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

2. 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.

3. Different Types of Learning

4. When Lessons Collide Explicit Tacit

5. 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

6. Professionalism Values Easy to agree with Difficult to operationalize

7. Ann Intern Med. 2007;147:795-802. 1600 Physicians > 90% Agree Professional Self Regulation 50% take action

8. Disruption : Rude Behaviors or Comments (81%) Rude Behaviors or Comments (81%) Uncooperative Behaviors (51%) Uncooperative Behaviors (51%) Collective Tolerance Verbal Abuse (47%)

9. Not limited to MDs only

10. Another Pyramid 3%: recurrent, severe 25%: Isolated, serious ??%: hidden events ??%: no unprofessional behavior Hickson G et al. Academic Medicine, Vol. 85, No. 6 / June 2010

11. 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

12. The “Balance Beam Approach” Cons Pros

13. Balanced Decision Making Join in on the laughter/conversation Pro: establishes me as one of the group Con: makes me complicit, others may emulate Plan to report or counsel later Pro: a private environment  deeper conversation Con: makes me complicit, later often never comes; facts and emotion fade Take no action Pro: don’t disrupt the flow of the team Con: makes me complicit, they may do it again

14. Balanced Decision Making Intervene 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

15. 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

16. Why is inaction the favored response? Moral Decay? Existential Despair? Dehumanization? Anomie? Akrasia? Pessimism and Futility

18. We are socialized not to intervene: Three psychological theories 1. Normalization of Deviance 2. The Bystander Effect 3. Law of Invisible Benefits

19. Normalization of deviance Denial: It’s not really unprofessional Deflection: It is unprofessional but… everyone is just blowing off steam everyone 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.

20. The Bystander Effect The 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

21. 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.

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

23. Two Type of Competencies Correction 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 18 Strategies to intervene when repeated disruptions occur Typically the responsibility of Bystanders: those with authority

24. Correction in the Moment Attitudes: Reframing the Issue as one of competency and coaching Work is stressful and at times we may slip All would want someone to help us avoid behaving in a way counter to our values We must be willing to coach and be coached Knowledge: Unprofessional comments & behavior: disturbs our climate of professionalism and integrity increases the likelihood of errors and patient dissatisfaction decreases morale and increases turnover.

25. Correction in the Moment Skills Artful interruption Peer coaching Goal: Disrupt the disruption

26. 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?”

27. 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

28. 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.

29. 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

30. Team Leaders can increase the likelihood of success Plan for common slips Start 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 situations Take 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?”

31. 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

32. 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 planning What do I hope to accomplish? How might they respond? What leverage do I have? Return on December 18 for more details…

33. Eliminating the Hidden Culture: Message is simple: We have a desired set of behaviors. Implementation is difficult: Constant Evolutionary Pressure rather than Revolutionary Verve

35. Strategic Confrontations Critical Components Prepare the message Deliver the message Ensure the message is received Follow-up on message/behavior

36. Strategic Confrontations Message Clarity: Non-Verbal Cues Timing Degree of Formality Emotional Nuance Voice tone Body Language

37. Source: The Advisory Board

41. 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 ……”

42. 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

43. Usual Approach: Ignore Belief in Auto- Correction Concern about Embarrassment Worry about Relationship Behavior will be repeated BUT Lessons will be Learned Climate will be Impacted Concern about Authority Dominant Assumption?