Tip 22: The Era Of Old-Fashioned Modern Medicine

Over the past year, every Coach Leader I've written, regardless of its specific emphasis, always reiterates the importance of beginning every discussion with, "What matters most to patients?" The CEO of an organization I just began working with recently asked me how I first made that determination, and how I continually remind myself of the importance of that question as a foundational starting point for everything I/we do. When I answered, "Improving organizational culture begins by talking with patients," my client responded saying that his schedule pinned him behind a desk most everyday, and wasn't sure where rounding on patients fit would in to his overloaded to do list. When I told him that all my clients perform rounds a few times a week, he wasn't sure what to say or where to start.

To best illustrate my point, I gave him the following excerpt from my soon-to-be-published book, Heroes Need Not Apply. It helped him to immediately see the merits of these actions, how it actually plays out and the positive impact it can have on patients and staff.

In the scene below, you'll meet CEO Jane Carolli (who started her career as a nurse) and her new VPMA Dr. Jack Martin. Jane brought Jack aboard to help her build a more collaborative workforce like he did in the Montana hospital clinic he came from. Even though Jane brought Jack aboard, it took awhile to build the relationship to this point:

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    "Don't you go on rounds, Jane?"
    "Well I used to as a nurse of course, and I know some managers have. But besides the fact that I don't have time for it, I'm not sure what to say. Funny enough, after half of a lifetime working with patients, it's a little out of my comfort zone."
    "All that I can tell you Jane, is that everything we're talking about began with performing rounds in Billings when I didn't have any patients. At first, I started asking them what kind of improvement they'd like to see - big mistake. I already knew the answer and every conversation started off negatively. Then, I asked them what was really important to them, and I got an entirely new perspective, something I could really use. Although patients framed their answers differently, they all essentially said the same thing."
    "They were saying that they wanted to trust their caregivers?"
    "Not in those specific terms, but yes, they were all alluding to something relational instead of physical. They all had their own hierarchy of concerns, and everything funneled down to trusting that we were all truly listening to them and hiding nothing from them. Like you just said, they want to feel engaged in a team effort to make them better."
    Jane smiled, "So basically, the patients are looking for the same things we need from each other, the ability to put all of our past stuff aside and work together."
    "Bingo."
    "In fact Jane, once I figured it out, and things began to improve, I looked forward to rounding more than anything else. When the improved workforce started taking shape, the patients started raving about the care. I realized that if I needed a pat on the back, I'd get it from rounding. Sold yet?"
    As she rose and headed for the door she said, "Call my office and set it up."

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    "Jack, before we go in, I'm not sure what I should talk about."
    "First off, it's more about asking something and spending most of the time listening. If we're going to give these patients what they need the most, we have to listen."
Saying it almost to herself, "Sounds like making a basic diagnosis."
    "So what do you think you should ask Jane?"
    "Well what if I ask them how we could improve their stay?"
    "You tell me Jane, is that something that you don't already know? Will that yield you deeper insights into what we're trying to validate?"
    "No."
    Jack let her think for a moment and then said, "You mentioned making a basic diagnosis. This is a lot like that. Because the only way to really get to a more patient-centered approach is knowing how to ask the right questions. What do you want to know from them?"
    "I guess I want to know what's most important to them - what really matters to them."
    "There you go."

