Since I began promoting myself as a coach I have received a lot of curiosity from medical colleagues around what I do and why. I hope this podcast answers some of this. Its 30 minutes and discusses the history of coaching and what I believe coaching has to offer medicine. Comments and suggestions welcome!

Click on this link - Coaching In Medicine
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free use image from Pixabay

It's that time of year again. New residents coming into programs and senior residents graduating. I have been reading all the "Tips for New Docs" on twitter and this made me reflect on advice that I would give my graduating residents. Here are my pearls - Hope that you find them useful

1. The only thing you have earned is the right to apply your skills and knowledge and get paid for it. You still need to earn the respect of your colleagues. Establish (and be true) to your brand name.
   
2. You still only know 95% of what it takes to be competent. Tread carefully over the next 2 years.
   
3. You have sacrificed so much effort becoming an attending physician that you may have lost sight of the fact that you are WAY BIGGER than just an “attending physician”. Create a personal mission.
   
4. You also only know 80% about life. Read. Learn from others. Listen. Ask yourself some key questions.
   
5. The life side is way more important than the med side. This is where your focus should really be. 
   
6. You probably also only know 80% about yourself. Introspect - what do you believe? Why? What do you value? Why? How do you undermine yourself? How do you talk to your self? Who are you? What is your purpose in this life?
   
7. Think DEEPLY before you decide. Anything you sign up for needs to align with your values. If it doesn’t just say no.
   
8. You are a leader - you don’t need a leadership position in your group to behave like one. LEAD!
   
9. It doesn’t matter what the data shows or who is right - people need to feel heard and valued. You will ALWAYS have to win people over. 
   
10. A good life is about people, connectedness, memories and experiences - you need a lot less money than you think you do.

​Not long ago I facilitated a small group session on "crucial conversations" as part of the USaskEM's non-medical expert CanMEDS curriculum. From what I read (and my experience reinforces this) we tend to avoid conflict in the ER. Your workplace is probably no different. Unfortunately, our avoidance to take on challenging interpersonal situations contributes to ongoing inappropriate behaviour which itself creates even more workplace conflict. This topic is so important that people have written books on "difficult" or "crucial conversations".

Courageous conversations are actually an important form of collegiality

The main reason we avoid conflict is fear. It takes courage to do what is right and face the blow-back and so I think we need to redefine these conversations as  "courageous". My experiences also have taught me that it is also "collegial" to have them. My hope is that, by reframing the concept, we may begin to shift our approach from disengagement to dialogue - because ultimately we are all professionals on the same side. So read on - comments welcome!

Emotions in the Workplace:

• There has been a significant recent research interest in emotions in the workplace. What we know:
  • They affect interpersonal interactions, decision-making and more
  • They affect our learning and growth
  • Ultimately they have a HUGE impact on organizational performance

• In 2016  the current ‘State of the art’ business philosophy talks about ‘emotionally capable leaders’
  • Studies show a positive relationship between emotional intelligence and leadership performance, job satisfaction and several other workplace outcomes [team performance e.g. there was a recent medical publication showing  that rudeness affects team performance in code situations]
• FACT: We are all leaders in medicine.

What defines a courageous conversation?

• It's unavoidable [e.g. after an error]
• It is high stakes
• It is emotional
• There are conflicting views and conflicts of purpose

Signs and Symptoms you’re in (or about to have) a courageous conversation:

Physical signals:

• Sweaty hands
• Dry mouth or eyes
• Flushed skin
• increased heart rate

Emotional signals:

• Anger – tightness of shoulders and neck
• Hurt – tightness of chest
• Fear – tightness of stomach

Behavioural signals

• Raising of voice
• Pointing of finger
• Becoming quiet

Why courageous conversations do not happen enough:

• Lack of knowledge, skills and training on interpersonal conflict
• Our natural tendency to avoid conflict and the negative fall out thereof
• Poor past experiences:
  • As humans I think that negative encounters impact us more profoundly than positive ones. Plus they often happen by surprise – providing no time to rehearse | reflect
  • Poor emotional intelligence (EQ). Collectively I feel we need to pay more attention to EQ in medicine.
  • Self defeating behaviours like Sucker’s choice.  Sucker's choice is a simplistic tradeoff that actually prevents us from thinking creatively of ways to get to dialogue, (and further justify our silly games) - e.g. do you confront that negative colleague and face his anger or do you ignore it and hope that someone else notes it and complains (while back-stabbing them to everyone else and painting their entire department with the same brush) ]
• Framing these conversations as "difficult" and "crucial" has only made it more challenging to engage in dialogue.

