetition, hesitation, or “just checking.” To take a question seriously is to treat it as an expression of agency rather than an inconvenience. A rushed dismissal teaches the patient what not to ask.
• Attend to what is worthy of affirmation: Illness narrows identity to symptoms and deficits. Recognition restores dignity where illness erodes it. To affirm perseverance, clarity, humor, or resolve is to refuse reduction. Patients remember acknowledgment as distinctly as they remember prescriptions.
• Speak ill of no one: Contempt is corrosive and spreads quickly in clinical settings. When speech becomes dismissive, the moral climate shifts. To speak ill of a colleague, or of a patient, in the presence of others is to grant permission for the same. Restraint protects the whole room.
• Extend equal concern to all: Distress does not present uniformly. It may appear as gratitude, hostility, compliance, or resistance. Equal concern requires steadiness toward every form of suffering, including those that complicate the schedule. Justice begins with refusing to divide persons into categories of worth.
• Guard privacy in word and manner: Privacy is not simply regulation; it is reverence. Vulnerability is entrusted. A lowered voice, a closed screen, a careful chart, and a discreet gesture all signal that what has been shared will not be handled casually. One careless remark can undo years of trust.
• Be present, however briefly: Presence depends on attention, not time. Even under constraint, attention can be whole: sitting down for thirty seconds, turning from the screen, letting your gaze land on the person rather than the problem. In that moment, a patient who feels seen is recognized.
• Exercise humility with humor: Humor can soften fear and narrow hierarchy, but it is also sharp. When directed at the clinician’s own limitations or at the absurdity of the situation, it can be solidarity. When directed at the patient, it becomes exclusion. Civility asks for levity that never makes another person smaller.
• Let the patient end the encounter: When the visit has reached its necessary close, allow the patient to have the final word. Illness strips control from daily life in a hundred small ways. Allowing the patient to release the encounter restores a measure of agency. A hand on the door handle before the patient has finished speaking is an assertion of exit, not an act of care. Civility is the final pause that belongs to them.

Ultimately, conscience is not a flame that burns automatically. It is a fire that must be tended with deliberate, repetitive labor. Character in medicine is formed in quiet acts of restraint: the retort not spoken, the extra breath before entering a room, the decision to turn back from the doorway, the refusal to let dignity become the cost of exhaustion.

Civility does not promise clinical perfection. It asks for disciplined attentiveness: the habit of remembering that an ordinary clinic visit may carry extraordinary weight for the patient. To practice that habit is to keep conscience alive, and to leave the room in a way that honors the person who remains.

Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.