---

    They continued on toward the room and Jack shared, "We're visiting Bill Meyers, a 56 year old male scheduled for a coronary angioplasty first thing tomorrow morning."
    They walked into the room and Bill Meyers was facing the TV, but you could tell he really wasn't paying any attention to it. He almost snapped to attention when a new physician and a suit entered the room.
    "Hi, what's going on, is anything wrong?"
Jane jumped right in, "No Mr. Meyers, we're just stopping by for a visit. I'm Jane Carolli, I kind of run things around here, and this is Dr. Jack Martin, he's in charge of Medical Affairs. We just wanted to check in and see how you're doing."
    "Wow, is this SOP? Oh, excuse the acronym, you can take the man out of the Marines, but not the other way around... is this standard operating procedure?"
    "Well yes and no," Jane answered. "We like to get out and visit with as many people as we can, when time permits."
    "What can I help you with Miss...?"
    "Jane. It's the other way around Mr. Meyers. You're the one who can help us. I just want to know more about what everyone's thinking around here. Tell me, what's the most important thing on your mind right now?"
    "You mean besides getting out of here in one piece?"
    "I mean, is there anything in particular that you're thinking about? Anything that would reassure you that you'll get out of here in one piece?"
    "Well, there are a lot of people going in and out of here and I can't help wondering if they're even talking to each other. It seems like twenty different bodies ask me the same question all day long, like one hand doesn't know what the other's doing. I mean no disrespect, but you hear about people getting the wrong meds and such, and it sure would be nice to know that everyone's on the same page, that people are actually talking to each other about me. Having my heart worked on is stressful enough if you know what I mean."
    "I do," said Jane, "is there something you'd specifically like to see or hear?"
    "I don't know." He stared right through the TV again for a minute. "I guess seeing more interaction would be nice... but I also realize there's probably all of that going on behind the curtain and I'm just not seeing it. I just want to believe it is. It would be nice to feel more confident about everything. I mean, not about my doc, or each of the nurses, just about everyone combined."
    "This is why I'm here Mr. Meyers..."
    "Bill."
    "Bill. I need to hear this from you so that I can figure new ways of making sure you get the peace of mind you deserve."
    "Or at least some peace of mind," he countered, "until they've been in and out of my arteries, it's hard to relax. But it sure would help if it felt like all of these people were on some kind of team."
    "Let me see what I can do about that," Jane glanced back at Jack, "and I'll stop by tomorrow after your procedure and check in. I'll also stop by the nurses' station right now, and double check everything for you. I was a nurse and nurse manager, and I know there is a lot going on behind the curtain, as you said, but I also know that you shouldn't have to wonder about these kinds of things."
    "Thank you."
    "My pleasure Bill. See you in the morning."

Coach Leader Tip 22: It's the old-fashioned tools patients value most

After reading this excerpt, my CEO colleague looked at me and exclaimed, "You sure you didn't use my hospital as the back drop for your book Brian? This lack of communication goes on every day, but we rarely put it into context as to how it immediately and directly affects our patients until something goes south."

This excerpt and tip is much more than a lesson in rounding. It reminds us that modern medicine is in danger of losing powerful, old-fashioned tools that have the most impact on our one-to-one relationships with our patients - human touch and listening. In his 2011 TED talk, physician and best-selling author Abraham Verghese describes our strange new world where patients are merely data points, and calls for a return to the traditional one-on-one physical exam. He emphasizes the importance of touching and the trust and impact our hands can have on strengthening relationships with our patients. Abraham reflects on how quickly and readily we physicians interrupt our patients and the effect impersonal communication has on our ability to care for them. Having spoken to hundreds of physicians about this very issue, it's clear what is driving these ineffective interactions. Many physicians tell me that if they ask open ended questions like " Is there anything in particular your concerned about?", the patient will ask for more than we can give. They assume that their response will take up more time and put them further behind. We know from experience this is simply not the case and a very costly assumption. Abraham and the physician leaders I work with know that patient experience and outcomes are only as good as our clinical team's ability to touch, listen, and ask patient-centric questions. For a patient, nothing inspires confidence more than trusting that every physician and nurse entering your room takes the time to ask the right questions, to listen to your answers and to ensure that the entire team is focused and dedicated in providing what matters most to you.

Tip 21: When patients are in the line of fire

Is incivility causing your organization to be less compassionate? And what impact does it have on safety and overall patient experience?

A recent Harvard Business Review article titled, The Price of Incivility, by Christine Porath and Christine Pearson suggests rudeness at work is on the rise, and their findings are quite consistent with what we see in the organizations who call us for help.

Over the past 14 years Porath and Pearson polled thousands of workers about how they're treated on the job, and 98% have reported experiencing uncivil behavior. In 2011, half said they were treated rudely at least once a week—up a quarter since 1998. We can only conclude that these uncivil behaviors, exchanges and experiences are chipping away at our organizations' ability to prevent harm, improve quality and build trust in our communities. The authors point out that most managers believe incivility is harmful, but many leaders do not recognize the widespread affects and tangible costs. The authors' research of 800 managers and employees in 17 industries including healthcare, demonstrate the widespread effects of these actions. Among workers who've been on the receiving end of incivility:

• 12% said that they left their job because of the uncivil treatment.
• 38% intentionally decreased the quality of their work.
• 47% intentionally decreased the time spent at work.
• 48% intentionally decreased their work effort.
• 63% lost work time avoiding the offender.
• 66% said that their performance declined.
• 78% said that their commitment to the organization declined.
• 80% lost work time worrying about the incident.

