Dealing with Professionalism Lapses: Beyond “he said, she said” Catherine Lucey MD UCSF December 18, 2012

A common scenario A nurse files a complaint through the incident report system about a resident, stating that he is rude and arrogant and was mean to a patient’s family member when questioned about the status of his loved one. The nurse states that this isn’t the first time he has witnessed this resident responding in anger when his judgment was questioned: “all of the nurses on the floor know what he is like.” You call the resident into your office to discuss the complaint with him.

Which is the most probable response when the resident is approached about this issue :  I don’t remember what she is talking about.  It didn’t happen that way.  That nurse is a trouble maker– all of the residents know to steer clear of her.  I didn’t give that family member information because he wasn’t entitled to the information he was requesting. Hasn’t she heard about HIPPA?  I didn’t handle that well. Can you help me do better in the future?

People are People NEUROSCIENCE: When people they are in danger, they react predictably FIGHT Denial: It didn’t happen Deflection: It did but it was justified (“justdoing it for my patients…”) FLIGHT Distancing: It did happen, I’m sorry

Today Briefly review the paradigm of professionalism as a multidisciplinary competency Describe how that competency helps us frame different conversations about professionalism Use that paradigm to analyze a professionalism lapse in preparation for a coaching conversation. Try a structured debrief of a professionalism lapse

A Brief Review

Professionalism Lapses, Like Medical Errors Prevalence is common and inevitable Severity and impact vary widely Negligence is uncommon Caused by good people with transient deficiencies in knowledge, judgment or skills Systems may set people up to fail

Root Cause Analysis: Why do good people lapse?

Professionalism Paradigm Shift FromTo GenesisCharacter Trait Personal Capacity Educational Approach Rules, Role Models Skill development EvaluationAssumptionTesting LapseFlawDeficiency ReactionRemovalCoaching Prevention

Curriculum for Professionalism Lapse Prevention Knowledge: Professionalism Values DDX of professionalism lapses Judgment: Identify “at risk” encounters and situations Reason through Alternate Strategies Skills Self Awareness & Self Control Social Awareness & Management Systems Contributions

Goal: To Be More Effective Self Awareness & Self Control Social Awareness & Management Triggers and Clues Time Outs Thoughtful Reflection Shared Mental Models Conflict Resolution Negotiation De-escalation Peer Coaching

Changing the frame changes the goal Paradigm OutcomeBurden of ProofProcessResult Trait Discipline High Investigation of Facts Inaction Competency CoachingLow Understanding of Perceptions Skill Building

Debriefing Professionalism Lapses An Exercise in Guided Reflection and Problem Solving

Preparing for a Conversation: Exercise 1 Root Cause Analysis of a Professionalism Lapse Goal: Help the Coach: Understand the complexity of the situation Move from negative reactions to positive plans Prepare to help the learner or peer

Structured Reflection Empathy Can speculate on the emotional state and rationale of other involved parties Alternate Strategy Identification Can brainstorm different options for dealing with any identified problem Skill Assessment Can identify what skill sets they would need to avoid a similar situation in the future.

Lessons from LeAP Step 1: a chief complaint (done for them!) Step 2: Describe the encounter (Subjective) Step 3: Reconsider the encounter through other’s eyes (Other) Step 4: Summarize your learning needs (Assessment) Step 5: Next steps (Plan ) Med Ed Portal

Starting the Conversation Make it safe “All physicians want to be professional but it is hard sometimes” Preempt the likely argument “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.” Set the Goal “Our goal today is to work through this case and see how you can be more effective next time.” Reinforce the Purpose “I know you want to have the reputation as someone who others trust and can approach with concerns.”

1. What professionalism themes are relevant in this case? (understanding) 2. What were you feeling? Why? (self awareness) 3. What do you think the other person was feeling? (empathy) 4. Why do you think they interpreted your behavior in a negative way? What part of this do you own? 5. What would you do differently? (alternative strategy identification) 6. What would be most difficult for you? (self awareness) How will you learn to do it? 7. How will you know if you are successful?

Toolbox for Intervention: Exercise 2

Prognosis: Exercise 3 Incompetence? -or- Intransigence?

Intransigence: A disciplinary problem 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 ……” Offer support but make the responsibility clear “I am willing to help but you must make the needed changes.”

Next Steps … For you as a faculty member? For us as a community?