dealing with professionalism lapses: beyond “he said, she said” catherine lucey md ucsf december...
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Dealing with Professionalism Lapses:Beyond “he said, she said”
Catherine Lucey MDUCSF
December 18, 2012
A common scenarioA 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:1. I don’t remember what she is talking about.
2. It didn’t happen that way.
3. That nurse is a trouble maker– all of the residents know to steer clear of her.
4. 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?
5. 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
TodayBriefly 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
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
Professionalism Paradigm ShiftFrom To
Genesis Character Trait
Personal Capacity
Educational
Approach
Rules, Role Models
Skill development
Evaluation Assumption Testing
Lapse Flaw Deficiency
Reaction Removal Coaching
Prevention
Curriculum for Professionalism Lapse Prevention
Knowledge: Professionalism Values DDX of professionalism lapses
Judgment: Identify “at risk” encounters and situationsReason through Alternate Strategies
SkillsSelf Awareness & Self ControlSocial Awareness & Management
Systems Contributions
Goal: To Be More Effective
Self Awareness & Self Control
Social Awareness & Management
Triggers and CluesTime OutsThoughtful Reflection
Triggers and CluesTime OutsThoughtful Reflection
Shared Mental Models
Conflict ResolutionNegotiation
De-escalationPeer Coaching
Shared Mental Models
Conflict ResolutionNegotiation
De-escalationPeer Coaching
Preparing for a Conversation: Exercise 1
Root Cause Analysis of a Professionalism Lapse
Goal: Help the Coach:Understand the complexity of the
situationMove from negative reactions to
positive plansPrepare 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 LeAPStep 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 ConversationMake 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?
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.”