Arguably the most concerning finding for our industry might be that 25% of respondents admitted to taking their frustration out on customers. It goes without saying that our organization's culture has a tremendous influence on improving safety. These are just a few of the challenges we must begin giving more attention to as an industry if we are to get a a better handle on preventable patient harm.

The authors interviewed employees, managers, HR executives, presidents, and CEOs. They administered questionnaires, ran experiments, led workshops, and spoke with doctors, lawyers, judges, law enforcement officers, architects, engineers, consultants, and coaches about how they've faced and handled incivility. They collected data from more than 14,000 people throughout the United States and Canada in order to track the prevalence, types, causes, costs, and cures of incivility at work. They concluded two things: Incivility is expensive, and few organizations recognize or take action to curtail it.

Let's remind ourselves that incivility doesn't have to be a mad surgeon throwing a scalpel in the OR to harm the patient, but a simple rude comment that creates the conditions for one staff member to avoid the other, impairing communication and setting the stage for patient harm.

While this article offers a number of valuable findings on incivility and the effect disruptive cultures have on organizational performance, I wanted to concentrate on one specific finding we are all to familiar with. The authors share that only 11% of organizations report considering civility at all during the hiring process, and many of those only investigate it in a cursory fashion. These findings are consistent with our experiences working with healthcare systems across the country. The good news for our patients on the receiving end, is that we are starting to see more organizations connecting the dots... recognizing just how much collateral damage and patient harm can occur when we don't hire the right folks. Many organizations neglect to see hiring and recruitment as the first line of defense in their patient safety infrastructure.

The authors share that incivility leaves a trail of some sort, which can be uncovered if someone's willing to look. Here's one example, "One hospital had a near miss when bringing on a new radiologist. It offered the job to Dirk, a talented doctor who came highly recommended by his peers and had aced his interviews. But one assistant in the department had a hunch that something was off. Through a network of personal contacts, she learned that Dirk had left a number of badly treated subordinates in his wake—information that would never have surfaced from his CV. So the department head nixed the hire. Dirk doesn't realize the impact his behavior is having on patients and it's one that I illustrate in my upcoming book, Heroes Need Not Apply: How to build a patient accountable culture without adding more to your plate, where a Dr. Hartley, an oncologist makes a few harmful comments that wind up creating a trail of destruction for one of his patients: His incivil behavior toward his transcriptionist resulted in his surgical notes being incorrect, which ultimately led to the death of a patient. He instilled such fear that his transcriptionist threw in the towel and guessed on one word... which happened to be the difference between life and death.

CL Tip 21: Civility: Screen for it and coach with it

What happens when you leave aligning what matters most to our patients and culture to chance? We get an organization that is less likely to be compassionate with the increased risk of incivility.

Porath and Pearson share, "We're always amazed by how many managers and employees tell us that they don't understand what it means to be civil. One quarter of the offenders we surveyed said that they didn't recognize their own behavior as uncivil."

But why is there such a disconnect in healthcare where compassionate people come to work? We are an industry that has a long history of rewarding the T.E.D. attributes (see image on left), and neglecting the human side of our business... the actions and behaviors that matter most to patients (T.R.U.S.). If you've been in healthcare long enough, you've been exposed to a number of living examples and products of healthcare culture. You know, the talented, well trained nurse/doctor/leaders who get the results, but don't play well with others. They seem to create a "windchill effect" when they come into the room as they are often disrespectful and unapproachable. They don't recognize the effect they have on their staff and/or colleagues and how their tone starts a chain reaction that put's the patient's life on the line. The article describes how targets of incivility often punish their offenders and the organization, suggesting that most hide or bury their feelings and don't necessarily think of their actions as revenge. For a moment, consider how this cycle can and does impact our patients? This is a critical problem that doesn't need initiatives or huge budgets to repair. As someone wise once told me, "I'd rather have someone nice and teach them to be smart than have someone smart and teach them to be nice."

Email me or share your thoughts on our Facebook page.

