Confronting the Hidden Curriculum: Active Management of Professionalism Lapses Catherine R Lucey MD Vice Dean for Education UCSF School of Medicine 9/4/12.

Confronting the Hidden Curriculum:Active Management of Professionalism

LapsesCatherine R Lucey MD

Vice Dean for EducationUCSF School of Medicine

9/4/12

Cases overheard on rounds…

A senior resident tells a student that she is too smart to go into her chosen specialty– that specialty is for dolts.

An intern continuously joked and made disparaging comments about fat people while they were caring for morbidly obese people.

An attending complained about the incompetence of another service who refused to accept a difficult patient in transfer.

A nurse demeans the reputation of an intern who disagreed with a decision that she made.

A senior attending refuses to participate in the pre-procedure checklist.

Different Types of Learning

Explicit

Tacit

Expertise

When Lessons Collide

The Hidden Curriculum

Explicit

Tacit

The Rules of Professionalism

Be altruistic

Be honest

Have integrity

Be respectful

Maintain confidentiality

Avoid conflicts of interest

Engage in professional self regulation

Steward resources

Ensure life long competence

Professionalism ValuesEasy to agree with

Difficult to operationalize

Ann Intern Med. 2007;147:795-802.

1600 Physicians

> 90% Agree

Professional Self Regulation

50% take action

Highly Publicized Illegalities and

Physically abusive behavior

Disruption :

Rude Behaviors or Comments (81%)

Uncooperative Behaviors (51%)

Collective

Tolerance

Verbal Abuse (47%)

Not limited to MDs only

Another Pyramid

3%: recurrent, severe

25%: Isolated, serious

??%: hidden events

??%: no unprofessional

behaviorHickson G et al. Academic Medicine, Vol.

85, No. 6 / June 2010

Actions of those in attendance ?

Join in the laughter/comments

Plan to report to a higher authority

Plan to discuss with the individual later

Take no action

Intervene and remind people of professional values

The “Balance Beam Approach”

Cons

Pros

Balanced Decision MakingJoin in on the laughter/conversation

Pro: establishes me as one of the groupCon: makes me complicit, others may emulate

Plan to report or counsel laterPro: a private environment deeper conversationCon: makes me complicit, later often never

comes; facts and emotion fade

Take no actionPro: don’t disrupt the flow of the teamCon: makes me complicit, they may do it again

Balanced Decision MakingIntervene

Pro: It is clear where I stand on the behavior in question; I can make a point about professionalism

Con: I don’t know how, it won’t work, I don’t have the authority

Actor

EnablerCollaborator

Bystander

It takes a village…to create a culture

Source: The Advisory Board

A person who causes a

disruption

A person in power who

fails to respond to a disruption

A person whose action or inaction

authorizes the disruption

People who preserve and

perpetuate the disruptive

culture

Why is inaction the favored response?

Moral Decay?

Existential Despair?

Dehumanization?

Anomie?

Akrasia?

Pessimism and

Futility

We are socialized not to intervene:

Three psychological theories

1.Normalization of Deviance

2.The Bystander Effect

3.Law of Invisible Benefits

Normalization of devianceDenial: It’s not really unprofessional

Deflection: It is unprofessional but…everyone is just blowing off steameveryone slips sometime.

Distancing: It is unprofessional but.. it is over now– no use calling attention to it.

Maladaptive Collectively

Acquired Defense Mechanisms

Mizrahi. Soc Sci Med 1984:19:135.

The Bystander EffectThe likelihood of an individual

intervening in a given situation is inversely proportional to the number of people present and witnessing the situation.

Diffusion of Responsibility

Darley and Latane, 1968

The Law of Invisible Benefit

The likelihood of intervening in a situation is inversely proportional to the immediate pain and directly proportionate to the visibility of the future benefit.

Whenever we ask people to act against instinct and norm…We are dealing with a problem of

acquired competency.