Why it is important to know about and have courageous conversations in healthcare:

• It's part of being a leader in medicine (and I would argue a required competency). We need to reframe them as a form of collegiality.
• Our job is to have the patients' back. There are 7000 US deaths/y due to medical error (think about all those times you should have said something or dug your heels in) 
• Feedback allows opportunity for change. Remember almost all of us are in this because we wanted to help people. Disruptive colleagues are usually good people with symptoms of an underlying problem on the life-side (divorce, other life problems etc).
• Build a new culture of openness, trust, empathy and dialogue in place of the current culture that espouses criticism and out right hostility. 

How we undermine meaningful dialogue:

SILENCE = purposefully withholding information from the dialogue.

• Used to avoid creating a problem. 

• Always restricts the flow of meaning.

Common forms of silence: 


1. MASKING: understating or selectively showing what you actually think. Sarcasm, Sugarcoating, Couching, etc.
2. AVOIDING: not addressing the real issues. Changing the subject, shifting the focus to others, etc.
3. WITHDRAWING: not engaging in the conversation any longer. Exiting the conversation or room all together.

VIOLENCE = convincing, controlling, or compelling others to your viewpoint.

• Violates safety by forcing meaning into the pool

Common forms of violence:

1. CONTROLLING: coercing others to your way of thinking. Cutting others off, overstating your facts, speaking in absolutes, dominating the conversation.
2. LABELING: stereotyping or categorizing people. Name-calling, generalizing

3. ATTACKING: belittling or threatening the other person.

Start having courageous conversations by creating inner shifts:

• Ugly conversations stem from:
  • Lack of emotional safety – [see above] e.g. On a day when high demand for DI the rad resident complains that “you ER docs just overuse imaging!”
  • Threats to Identity – Note it’s not the content per se [ER docs DO overuse imaging], but the intent behind it [Insulting? Complaining?]
  • It’s always personal – docs become who they train to be. We make this immense investment, expending "blood sweat and tears". We are also generally emotionally unintelligent creatures. This is the perfect set up for threats to identity.
• Important to listen deeply for the meta-message not just the content. Clarify. Acknowledge.
• Create an inner shift - We make ourselves upset during crucial conversations when we:
  • Cover up or ignore our role in creating the problems we're discussing
  • Exaggerate others' role in the problems by attributing the worst possible motive to them. [See Jim Force link below for clever stories we tell ourselves]
  • Fail to exert ultimate self control. Be mindful of the persons dignity. Respecting them = self-respect.
  • Adopt a mindset of inquiry and may even curiosity

 
Guiding principles of courageous collegiality:

• Be sincere. It is important to establish common goals or shared interests, but don’t just say what you think the other person wants to hear. Share your genuine thoughts, feelings, and interests and be open and respectful to what others have to say. 

• Be present in the conversation. Listen to what the other person is saying rather than think solely about what you are going to say next or cast judgment. Look at the other person when they are talking, put aside distractions (shut off the computer, turn off your phone, shut the door). 

• Be courageous, but not arrogant. When you are confident, it can put the other person at ease. Even if you are a bag of nerves, confidence can come from smiling, holding your head up, and talking with a clear voice and seeming happy.
• Be mindful. Notice non-verbals, physical cues emotions, your buttons and your impact on the conversation. Notice signs of safety breach [see above]. Learn how you tend to handle stress. Learn how you handle thwarting ploys [silence, sarcasm, accusations, stonewalling]. Call them out into the room openly and sincerely “I don’t know how to respond to your sarcasm. What is it you would like me to do?”]
• Be empathic. Everyone comes to the conversation with a different history or perspective, and having empathy for these different views is the best way to build a relationship. Recognize and respect how others are feeling, even if you do not agree with their point of view. 