Tip 20: Leaders think small to improve safety

Leaders think small to improve safety

In our overly complex world of Healthcare there is something to be said for thinking small when searching for the right solution to a complex problem like safety. Don't underestimate the genius of small ideas and actions. These little things often surprise us by generating subtle but substantial change that leads to amazing results. From time to time I'm reminded of the light hearted side of the theme: the famous "Think Small" Volkswagen Beetle ad campaign that came out in the 1950's, Steve Martin's album "Let's get small" in 1977...certainly worth listening to if you haven't heard it in awhile. The reality is that there is true value in "thinking small" if you're a leader and/or physician looking to help your staff have a greater impact on improving patient safety.

I was reminded of the concept in a recent article in the New Yorker that tracked the origin of Earth Day. Today, we all know Earth Day as a global movement that led to the Clean Air Act of 1970, the Clean Water Act of 1972, the Endangered Species Act of 1973, and just eight months after the inaugural event, the establishment of the Environmental Protection Agency. Throughout the seventies, Congress passed one environmental bill after another, establishing national controls on air and water pollution. Most of the powerful environmental groups we know today are by-products of the Earth Day movement. Many of colleges and universities instituted environmental studies programs, and many news agencies became dedicated to regular reporting on environmental issues. Earth Day is just one of many examples of how movements that led to great change didn't require highly coordinated efforts. Quite the opposite really, and in the case of Earth Day, those closest to the movement will tell you that it was largely uncoordinated. The rapid success of the movement took it's champions by storm, captured the hearts and minds of millions, and has contributed to small changes in behavior across the globe that made a substantial difference.

So how can the Earth Day movement help inform healthcare leaders on how to have a greater impact at improving patient safety?

It helps us to realize that as leaders a handful of small actions can lead to big results. Improving safety doesn't always require a well coordinated movement or major organizational initiative. We don't need to wait for the board or medical staff consensus to authorize new initiatives to achieve the patient safety outcomes we keep talking about. Many of the organizations we work with have done an outstanding job improving safety, but often discover that all the checklists and initiatives in the world only get you so far. Your future gains in reducing harm and improving safety will need to come from a different place. As the coach of your team who understands that small insights and actions will contribute greatly to safer conditions can also lead to a movement that even surprises you.

CL Tip 20: The Power of Small

Recently, I've been asked to do several interviews to discuss my upcoming book Heroes Need Not Apply: How to build a patient accountable culture without adding more to your plate. I am asked regularly why a doctor would be anti-hero? I keep reminding people that I'm not anti-hero....just anti-heroic effort. Heroic effort certainly did not make the Earth Day movement a great success and it's certainly not going to be the driving force for making patients safer. The hero mindset in healthcare has minimized teamwork and has led to cultures that generate episodic excellence. That sounds a bit unpredictable if you're the patient. The only way to achieve systematic excellence is through small behaviors and actions that reinforce collaboration, matter most to our patients, and create safer conditions.

I've been listening to your feedback, I understand that most leaders in healthcare realize the value in coaching their staff. The concern is where to start and how to find the time?

As we've pointed out in prior issues, introducing coaching into your leadership practice doesn't require more to do, but often provides leaders tools that result in time saved. One of the benefits of incorporating coaching into your leadership practice is that it offers more frequent opportunities to guide staff, build team trust and strengthen relationships. More frequent interactions with staff doesn't translate into more time leading... as the leaders I work with report significant time saved due to less upward delegation and more effective/shorter meetings. Coaching isn't something you do every 6 months at a performance review and it doesn't need to take place in a private room with comfortable seats and subtle lighting, nor does it need to take hours like some leadership approaches we know.  Keeping with our theme of small actions - big results, this tip might be one of the most effective and underutilized skill leaders practice:

Use silence effectively to allow others to think.

While the idea of using silence as a coaching tool could be perceived by some as a whole lot of nothing, the most effective leaders we know in and out of healthcare apply it to every conversation. Just the word "silence" suggests passive behavior, but we've found it to be anything but. As a physician, I discovered the benefits of using silence or what I often refer to as "creating space" so that my patients have the opportunity to tell their story. As providers we have grown fearful that if we offer space in the conversation for our patients to ask a question or share a thought, they'll ask for more than we can give...simply not the case. The opposite is true. When you offer patients and/or staff the opportunity to think by creating space, you create an opportunity for listening to occur and an insight to be made. When your staff/patient is aware that you listened to them, they feel safer, they are more likely to trust in your leadership, and engage in the change you're advocating.

