The Death of Decorum

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I decry the death of civil decorum and protocol. We are in the midst of a war on decency, responsibility and proper human discourse. Those who know me will concur that I am not a prude. In fact, far from it. I advocate no thought police, fashion police or official adjudication of language or manners. After all, we’re not the French (sacrebleu!).

Let’s make the ED a bastion of egalitarianism, a final outpost in America’s war on common decency.


I decry the death of civil decorum and protocol. We are in the midst of a war on decency, responsibility and proper human discourse. Those who know me will concur that I am not a prude. In fact, far from it. I advocate no thought police, fashion police or official adjudication of language or manners. After all, we’re not the French (sacrebleu!).

I believe the government that governs best governs least. But I also believe that there is a growing complicity with public vulgarity and indifference to behaviors that are, in the long run, ruining the culture. I believe individuals have a right to their own private decisions and affairs, as long as they take legal and financial responsibility for their actions.

Lest you think this is just a hyperbolic reaction to Miley Cyrus’s antics on the VMA Awards, I was organizing this piece in my head long before twerking was invented. It is interesting how every generation feels it invented lust. Ovid actually invented sex-trash prose, which got him kicked out of Rome and almost executed by Augustus Caesar (who was a prude).


My desire to defend civility and some semblance of virtue against the crassness of modern culture is virtually an exercise in futility. I understand this. But let me proceed. It seems that Boogie Nights has gone prime time, all the time. To paraphrase Richard John Newhouse: If the American experiment in representative democracy is not a conversation with faith and civility, it is not a conversation with the overwhelming majority of Americans who believe we need a moral base on which to proceed. To the extent our public forums are indifferent or hostile to the language of civility, our social and political order faces an ever-deepening crisis of legitimacy.

This discussion is prompted by a few days of actually watching TV talk shows, listening to talk radio and reading the news on the internet. All of these experiences seriously challenge the proposition that there is any intelligent life on this planet. The mainstream media bring a new meaning to the term “dumb it down”. The yelling, shrill tones and lack of any active listening make the Coliseum seem downright sophisticated. The Age of Reason is gone. I pray daily for the return of the buffalo, the nickel Coke and William F. Buckley Jr.

There is a hard-hearted liberalism that says “whatever blows your skirt up” should be the new norm. It’s an apocalyptic mentality that accepts national bankruptcy, population degeneracy and virtual abandonment of the public school system in the name of political correctness. I put forward Anthony Weiner as the quintessential politician of our time. “Quit isn’t the way we roll in New York” is an insult to every New Yorker who gives a damn about his/her kids or community. Come on.

By now you should be asking about how this relates to seeing patients in an emergency department. You’re telling me, “We agree, the place is going to hell. So what?” First, we must deal with the hard fact that the ambient public culture where we both live and make a living has become toxic in so many ways that we can’t ignore the problem. To say that there are powers at work to cheapen the higher human experience is an understatement. There is a new aggressive non-moral secularism which promotes the concept of a naked public square in which all behaviors are tolerated. When was the last time you had the local police and/or hospital security refuse to take action in defense of you or your staff for fear of infringing the rights of a belligerent or unruly patient? I’m sorry. Not all behaviors are acceptable in a place like the emergency department where common interests must be served.


Medical providers have rights, and to not have the full backing of the hospital, the authorities and the court system is totally unacceptable. We are required by federal and often state statute to see everyone, and see them we will. But the quid pro quo is obvious – less than civil behavior will not be tolerated. A judge who does not send this message needs to be removed from the bench. What is just? What is prudent? I’ll be happy to answer that question for people who think we “don’t understand other cultures.” We have a need to provide both care and tranquility to all. We are the guardians on the wall between the outside world and what should be calm and reasonable medical care.

Second, we are the new hub of clinical decision making. I don’t care what type of payment program you wind up with. The emergency department will play an ever-increasing role in answering the most important question, which is: In or out? No, I’m not talking about the California burger chain. It’s, “Can we treat you with outpatient, holding unit, or expensive in-patient care?” As the gravity and frequency of such decisions increases, the potential for unpleasant confrontation increases. There are many families who don’t understand that admitting grandma to the hospital frequently does not improve her disease process. If you don’t believe that this will magnify safety concerns for emergency department staff, I don’t know where you work. It’s real. And this is an area where our professional societies need to take unequivocal action, particularly at the state and local levels.

The third pillar in improving the kindness and civility of human discourse is to do just that. I’m on my manners kick again, having just watched some teenagers behave like rude impudent little troglodytes. I came from one of those immigrant families that flowed to America during the Depression. These folks had little in the way of resources or book learning but they knew how to behave. I’m almost glad my parents are dead because they wouldn’t recognize the public schools or for that matter the public forum. But the fault lies not with our young, but with ourselves. Our mannerisms inform the young. Whether we want to recognize it or not, our conduct is monitored by all around us. The emergency staff must be the example of excellence in meting out what are acceptable standards: proper introductions at the beginning of an interaction; exchange of names; thanking people for their efforts and particularly the patients for utilizing the facility; and proper etiquette should motivate the staff and set the tone for everyone’s behavior. Humans are essentially herd animals. They will tailor their behaviors to what they see about them. Be the role model, not the critic.

My proposal is simple enough. Let’s make emergency departments real centers of excellence for proper handling of human beings. Lord knows we have pseudo designations for centers of excellence in everything else with little proof that there’s real change in the outcomes of disease in most of these areas. I understand I am advocating the support of some ritual behavior, but we are defined as humans by ritual. We continue to beat the chest of those brought in long since dead more on expectations than an outcomes basis. We start IVs on probably ten times the number of people we need to because that’s what our patients have seen on TV. It’s medical holy water applied liberally at $65 per bottle.

I advocate that we become the last place in the public square that treats everyone with decency and respect. The hopeless vulgarity which has continued to grow since the 1950s should not control our behavior. The behavior of the patients should not set the tone for us. I am not naïve. We will not go back to the days of Ozzie and Harriet. We cannot draw the cordon sanitaire around the patients or their families. But we can promote the idea that the emergency department is a center of egalitarianism.

Equal does not mean mediocre. I do not advocate equal disdain for everyone as the norm. To do less, to not give people proper care in this world where things are falling apart, is to participate in the lowering of these standards. The patient really should not have to pay more (which they do) and get considerably less.

Ex animo—“from the heart”

Qui tacet consentire—“silence gives consent”

Greg Henry, MD is Founder and CEO of Medical Practice Risk Assessment, Inc.; past president of ACEP.


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