• Be honest. Say what you mean, do what you say, and follow through with what you commit to doing. Relationships are built on trust. If you say one thing and do another, that trust will quickly evaporate. 

• Be Solution-focused. Try and meet in the middle. Direct your emotional energy into solving the problem rather than trading barbs.
• Be Objective. Stick to the facts. Acknowledge good counterpoints. This enables others see how a reasonable, rational and decent person would think and feel.
• Be accountable. End with clear expectations. Move to action by ensuring everyone is crystal clear about how to get the issue resolved once and for all. Come to specific agreement about who is going to do what by when.

My 4-p’s of Courageous Collegiality:

1. Perspective – need to understand conflict and emotions [see below]
2. Prepare – need to prep for each courageous conversation [Just like you prepare for a code]
   1. MOST IMPORTANT – check Yourself
      1. What do you want to accomplish? [Complain | vent |opine] – need to have a positive purpose.
      2. What are your assumptions? What story have you invented for yourself around this?
      3. What buttons being pushed? What’s your attitude?
      4. Who is the real opponent [colleague or system issue?]?
      5. How are you contributing to the problem [EI, lack of clear communication]
3. Practice – just like simulation scenarios ... with practice you will improve
4. Preach – need to discuss and disseminate these skills so that we improve as a community

How to measure your success:

1. There is a flow of information – objective | from both sides
2. There is dialogue – it is safe |it is respectful
3. You create Shared Meaning | Accountability

​
Homework:

1. How can you [as a leader] create an environment that makes it safe to discuss anything?
2. How can you remain engaged and create shared purpose when you yourself are threatened?

I would like to acknowledge the authors and resources below without which I could not have learned about this. The picture at the beginning of the blog is free-use media from the web.
​
Resources | References:
Patterson, Grenny, McMillan & Switzler 2002 . Crucial Conversations: Tools for Talking when Stakes are High . McGraw Hill. [Below is a link, which outlines some of the major points of the book by Jim Force]
https://www.evernote.com/l/AAvJ6GOTPtNMiao2R3SvjVCxCM3izxkUVLI

Judy Ringer blog post on difficult conversations:
http://www.judyringer.com/resources/articles/we-have-to-talk-a-stepbystep-checklist-for-difficult-conversations.php

Janine Bowen article on Emotions in Organisations:
https://www.evernote.com/l/AAsJyOAGLvJPMpaFCtqEhqY3-3FswxRon2Q

Crucial Conversations for Dummies Cheats:
https://www.evernote.com/l/AAt_Ogc06QtBxpXpKDVG0i1UFZ-1sPy7Ses

Business Lit blog article
https://www.evernote.com/l/AAsBG1ipIahHlaKQL416Lg77KsAo7rAxyD0
​
ERmentor on EI:
http://ermentor.com/2013/04/how-to-be-a-selfish-altruist/

I created this slide as part of a talk I gave at the University of Saskatchewan's Emergency Medicine winter retreat. I thought that I'd share it and some reflections here. 

During the talk I used my own personal experience as a burning-out PGY3 resident struggling with issues of fatigue and low sense of accomplishment, self doubt, compromised relationships, lack of wellness and a decreased sense of purpose. Sound familiar?

It's only a few years after the fact looking back on things that i realized that I was burnt out, unwell, unaware and living in a horrible environment! I wish I knew then what I knew now. The diagram above represents what in coaching circles we refer to as the 'Logical Levels of Self' [adapted from the work of anthropologist Gregory Bateson].

Struggling Nadim was stuck at the bottom of this pyramid - questioning the choices he had made to get him to this point. He was perseverating on the negatives and oblivious to how far he'd gotten off his wellness track. He was living in a noisy apartment with construction noise all day and into the night - impeding his ability to sleep. He was also struggling with the cultural expectations of being the eldest son in an ethnic family. 