Creating space might look and feel like a small thing, but the safe exchanges it creates have a remarkable impact on improving care. Effective coaches know that every conversation they engage in can offer perspective and insight... all you have to do is pause from time to time.

Email me or share your thoughts on our Facebook page.

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WHAT'S NEW @ THE BEDSIDE TRUST

Dr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.







Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Check out the new video interview with Brian Wong, M.D.

to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>

Tip 19: Coaching: The path to patient safety

Coaching: The path to patient safety

In our last issue we discussed how to navigate medical hierarchy in the most difficult of circumstances and shared a proven coaching tool for defusing potentially harmful conversations among physicians. The safety challenges that medical hierarchies present are no surprise to the physicians at the Bedside Trust. What is surprising to them and most of us, was just how effective a question like "what matters most to our patient this moment?", could be at disarming unsafe exchanges among providers. One reader commented, "You know... it's one thing to sit in the boardroom and discuss putting the patient in the center, and it's another to have physicians asking each other the same questions at the bedside where it really counts." In her recent New Your Times article, "Afraid to Speak Up to Medical Power", Pauline Chen, MD discussed her personal experience in dealing with the all too common unsafe medical hierarchy that is endemic of our current healthcare culture. I'm glad to see such well respected physicians confronting these "old rules" that have such a profound impact on patient safety.

But what's keeping patients from consistently experiencing the benefits of physician coaching every time unsafe exchanges arise? I use the term "physician coaching, not just because it's more relevant to physicians than the concept of leadership, but because coaching offers the tools that keep patients safe. Chances are you have heard talk about having a coaching culture or a coaching style of management.

A client recently sent me Atul Gawande's article Personal Best, published in The New Yorker September, 2011. Gawande makes the general case for coaching by offering this statement " No matter how well trained people are, few can sustain their best performance on their own. That's where coaching comes in." He also pointed to a limitation of coaching saying, "The concept of a coach is slippery." The concept of coaching is slippery because it lacks definition in most organizations. Coaching is one of those concepts where definitions vary according to who you ask. Can you think of other terms in healthcare that are hard to grasp: patient-centered, leadership, physician leadership (if you really want to confuse physicians), even the concept of accountability and culture requires context to truly understand the concept. 

When I first begin to talk about coaching to most leaders in healthcare they immediately think of the context of a sports coach. As spectators, the camera often pans to the angry coach on the sidelines yelling orders to his players. You might categorize this best as a directive style of coaching. For those leaders that feel the need to show authority, the non-directive style can appear soft or weak. And yes, telling people what to do is often perceived as quicker and more effective on the field or in the ED, but only in the very short-term. In other words, if you're a coach of a professional football team or a physician needing to improve the performance of your ED staff, you'll recognize that directive styles have considerable limitations long-term. If we are going to achieve sustained excellence in patient safety, we healthcare leaders need to practice and emphasize our long-game coaching tools.

Tip19: A culture that rewards and recognizes coaching is a safe culture.

Coaching can involve a range of styles and techniques with a directive approach at one end of the spectrum and non-directive at the other. If a first year ER resident is learning a new technique for intubating a patient and has no idea what he is doing, then clearly the Resident needs to be given instructions and shown what to do, requiring a directive approach.

Even in healthcare, which can often feel like the ultimate sport, leaders and physicians have ample opportunities to offer non-directive coaching to staff. Take a very well trained nurse manager who may be experiencing a period of less than stellar patient satisfaction results.This person has the skills to do her job, so taking more of a non-directive approach to improve performance may be required. While a directive approach relies heavily on giving answers, non-directive coaching emphasizes questions designed to get the team member to explore previous experience for solutions. Listening and properly reinforcing their confidence and ability is more likely to get the engagement required for the results you expect.

Non-directive coaching tools can be very effective for the development of people and when behavior change is required. And I don't have to remind you that these are the issues that most challenge leaders and cause harm to patients. For example, if someone is unsure about a decision they need to make or how to handle a problem, is just giving them your answer the most effective way of teaching? I suppose if the decision was urgent as in some healthcare situations, then maybe you would have to. However, if it wasn't, for improved personal development, you could ask them what they would do and get them to think of other options?

