We all wish we were paragons of virtue, exemplars of professionalism, trusted, respected and beloved colleagues with eternal patience and abundant good cheer. We work in a stressful and demanding profession, however, and in a world permeated by increasing concerns regarding qualifications, disruptive physician policies, and discipline committees. There are a few Gandhi's and Mother Theresa's but maybe more than a few House's (that caustic misanthropic doc on the television series of the same name).

Extremes on both ends of the physician behaviour spectrum are easy to identify. It's not difficult to exalt the saintly or condemn the execrable. The hard work is in between.

Most interactions between physicians observe a certain patterned etiquette. Collegiality is the general norm; this is the zone we aspire to operate in. There are behaviours, though, regularly observed, that fail to meet that standard. While not qualifying as frank ethical breaches, they diminish the quality of our lives. Some of these occur in exchanges between family docs (FPs) and specialists, and others between family practitioners.

Sources of friction
On that particular clinic day, inside the envelope was a memo saying that the specialist had ordered a test and could we please oversee and manage the results. To say that we were less than amused would be an understatement. I walked over to her office ready to do battle. Fortunately, she was with a patient. This likely avoided a nasty confrontation. Instead, I left a sharply worded note. As my handwriting is appalling, and even worse when in a rush, I imagine she was puzzled when she picked up a sheet of paper with what could pass for Hittite cuneiform and a phone number. By the time she called, I had settled down.

Most confrontations and irritations arise from a failure to respect others or to observe some variation of the golden rule. When busy, time pressured and stressed, it's difficult to take some simple steps to prevent quarrels and outbursts of anger. Below we outline a brief taxonomy of violations and some simple remedies to correct them. As an additional exercise, we (the family physician and the neurosurgeon) tried to step into each other's shoes to identify some leading annoying inter-doctor behaviours.

Failures of communication to your own FP colleagues
Actions: Failure to notify; dumping work
Example: An FP goes on holiday right after telling a patient he would need his antihypertensive medications adjusted urgently. The FP's partner, not having been warned, is upset when this individual shows up on Monday morning.
Remedies: Communicate anything a reasonable colleague would want or need to know about your patient. Explain, in advance, the complex cases you're handing off.

Failures of communication to specialists
Actions: Incomplete information, or misinformation, on referrals
Example: An FP calls to refer a patient with a straightforward cauda equina syndrome to the neurosurgeon on call at the teaching hospital. When this individual arrives, the specialist and his team learn that the patient is a brittle diabetic, has an artificial aortic valve and is fully anticoagulated. That same day, the same FP faxes a referral of a patient with sciatica to an orthopedic surgeon with "back pain" written on the faxed referral and nothing else.
Remedies: Make sure to give details that are tempting to withhold because of the time factor and/or potential interference with the fast off-loading of a challenging patient. Give full data on elective referrals.

Failures of availability
Actions: Lack of response to phone calls and e-mails; inability to find a physician
Example: A complicated patient with colon cancer calls his FP -- he's failing at home with recurrent vomiting and melena. The oncologist managing his care can't be found by the FP for advice on management.
Remedies: Be as available as possible for your colleagues. Respond to telephone calls or e-mails in a timely fashion or communicate by voice message or electronic out-of-office autoreply that you're unable to do so. This way, the FP can seek an alternative solution.

Failures of civility
Actions: Rudeness; condescension; arrogance
Example: The first-line practitioner calls a neurosurgeon to ask his advice about a patient with severe sciatica but no cauda equina syndrome. The neurosurgeon responds sarcastically: "There are 5,000 people walking around like your patient today; I suppose I should talk to all their FPs?"
Remedies: Remember that we're all on the same team and specialists can't expect family physicians to know as much about a disease entity as they might.

Failures of respect
Actions: Name calling, profanity
Example: A family practitioner calls a cardiologist "an arrogant, lazy ***" within earshot of other colleagues and residents. The cardiologist had placed the burden of organizing all the diagnostic tests back onto the FP, instead of doing it himself.
Remedies: Take a deep breath. Don't say anything you could later regret.

Let's all try to do better
These are but a few examples and the list is not exhaustive. We all get up every morning with the intentions of benefiting our patients and being good colleagues to our peers. It doesn't always work out exactly that way, and we must forgive ourselves and others when we fall short -- as long as we always strive to do better.