Courageous Collegiality in Medicine

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​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

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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.
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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
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ERmentor on EI:
http://ermentor.com/2013/04/how-to-be-a-selfish-altruist/