Little did he know that he unwittingly built this basement that he was living in piece-by-piece with his beliefs, blindspots and lack of introspection and self-awareness.

While he had some idea of his skills and capabilities, he really didn't know his strengths or inner resources. He had never learned how to deal with his emotions or to have courageous conversations. He had never learned to deal with his inner critic. At some point in time he may have had a vague sense of what was important to him, but like most people he’s never really sat down and reflected deeply on this. Fast-forward to where he is right now – questioning his sense of self, his ability and role in life. 

I wish I had the chance to coach this young man. I hope that all future Nadim's won't even need a professional coach, because this stuff will become 'baseline knowledge' in medicine.  In order to build your life from the inside out ... you first need a 'home inspection' of your Logical Levels pyramid:

Get to know your basement:
Understanding your pyramid begins with spend some time looking at the basement you've created. You need to have a good realistic grasp of your environment. While it's important to understand some negative aspects [such as the ambient noise and how it was affecting Nadim above] I want you to shift the focus onto all of the positive things. Appreciate where you are and the good things you've accomplished. Get a good sense of the tasks in your life that require prioritizing. The most important of these is self-care.

Understand your capabilities:
Everyone I have coached is universally blind to some of their strengths. You got here somehow - reflect on what it takes to make you achieve. Look at other areas of your life where you have more agency - this will make you more aware your strengths.

Learn how to deal with your inner-critic:
Everyone I have coached is also hampered by negative self-talk. Your inner critic has served a valuable function in your life, but if you want to excel you need to be in the driver's seat. Acknowledge these thoughts, but choose to accept or refute them.

Learn how to deal with people - including yourself:
Read up on emotional intelligence and courageous conversations. Reflect on situations that made you emotional. Ask yourself why? What does it say about what you value? How might you do things different? [Hint: go easy on yourself - you're only human]

If you want a better basement start from the top:
You might not know your purpose in life, but you still need to ask yourself some tough questions. Understanding what you are about and what you value takes time. Sometimes what you think you value is just a 'surrogate' marker for something else. Think deeply. Strip away the layers so that you have a list of your core values. Challenge your firmly held beliefs - why do you believe these 'facts'? I read a book called The Four Agreements. The biggest pearl I found in there was that we inherit many of beliefs from our well-meaning parents. We never had informed consent about these. If you could clear the slate and go to an app store of beliefs today- which ones would you download? Your purpose should start to become more clear to you as you reflect on these things. 

Get building!
Once you've done all the mental footwork the rest comes easier - you just need to nudge yourself forward. Align your actions with the things that you value. Play to your strengths and start winning :)

Photo Credits:
Depressed doctor:  www.medscape.com article
Call to action: www.overpass.co.uk

Just watched a very interesting TED TALK by Amy Cuddy on body language. Watch the TED TALK here. Amy's research shows that just 2 minutes of creating a powerful presence using your body posture actually leads to a powerful presence of body and mind. She showed that by assuming a powerful posture subjects not only increased salivary testosterone [more power] and reduced cortisol [less stress], they put themselves out there, excelled at a high stress interview and were more likely to be selected by blinded observers. Her last pearl was that practising powerful poses leads to becoming more powerfully present over time.

The talk inspired me to think of how one could apply this wisdom in two common high-pressure situations in emergency medicine and residency training  - code | simulation scenarios and oral exams. 

My residents will tell you that I teach them to find some way of getting into the right head space before simulation scenarios and oral exams. The goal is to fashion a powerful presence while being stress-resilient. I believe that Amy's wisdom provides another avenue for this.

So next time you're feeling a bit overwhelmed before a code | simulation scenario or oral exam, try 2 minutes of a powerful pose [or assuming a powerful pose during the scenario] - see if you can create a more impactful presence.  If it works - practise it! Comments welcome

Over the years I have come to realize that my medical community is pretty small. Because of this fact - people [that I have never met] have opinions of me. This is my reputation and it didn't happen by accident. 

