Administration RoundsSession 1

Yael Moussadji, PGY3

Emergency Medicine

Preceptor: Dr. Roger Galbraith

Why is Administration Important?

Historically, Emergency Medicine had no legitimacy, no specialized field of knowledge and expertise, no organization, and no identityIt had no specialty status, no training programs, no board certification process, and no respectToday, EDs face multiple contemporary issues including staff shortages, overcrowding and ambulance diversions, increased workplace stress, and environmental concernsAdministration, and administrators, in a variety of capacities have worked to bring our specialty out of the past, and continue to enrich it through the current challenges that we face

The Role of Adminstration in Emergency Medicine

AdvocacyProfessional EducationClinical standards of practice and policiesResearchPractice ManagementLeadership and leadership developmentInterest groups and networking, and identityWellness and well-beingService to the public

Roles

AdvocacyDespite being a young specialty, EM needs an active and aggressive public relations and lobbying effort in order to ensure public knowledge of its existence and public support and endorsement of its goals and agendas

Professional Education This involves both Residency training programs and conferences in order to educate ED care providers with the unique body of knowledge that is emerging

RolesClinical Practice Guidelines/Standards

EM must establish a set of its own clinical guidelines that have not only ethical considerations, but reflect the unique realities of the ED population and environment

Research We need a network of information and information-sharers that allows researchers to communicate and that provides research results to the ED communityWe need to support EM research financially, and provide a vehicle for training researchers and publishing their workThe research of EM must answer the questions posed by the practitioners of EM

RolesLeadership

If we are to develop credibility as a full-fledged specialty, we must develop our own leaders to become spokespersons and advocates, who will then become involved in other areas of influence such as hospital adminstration, governmental agencies, private industry, and larger professional societies

Practice ManagementED managers must acquire a specialized skill set that allows them to manage a highly developed, multiple tasking, technology driven complex environment where patients with a huge variety of problems are encountered by a large degree of highly specialized personnel, all in a cost effective and efficient manner

RolesWellness and well-being

Ways of enhancing wellness and limiting stress have to be found in order to promote longevity and long term survival of the specialty

Service This is the most intangible, but most significant; it is why we do what we do and is what maintains the ultimate success of our specialty Medical ethics, QI, medical error, communications skills are all contributors

Communication Skills

Breaking Bad News

Telephone Advice

Conflict Resolution

Breaking Bad NewsBad news is defined as “any news that negatively alters the patient’s [or family member’s] view of his or her future”Hippocrates advised “concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity… reveal nothing of the patient’s future or present condition”.Now, with an emphasis on patient autonomy and empowerment, we know that the majority of patients desire and deserve full disclosure

Literature

What patients and families experienceUse of technical language (eg. relative risk)

Breaking of bad news in a hallway or location lacking privacy

Neglecting to offer social or clergy supports

Perceived lack of sympathy, lack of information, and being unable to answer questions

Neglecting to prepare family members of the possibility of an autopsy

LiteratureWhat patients and families want

A clear, direct statement of the news Time to talk together in private Openness to emotion Ongoing involvement in decision making

Diversity among patients and families In a study of 54 surviving family members of patients who died from trauma, 9 desired a hug, handholding, or a pat on the shoulder when receiving bad news; 16 did not want any type of physical touching

Physicians and Bad NewsMost of us struggle with giving bad news because we don’t have adequate training in giving it, have a fear of being blamed and not knowing all the answers, and fear our own emotional reactionsConsensus guidelines have been created to help usFollowing traumatic deaths, the most important features judged by families were the attitude of the person giving it, the clarity of the message, privacy, and the newsgivers ability to answer questionsTherefore, it is not an isolated skill, but a particular form of communication with which we need to be comfortableOur own humanity may at times be the most powerful healing instrument

The ABCDE’s of Giving Bad News

A – Advanced preparation

B – Build a therapeutic environment/relationship

C – Communicate well

D – Deal with patient and family reactions

E – Encourage and validate emotions

Advance PreparationKnow the relevant clinical data, review the medical record and talk with consultantsArrange for adequate time in a comfortable quiet room with seating for all involved and determine who should attendConsider the goals of the meetingMentally rehearse how you will give the newsPrepare emotionallyTake a step back

Build a Therapeutic Relationship

This stage is where you build rapport and trust

Introduce yourself to everyone and ask for names and relationship to the patient

Determine what the patient and family want to know and already know

Use pacing and reflective listening to quickly demonstrate empathy and compassion

Provide a brief summary of the patient’s illness

Communicate Bad NewsSpeak slowly, deliberately, clearly, presenting information in small chunksForeshadow the bad news “I’m sorry, but I have bad news” or “I have difficult news”; pause for a momentSpeak frankly and compassionately, avoiding medical jargon and euphemismsUse the words “cancer” or “death”Once the news is delivered allow for silence and a chance to absorb the information and respond; this pause allows the anticipatory grief of all the implications of this news, and the way they are responded to can determine the future course of the acceptance process

Deal with ReactionsAssess and respond to emotional reactionsAllow the patient time to talk early and often; encourage questions and provide information at their paceCheck their understanding to make sure they are receiving the information we are givingCommunicate compassion, kindness, caring, and empathy by acknowledging, validating, and relfecting emotion It is appropriate to say “I don’t know”

Encourage, Validate, Provide Support

Offer realistic hope and explore what the news means to the receiver; ask if there is something we can do to help

Use interdisciplinary services to enhance care and facilitate their access to support

Bring closure to the interview, and outline the potential next steps for the family