Look no further than the all too familiar example provided in our last Coach+Leader. Two physicians, one afraid to approach the other, due to the unsafe conditions created by medical hierarchies. In many of the cases we see, the physician has ample time but fails to act simply due to the fact that the medical staff does not emphasize coaching as a core component of it's culture. Open ended questions like the one we shared are perfect coaching tools to combat medical hierarchies as they redirect the physicians in question to focus on what matters most to our patients, rather than trying to determine the smartest person in the room.

If you're a leader, a physician, or in a management position, you are in the right place to start thinking like a coach. In the case of coaching, there needs to be a top down approach, because leaders have the most impact on building a Patient Accountable Culture. As healthcare leaders, coaching must be viewed as a primary tool not just for improving team performance, but for improving patient safety. Our patients expect us to work as teams... patient-centered teams need coaches, and every leader has a coaching role.

Stay tuned to Coach+Leader as we continue to build the case for how leaders and patients benefit from organizations that make coaching a priority.

Email me or share your thoughts on our Facebook page.

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WHAT'S NEW @ THE BEDSIDE TRUST

Dr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.

Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Check out the new video interview with Brian Wong, M.D.

to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>

Our Coach+Leader blog helps you have a greater impact on improving care. It offers healthcare leaders sound perspective, road-tested tips and tools that remove unneeded complexities... allowing leaders to focus on what matters most to patients. Every so often we hear about exceptional people doing exceptional things and believe it is important to share these stories with our community. Our friend and physician wellness expert, Randall Levin, MD, F.A.C.E.P. shares our passion about making sure physicians and clinical leaders are well prepared to serve their patients. Dr. Levin and I are equally concerned about the current state of physician satisfaction, engagement and more importantly wellness. As these symptoms worsen due to reform and other contributing factors, it has become more apparent that we as an industry must make physician wellness a priority if we expect to see safety and quality improve. Dr. Levin practiced emergency medicine for 28 years, was a director of an emergency department, and is ACEP's physician wellness editor. Dr. Levin is an expert on physician wellness and we are lucky to have him as a contributor at the Coach+Leader. Please share his insights and solutions with your colleagues.

Brian Wong, MD

Provider/Physician Burnout: Taking The Battle to the Brain

Using Positive Psychology to Improve Engagment and, Ultimately, Patient Care

We all know something has to change. Debates on the direction of the healthcare system and competing approaches to patient care are flying fast and furious around us. Now is the time when we, the people who know patients best, need to be at the top of our game. This will allow us to be participating partners with our physician leaders in helping re-create the patient focus medical environment. A sense of well-being and decreasing burnout goes hand in hand with much needed change. Refocusing from provider survival mode to a role as a facilitator for patient outcomes can not easily occur without the element of wellness among providers and other healthcare team members. However, a recent Medscape survey indicates many of us are not at the top of our game.

39.8%
of responding physicians reported they are burned out

A recent Medscape survey (http://www.medscape.com/viewarticle/781161) found 39.8% of all responding physicians were suffering from burnout. The numbers are even more daunting when drilling own in to specialties with Emergency Medicine and Critical Care physicians reporting burnout rates at or above 50%. All the specialities identified in the survey reported burnout levels exceeding 30%. How can we expect to be open to, or craft creative solutions and offer the very best care to others when we struggle so plainly to care for ourselves?




A View of Burnout In Action

Here is a scenario many physicians, especially those in emergency medicine, can no doubt relate to:

It is an overwhelming busy day in the ED. All the rooms are filled with 10 (20, 30, etc) charts of patients who need to be placed into rooms. We are top-bedding admitted patients in our ED, because there are no vacant beds in-house. This top-bedding of patients in the ED, limits freeing beds up for our patients from the waiting room. The waiting room is filled to capacity and we are unable to divert (when an ED is overwhelmed you can divert any further ambulance patients to other open hospitals until the overcrowding resolves) our patients to another hospital due to protocol criteria (if all EDs are diverting then all EDs open up and cannot divert). The staff is overwhelmed and showing signs of stress, being short with colleagues and remaining disconnected from the patients being seen. We cannot "close" to take the pressure off and our lack of resources is causing what systems we had in place to unravel. The next moment I hear the EMS call-in box transmit information concerning a new patient being brought into the department. I think to myself, "Where will I put the patient? How can we safely care for yet another patient?".

