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

• Systems may set people up to fail

Lucey & Souba Academic Medicine, Vol. 85, No. 6 / June 2010

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!

Why do Professionalism Lapses Occur?

Why do Professionalism Lapses Occur?

HALT: Hungry, Angry, Lonely, Tired

Personal stressors

Inter-Personal stressors

• Competency• Distractions• Psychological• Substance Abuse• Physical Illness

• Unshared mental models

• Disagreement• Poor communication• Poor understanding of

role

Why do Professionalism Lapses Occur?

Situational stressors System stressors• High workload

• Emotion in clinical setting:• Death• Trauma• Violent patients• Angry families

• Inefficient workflow• Conflicting policies• Hierarchical system

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!

Responding to lapses: A Paradigm ShiftFrom To

Genesis Character Trait Personal Capacity

Educational Approach

Rules, Roles, models Skill Development

Evaluation Assumption Testing

Lapse Flaw Deficiency

Reaction Discipline & Removal Coaching & Prevention

Changing the frame changes the goal

Coaching After the Moment

Trait

Vs.

Competency

Outcome Discipline Coaching

Burden of Proof

HighFigure out what’s right

or true, witnesses

Low There was an encounter and

I want to help you so that doesn’t repeat

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”

Acknowledgement and Thanks

• Catherine Lucey

• Maxine Papadakis

• Christian Burke

Practice

• 3 Cases – Resident/Faculty, Student/Faculty, Faculty/Faculty

• Rotating Roles

• 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.

Play video clip now…