Two Type of CompetenciesCorrection in the Moment: TODAY

Strategies to intervene when unprofessional behavior or comments are occurring

Can be used by those who would be enablers or collaborators

Correction after the Moment: Dec 18Strategies to intervene when repeated disruptions

occurTypically the responsibility of Bystanders: those

with authority

Correction in the MomentAttitudes: Reframing the Issue as one of

competency and coachingWork is stressful and at times we may slipAll would want someone to help us avoid behaving in

a way counter to our valuesWe must be willing to coach and be coached

Knowledge: Unprofessional comments & behavior:disturbs our climate of professionalism and integrityincreases the likelihood of errors and patient

dissatisfactiondecreases morale and increases turnover.

Correction in the MomentSkills

Artful interruptionPeer coaching

Goal: Disrupt the disruption

Make a Difference: Four Steps and 90 Seconds

Infer and name the underlying emotion“I can see how frustrated (worried, upset) you

are about this patient.”

Validate the emotion“I am concerned as well.”

Recalibrate the correct behavior“Let’s not take our frustrations out on the

internists– they are probably struggling too.”

Redirect the conversation“what can we do to help this patient?”

Critical Elements to this Conversation

Makes it clear that you don’t endorse the situation

Stops the group from engaging in similar activity

Doesn’t call names– doesn’t accuse anyone of being unprofessional

Does express empathy for both the disruptor and the disruption

Cases overheard on rounds…

A senior resident tells a student that she is too smart to go into her chosen specialty– that specialty is for dolts.

An intern continuously joked and made disparaging comments about fat people while they were caring for morbidly obese people.

An attending complained about the incompetence of another service who refused to accept a difficult patient in transfer.

A nurse demeans the reputation of an intern who disagreed with a decision that she made.

A senior attending refuses to participate in the pre-procedure checklist.

Possible Outcomes?

110% Success: Disruptor stops, acknowledges slip, apologizes

and asks others to keep him/her on board in the future

100% Success: Disruptor stops, acknowledges the slip

50% Success:Disruptor stops, dismisses concerns

10% Success:Disruptor stops, changes focus of comments to

you

Team Leaders can increase the likelihood of success

Plan for common slipsStart the rotation with a request for

correction in the moment“we all may slip at some time. Let me give

you permission to call me on comments that aren’t positive and respectful

Recognize high risk patients and situationsTake time to debrief emotions and

reactions before they occur“I am having difficulty with my reactions to

this patient. Is anyone else struggling? Can we talk?”

Is more coaching required?

No: if isolated incident of moderate or less severity, particularly if positive response to intervention

Yes: if incident is severe, repeated, or in violation of HR policies

Persistent or Severe Behavior

Requires authority to deal with this

The judgmental nature of the conversation requires more private circumstances

Like all difficult conversations, requires planningWhat do I hope to accomplish?How might they respond?What leverage do I have?

Return on December 18 for more details…

Eliminating the Hidden Culture:

Message is simple: We have a desired set of behaviors.

Implementation is difficult: Constant Evolutionary Pressure rather than Revolutionary Verve

“Sunlight is the Best Disinfectant” Louis Brandeis

Strategic Confrontations

Critical Components

Prepare the message

Deliver the messageEnsure the message is received

Follow-up on message/behavior

Strategic Confrontations

Message Clarity: Non-Verbal Cues

Timing

Degree of Formality

Emotional NuanceVoice toneBody Language

Source: The Advisory Board

Source: The Advisory Board

Source: The Advisory Board

Source: The Advisory Board

Three Step Approach

Describe the unacceptable behavior“Rolling your eyes and conducting loud side

conversations during the department meeting is unacceptable.”

Define the conduct expected“You must not talk when others are

presenting.”

Describe the consequences if unacceptable behavior continues“If this behavior continues you will ……”

Medical Students’ Experiences of Moral Distress: Development of a Web-Based Survey Catherine Wiggleton, MD, Emil Petrusa, PhD, Kim Loomis, MD, John Tarpley, MD,

Margaret Tarpley, Mary Lou O’Gorman, MDiv, and Bonnie Miller, MD

Usual Approach: Ignore

Belief in Auto-

CorrectionConcern about

Embarrassment

Worry about Relationship

Behavior will be repeate

d

BUT

Lessons will be

Learned

Climate will be Impacte

d

Concern about

Authority

Dominant Assumption?