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Louise Aronson,MD, MFA; Christian Burke, Tess Lang, MD; Catherine Lucey, MD; Rachael Lucatorto, MD; Mary H. McGrath, MD, MPH; Patricia O'Sullivan, M.S.,Ed.D; Maxine Papadakis, MD;
Ann Poncelet, MD; Sandrijn van Schaik, Md,PhD; Arianne Teherani, PhD; Maria Wamsley, MD
Beyond “He said…she said”: Debriefing after a professionalism lapse
Ann Poncelet, MD and Maria Wamsley MD
November 3, 2014
By the end of this workshop…
• Discuss the range of behaviors that constitute a lapse in professionalism
• Identify the potential causes of a professionalism lapse
• Describe the outcomes of dealing with professionalism as a trait vs. a competency
• Demonstrate a six-step process to address professionalism lapses after the behavior occurred
A Case…
As the residency program director, you are informed that an attending has made disparaging remarks to trainees about patients with chronic pain. The resident
evaluation states she called these patients “a waste of time”, “lazy”, and is convinced they
are all just “working the system”.
You decide to bring up your concerns and ask her to come to your office for a talk.
What is the response?…
A. “That did not happen.”
B. “It did happen, but not that way.”
C. “I was only joking, I didn’t think
the residents were so sensitive.
D. “I am so so sorry.”
(denial)
(deflection)
(discounting)
(distancing)
Fight or Flight impulsesHmm…a talk in your
office…
“I did not handle that well, could you help me do better next time”?
Emotional High-jacking
Roadmap
• Introduction to professionalism
• Consequences of unprofessional behavior
• Causes of unprofessional behavior
• Reframing professionalism as a competency
• Six-step process for debriefing a professionalism lapse “after them moment”
• Practice!
Professionalism values
• Professionalism represents a set of values that guide our work:
• Compassionate, Respectful, Collaborative
• Integrity & accountability
• Pursuit of excellence
• Fair and ethical stewardship of resources
JAMA, December 22/29, 2010—Vol 304, No. 24
• Easy to agree with
• Harder to operationalize
• Need to be translated into behaviors
Highly Publicized Illegalities and
Physically abusive behavior
Disruption :
Rude Behaviors or Comments (81%)
Uncooperative Behaviors (51%)
Collective
Tolerance
Verbal Abuse (47%)
Consequences of Unprofessional Behavior
• Creates an environment where unprofessional behaviors are tolerated and modeled for others to emulate.
• Medical students experience mistreatment from faculty/residents including: public humiliation, required to perform personal services, and being subject to physical and racial remarks
• Severe unprofessional behavior in medical school is associated with future disciplinary action by the Medical Board.
Papadakis et al. NEJM 2005
Professionalism Lapses, Like Medical Errors
• Prevalence is common and inevitable
• Severity and impact vary widely
• Most lapses are not intentional
• Caused by good people with transient deficiencies in knowledge, judgment, or skills
Process Investigation of facts in an encounter where
people feel actions are not appropriate…many
perceptions of truth
Understanding of Perceptions Move away from “I have to know the
truth”…
Result Inaction Skill Building
………..………..
………..
Roadmap
• Introduction to professionalism
• Consequences of unprofessional behavior
• Causes of unprofessional behavior
• Reframing professionalism as a competency
• Six-step process for debriefing a professionalism lapse “after them moment”
• Practice!
Six step process to coach after a lapse…
1) Ask Permission: make it safe to talkGet away from the adrenaline surge “All physicians want to be professional but it is hard, even I struggle sometimes”
2) Behavior: Describe it and wait for their reaction
3) Common responses: Preempt the likely argument of Denial, Discounting, Distancing
“You may not agree with the way X characterized this encounter—but we have a responsibility to own the perceptions of others in the clinical environment.”
Six step process to coach after a lapse…
4) Dialogue: Action focused reflection exercise
• Set the goal • “Our goal today is to work through this and see how you
can be more effective next time.”
• Reinforce the purpose: so you can have the reputation you want to have.• “I know you want to have the reputation as someone
others trust and can approach with concerns” • “This is what they expressed, this is the reputation you
have, is this the reputation you want?”
Six step process to coach after a lapse…4) Dialogue continued: Framing the lapse• Who was there and what were the professionalism values at risk?
(understanding)• What were you feeling? (self awareness)• What were they feeling? (empathy)• Why do you think your behaviors were interpreted negatively?
• What would you do differently? (alternative strategy identification)• What might be difficult for you?• “Curb my temper, eat ahead of time…etc.”
• How will you learn to do it? • “Take a time out, take a deep breath, eat on rounds…”
• How will you know you are successful?
5) Expect & Encourage
6) Follow up
Back to the Case…
As the residency program director, you are informed that an attending has made disparaging remarks to trainees about patients with chronic pain. The resident
evaluation states she called these patients “a waste of time”, “lazy”, and is convinced they
are all just “working the system”.
You decide to bring up your concerns and ask her to come to your office for a talk.
Six step process to coach
1) Ask Permission: make it safe to talk
2) Behavior: Describe it and wait for their reaction
3) Common responses: Preempt Denial, Discounting, Distancing
4) Dialogue: Action focused reflection with goals and purpose
5) Expect & Encourage success
6) Follow up: “Come back and let me know about a successful experience you have with these alternative strategies or any other things that come up”
• Each person will have the chance to play the part:• Intervening after a professionalism lapse• Receiving intervention after a lapse
Case #1: Department disagreement
It is nearing the end of the admitting team’s shift and Dr. Shauna Stern, an Internal Medicine resident, is paged about admitting her 9th complicated patient of the day.
After evaluating the patient, she told the ED resident to have the patient be evaluated by the surgical vascular team for admittance onto their service.
She receives a page to meet the vascular resident at the patients room.