I am not the only one wondering as I hear comments from both the medical and nursing staff.

• "I cannot take on another patient, I am overwhelmed."
• "I don't have anymore to give, and "they" (administration) can't expect us to stand for this."
• "If I have to care for another patient, I am going to quit."
  

These statements, clear implications of stress and burnout, framed our mind state and how we perceived the patient the whole day.

This scenario, while extreme, is all too common and illustrates the real hurdles we need to overcome. Too often though, we focus on the external as the only way we could make this scenario different. "We just need more staff." "A few more rooms will solve our problems." While these changes might indeed help to improve things, what do we until we get additional staff or those new rooms? What do we do if those two changes are not enough to make a hectic day like this better? What do we do? We think differently.

Three Ways To Think Differently

Here are three positive psychology approaches that could help us change the scenario not only for ourselves, but our patients as well.

Be Present (Mindfulness)

The scenario above was already a hectic one when the EMS call came. My focus was on my "survival" and became distracted from the patient. When that happened, I was already jumping three steps ahead imagining negative and defeatist implications. The next time you feel the day spinning out of control, stop, and focus on that one patient in front of you or the one you will be seeing next. Give them your whole attention and effort. Reconnect to your empathy and compassion if you are sensing a disconnect.

Maintain Perspective

In the scenario above, I and all the staff around me were focused on what we were feeling and what we wanted. We had lost sight of the person and purpose we were there to serve. Stop, and review your posture, attitude, and approach. Now imagine you were the patient, scared and frustrated, about to be attended by someone in your current mindset. Putting our concerns in the broader context, can help us to connect with our patients and support mindfullness.

Be Flexible

Too often a response to stress is to default to the familiar. If your familiar is an environment where over 30% (or more) of your colleagues are burned out and disconnected, you may be defaulting to a position that will not provide you or your patient with positive returns. Stop, take a deep breath and ask yourself if you could approach your scenario differently. Take it one step further, ask someone else. Take it one more step, and ask someone you don't normally speak to. Taking a moment to open yourself up to alternative ideas or options, could result in a new successful path, providing you and your patients with a more positive experience.

These suggestions are not a panacea, nor are they the only options available to us. But I can truly state that my mindset was changed and my body language was more of an anticipatory "thank you" for the patient – thank you for allowing me to be there for you and use both my didactic medical knowledge and skills, along with my empathy and compassion. I could again focus on the patient (and not on how was I going to survive). It was not about having to be a "hero", but how to be a human being helping another human being.

I have adapted these ideas from concepts explored by Neil Farber, MD, PhD. His series on Positive Psychology offers an invaluable overview of more techniques and approaches to incorporate positive psychology into your practice and into your life. You can learn more about this series http://www.mtmi.net/courses/PosPsy.php. Burnout is real and it's ability to blind us from how we and why we practice medicine is powerful. Using a new way of thinking we can start to take those blinders off and smother the flames of burnout.

Dr. Randall Levin, MD, F.A.C.E.P.

Director for Physician Education - Medical Technology Management Institute, a continuing education division of Herzing University

• ACEP Wellness Section Newsletter Editor
• Practiced Emergency Medicine for 28 years
• Past Director of Emergency Department - Aurora West Allis Medical Center
• Past Member of Executive Committee - Aurora West Allis Medical Center

Tip 18: If doctors are afraid to speak up who will?

If doctors are afraid to speak up who will?

In her recent New Your Times article, "Afraid to Speak Up to Medical Power", Pauline Chen, MD discussed her personal experience in dealing with the all too common unsafe medical hierarchy that is endemic of our current healthcare culture. I'm glad to see such well respected physicians confronting these "old rules" that have such a profound impact on patient safety.

Dr. Chen shared how when the hospital where she worked, hired a "Rising superstar in the world of oncology, a brilliant physician-researcher who had helped discover treatments for other cancers and who had been recruited to lead our hospital's then lackluster cancer center...", none of the incumbent medical staff felt comfortable challenging anything he said. Even the "Number 2" doctor on staff was afraid to throw in his two cents when he felt we was witnessing the wrong treatment for a patient. Long story short, due to an invisible, unspoken, fear driven medical hierarchy, two physicians who had more intimate knowledge of the patient than the new "superstar" kept quiet while suboptimal treatment was given causing a patient to die.

