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

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 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

Changing the frame changes the goal

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

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?

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?