The Civility of Care

Small Habits That Shape the Clinical Encounter

Written by Timothy Lesaca, MD – ACMS Bulletin Associate Editor

The most consequential gesture in a clinic visit is sometimes the smallest one: a hand on the door handle. The plan has been explained, the orders entered, the day is already running late. Then, as you angle toward the hallway, the patient says, almost as an aside, “One more thing.”

In that pause—whether you turn back, whether your face stays open, whether your attention returns—an entire moral weather system reveals itself. The patient may not remember the lab values, but they will remember what happened to them in that moment.

As a young man, George Washington copied—by hand—a list of 110 “Rules of Civility in Conversation and Behavior.” He did not write them. The maxims are often traced back to a sixteenth-century Jesuit manual on decorum, translated and 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.

That distinction matters. The point was not obedience for its own sake. These were sentences meant to shape a person from the inside—to cultivate restraint, humility, and attentiveness, especially where power is involved. Long before Washington was entrusted with authority, he was training himself in the manners by which authority can remain human—and in the ease with which it becomes careless when left unexamined.

Medicine unfolds in a similar landscape. Each clinical encounter is more than an exchange of information; it is a meeting shaped by an asymmetry of knowledge, authority, and vulnerability. Illness disrupts not only physiology but identity, time, and agency. The clinician enters that unsettled space not as a neutral observer, but as one whose words and decisions carry consequence. How that presence is enacted matters—and 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. The rules below are not techniques to execute; they are orientations to renew, sometimes in gestures so small they feel like nothing. Taken together, they help ensure that the encounter does not collapse into a transaction.

The Rules

Listen before speaking.

Listening is an act of respect before it is a method of diagnosis. Symptoms may fit patterns, but lives do not. To listen before speaking is to delay the comfort of premature certainty long enough for the meaning of the illness—not only its mechanism—to emerge. It may cost thirty seconds. Those seconds are often the difference between being managed and being understood.

Speak ill of no one.

Contempt is corrosive, and it spreads quickly in clinical spaces. When speech becomes dismissive, the moral climate of care shifts. To speak ill of a colleague—or of a patient—in the presence of others is to grant permission for the same. Restraint may feel like swallowed impatience, but it is also protection for the whole room.

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, apology restores equilibrium without surrendering competence. Authority does not confer exemption from accountability. A simple “I’m sorry this happened” can steady a room more than a paragraph of explanation.

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 version of suffering, including those that complicate the schedule. Justice in the clinic begins with the disciplined refusal to divide persons into categories of worth.

Receive every question with seriousness.

Questions are often made of fear. They arrive as repetition, hesitation, as “just checking.” To take a question seriously is to treat it as an expression of agency rather than an inconvenience. Respect requires patience with uncertainty—even when the answer feels obvious. A rushed dismissal teaches the patient what not to ask.

Guard privacy in word and manner.

Privacy is not merely regulation; it is reverence. Vulnerability is entrusted, not surrendered. A lowered voice in the hallway, a closed screen, a careful chart, a discreet gesture—these signal that what has been shared will not be handled casually. A single careless remark can undo what trust required years to build.

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 rest on the person rather than the problem. A patient who feels seen is not only reassured; they are recognized. The difference between being looked at and being looked through is unmistakable.

Attend to what is worthy of affirmation.

Illness narrows a person’s identity to symptoms and deficits. The chart becomes a biography written in problems. Recognition restores dignity where illness erodes it. To affirm perseverance, clarity, humor, or resolve is to refuse reduction. Many patients will remember that acknowledgment as distinctly as they remember the prescription.

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 the absurdity of the situation—it can create solidarity. When directed at the patient, even in jest, it becomes exclusion. Civility asks for levity that never diminishes another person.

Let the patient end the encounter.

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 before they’ve finished speaking is an assertion of exit, not care. Civility is the final pause that belongs to them.

These rules do not require softness. Civility is compatible with truth, boundaries, and saying no. It asks only that firmness be delivered without contempt, and that efficiency never be purchased at the price of humiliation. The clinician’s authority can remain intact while their manner stays humane.

Ultimately, conscience is not a flame that burns automatically. It is a fire that must be tended through deliberate, repetitive labor. Character in medicine is formed not only in dramatic saves or technical perfection, but in quiet acts of restraint: the retort not spoken, the extra breath taken before entering a room, the decision to turn back from the doorway.

Civility does not promise clinical perfection, nor guarantee a cure. It asks for disciplined attentiveness—the recognition that while a clinician may see twenty patients in a day, for the person in the gown this may be the most significant hour of their year.

To honor that weight is to practice these rules until they become not a checklist, but a habit of the hand and a steadiness of the mind.