Remain available to the family while they remain in the ED

Notify the GP and enlist their help in follow-up

Self-reflect

Conflict Management in the EDAll human interactions have the potential to develop conflictDefined as a disagreement within oneself or between people that has the potential to cause harmUsually involves differences in ideas, perspectives, priorities, beliefs, values, and goalsThe organizational structure of the ED can also contribute

The Natural History of ConflictPhase 1

One or more parties with experience frustration, a strong imperative undirected emotion that almost always demands rapid attention

Phase 2Conceptualization and rationalization of the cause in order to crystallize thoughts and feelings into action

Phase 3Expression on conflict; a series of behaviours directed toward our constructed cause

Phase 4Formalizes the conflict situation as behaviours result in destructive outcomes

The 7 Habits of Highly Effective People, by Steven Covey

While stressors responsible for conflict may be unavoidable or inappropriately conceptualized, the behaviours and outcomes can be modified by prolonging the time between phases 2 and 3Group exercise: Identify a conflict situation you experienced recently at work. What was the stimulus?

Make a note of the differences that caused the disagreementDescribe the phases of conflict and whether it involved differences of values, skills, priorities, or organizational structures?

Accelerators of Conflict

Role and identity issues

Performance, function, and process factors (as determinants of role conflict)

Differing goals and individual differences

Problems with communication** and feedback

Power and rivalry, lack of support and collegiality

Absence of role modeling and expertise

Four Ways of Handling ConflictAvoidance - denying existence of conflictAccomodation - letting the other party decideCompetition – aggressively pursuing ways to achieve your goalCollaboration – actively looking after your own interests but not losing sight of the interests of others

Conflict Management StylesAvoid

Usually involves no declaration from one of the parties and therefore no cooperation is soughtUseful as a short term strategy when there is a lot of “heat”; rarely useful for long term change

AccommodatePlaces the emphasis on achieving the other’s desired outcomeExpedient, but unlikely to result in a long term solution

CompeteEntails little cooperationWorks when outcomes are most important and resources are limited; works against attempts to forge cohesiveness

CollaborateMost time consuming and draining; best suited for sustainable change

Comparing Ways of Handling Conflict

Group Exercise con’t

• Each management style entails a different level of assertion and cooperation

• Describe the way in which you handled your conflict

Outcomes of Conflict

• Constructive Growth occurs Problems are resolved Groups are unified Productivity is

increased Commitment is

increased

• Destructive Negativism results Resolutions diminish Groups divide Productivity decreases Satisfaction is

decreased

Conflict in Emergency Medicine• Diversity in training, experience, and perspectives

between colleagues• Differences in professional opinion and value

systems• Effects of sleep deprivation and stress on

interpersonal communication• Lack of understanding of triage and role of ED,

excessive patient demands• Telephone conversations and lack of face to face

contact with consultants

Communication and Conflict with Patients

• Physician-patient relationship is sudden and occurs with little choice

• Frequent mismatch between the patient’s perspective of his/her illness and ours, which are impacted by social, cultural, and language barriers as well as differences in response to illness

• Patients are often under the influence of substances or disease states which can impair their judgment, or may refuse to consent for or comply with medical treatment

Strategies for Effective Patient Communication

• Instead of viewing the disease as the central issue and the patient in the background, start to view the patient as the central figure in the context of the illness or injury (shifts the motivation from treating the disease to treating the patient with the disease)

• Strategies to do this include conducting a more patient centred interview by sitting at the bedside, being eye to eye level, asking open-ended questions, and being as non-directed as possible (time permitting)

• Avoid an authoritarian approach, which can escalate during stress and fails to recognize patient fears and concerns

• Use a collaborative or participatory approach• Patients will respond more positively to a physician who is perceived

to be genuinely interested in their well being

Do’s and Don’ts of Patient Communication

• Do… Sit Make eye contact Use the patient’s name Touch the patient’s arm or

shoulder while examining them

Ask open-ended questions Involve the patient in

treatment options Find out the patient’s

concerns

• Don’t Stand over the patient Chart while talking Refer to the patient by their

presenting complaint Touch the patient using

only tools Use only yes or no

questions Ignore the patients fears

Communication with Nursing• Good nursing is crucial to emergency medicine• Nursing is defined as “the diagnosis and treatment

of human responses to actual and potential health problems”

• Borders between emergency nursing and emergency medicine are more indistinct than they are in other specialties, which contributes toward collaborative practice

• Therefore, failure to develop shared values can breed conflict

Collaboration with Nursing

• Nursing often provides the humanistic components of communication: time, patient education, and direct care

• Recognize their value and expertise in order to achieve our common purposes

• Other opportunities for collaboration include M&M rounds, involvement in academic research projects, and social events (team building exercise)

Communication Between Medical Colleagues

• The strongest perceived predictor of positive communication is the physician’s perceived autonomy

• Negative communication experiences are associated with perceived environmental stress

• Differing value systems can result in unreasonable demands or lack of availability of consult services, diagnostic, or therapeutic modalities

• Telephone consultation provides little feedback, limited time for discussion, and is impacted by excessive background noise, incomplete data, and inopportune timing

Approach to Conflict Resolution in the ED

Take Home Points• Establishing consensus and reaffirming common

goals is the first step toward conflict resolution (providing the best care possible to patients and families)

• Avoid accusations of laziness, not answering pages, or unresponsiveness

• Listen actively, have respect and display empathy, maintain a professional demeanor

• Compromise, but not on care• Be specific in your expectations, communicate clearly