We all know about those docs in the hospital that "throw tantrums in the O.R." or "always have bad consults".  We garner these reputations with our personal interactions, our written communications, the committees that we sit on, the lectures that we give, students that we teach and with how we practise our medicine. 

You are not immune - . There are perceptions out there about you. These perceptions could be good or bad , but they will affect how people interact with you.  They will affect how people judge you. The good news is that, over time – one’s good deeds overshadow the bad – it’s the pattern of behavior that defines our reputation. The first thing that you can do to create this reputation is to think of yourself as your own personal brand name.

The Art of Personal Branding

1) Brand yourself by:

• Reflection – What are you really about? Take time to think about this. Ask others.
• Recreation – You have to be true to your brand. Walk the walk and be consistent at it.
• Reaction – Things will happen that smear the brand – react to these moments. Make it right.
• Revolution – As a discipline we need to actively buck the negative ideas our colleagues have of us. Here’s a good start:

We need to collectively step up our game. Can you imagine what the brand of “Emergency Medicine” would be like if every ER doc in the world emulated what we read on LIFEINTHEFASTLANE,  AcademicLifeinEM  and BoringEM [to name a few]

2) Package yourself by:

• Looking professional – First impressions count. This is what adult patients and paeds parentsthink of our dress code. Our colleagues wear white coats – why don’t we? Yes white coats are fomites – what do you think of rolling up/tailoring the sleeves? Taking them off? Using them primarily when you’re teaching? What ever you decide to do – recognise that you’re “on show” – ill-fitting creased up and shabby cargo pants + scrub top is not ideal.
• Acting professional – It's tough to do, but one has to take the high road. One must be accountable for personal decisions.
• Communicating like a professional – Your communication style says a lot about your brand. If you want to be perceived as thoughtful and intelligent – you have to come across that way.

3) Market yourself by:

• Collaborating – “If you want people to talk about the wonderful things you do, then you must give them the opportunity to experience you” [G.R]. I was recently invited to help a senior anesthesiology resident give a Grand Rounds on Tranexamic acid. It was a good debate. No less than 4 anesthesiologists subsequently came up to me in the hospital to chat in the coffee line or in the corridor – That’s bridge building!
• Connecting – Join boards and committees. Do stuff for your regional College of Physicians. Connect with other professionals on LinkedIn. This is invaluable networking and garners respect for not only you, but also your discipline.
• Collegiating – Okay that’s not a real word, but what I mean to say is that we should engage in more collegial behavior. Ever get those “Hospital Staff Gala Dinner” invites in the mail? Ever gone to one of them? I recently participated in the new hospital design process. I got to roll up my sleeves alongside a variety of colleagues including the up and ups from hospital admin – all of us developed a new respect for each other.
• Culturing and curating – We teach all the learners in the system at one point or another. By being true to our brand and by packaging ourselves as professionals will eventually create a cultural shift. We will finally have the recognition and respect that our discipline deserves. The challenge then will be to nurture this incredibly hard-earned respect.

Resource Articles:
Fastcompany article

I've blogged before on personal branding - if you haven't read it please do. As I was creating this website I had to think about my personal philosophy. Most educators at some point reflect on their educational philosophy. It's important because it helps guide how you approach teaching and learning, but I think it's worthwhile to think more broadly. Here's a neat article that goes over some of the points below [ehow link]:

1. Reflect - what are you about? Ask your trusted colleagues. Look at your work.
2. Write down the words that represent these ideas
3. Arrange them into a paragraph with a sentence for each word
4. See if you can reduce this into a few short, powerful  and engaging phrases
5. Lastly try and think of one word that captures the entire philosophy - a word to live by

What might this look like?
Words that embody what I am about: hard work, achievement, mentoring, sharing, giving, life-long learning, being involved, paying it foreward. 

Check out my Landing page to see how I did. For those who are embarking on creating their own websites here's some tips on what your landing page should look like [article link] 

Having a powerful personal philosophy will help align your actions with your values. Everything you do should come back to "what am I about?". If you can distill this into one word - even better! I am still reflecting on my one word - as a Meducator I think it will also have to work as an acronym :)