Dr. Chen cited a recent New England Journal of Medicine article, "Speaking Up — When Doctors Navigate Medical Hierarchy" by Ranjana Srivastava, F.R.A.C.P. which equally demonstrated this fear-based hierarchy through the eyes of a Medical Oncologist who was handed a patient from a resident. The patient was scheduled for surgery just a few hours after the physician made his courtesy call. He found the patient, "Scrunched up in bed, tossing and turning, his sheets tangled between his legs. He's pale and uncomfortable, licking his lips, his IV fluids having run out. My immediate impression is that he's dying. But I remind myself that he's scheduled for surgery." After conversing with the patient, the Oncologist felt sure that the patient wouldn't survive a surgery. But in this particular hierarchy, the surgeon was king and very few (if any) would question him. So when the surgeon showed up ready to proceed, the Oncologist figured he knew what he was doing, so he kept his mouth shut. And although the patient survived the surgery, he died shortly after. 

Afterward, (better late than never), he spoke to the surgeon about it, and the surgeon admitted that he would like to be told if he was perceived as inadvertently harming his patient. But the Oncologist couldn't have known that since the medical hierarchy has always been there... and has always been present in every hospital he'd worked in.

The two agreed to be more open and sharing in the future... just not soon enough for this patient.

You would think that physicians intervening with each other to help treat a patient, and especially to save a life, would be a given. Sadly it's the exception and medical hierarchies like these have proven to be a significant contributor to unsafe cultures. Almost all physician you and I know have experienced similar situations. I rarely meet a physician who doesn't have his or her own poignant story to tell me about an unsafe conversation with another doctor that led to suboptimal care.

It's the right time for Dr. Chen and Dr. Srivastava to be voicing their concern on the issue as many suggest the symptoms are getting worse. When I began writing my book, "Heroes Need Not Apply", two years ago, it was clear that this challenge was becoming more pronounced, as healthcare reform places greater emphasis on providers working as integrated teams to improve quality, create efficiencies and reduce cost. Understanding that the severity and frequency of these unsafe exchanges has nowhere to go but up, my book takes a close look at the key factors that produce unsafe medical hierarchies and what we as medical community must do about it. Now that the book is set to be published this Summer, I'm hoping that this story and the leadership of physicians like Dr. Chen and Dr. Srivastava, can offer a new template for how we physicians interact, as there is no room for these medical hierarchies in these new care models.

Like most cultural challenges we face, medical hierarchies and the "old rules" that follow are steeped in medical training and can't be resolved with a checklist or confronted with punitive approaches. If we physicians are to prevent unsafe conversations, we're going to need to replace the template for how we interact. Consider our current context, a template for interaction that celebrates individual expertise, credentials and honors. In other words, a culture that rewards and recognizes individual heroic effort with little emphasis on peer coaching, physician collaboration,and clinical teamwork.

18 Tip: How to defuse a medical hierarchy in 5 seconds or less.

Medical hierarchies often create conditions that allow extraordinary power to be given to extraordinary physicians. These physicians are highly accomplished, have numerous credits to their name, and get excellent results. Physicians like Dr. Chen and myself operate within this hierarchical context, assuming that because they are the best at what they do, they must know what's best for the patient. This is the most costly (and incorrect) assumption we make,and it's ultimately shortchanging our patients. As we formulate assumptions like these, our "superstar physicians" become dangerously unapproachable, resulting in a system with fewer checks and balances. Simply said, we begin to rely too heavily on the smartest person in the room and minimize collaboration, which hinders patent-centered exchanges.

Keep in mind that incompetence is rarely the issue, as in most cases, our "superstar" specialist in question is often administering the right treatment for the condition. However, in many of the cases I've consulted on, similar to that of Dr. Chen and Dr. Srivastava, the lead physicians often become too focused on treating the disease without considering the human factors that matter most to the patient and influence outcomes. These physicians report getting fixated on the medical response while minimizing the concerns of the patient and/or another physician.

So what is the answer to defusing medical hierarchy? And how do we create a zone of safety and improve physician collaboration?The answer to this safety challenge is simpler than the average checklist and resides with just one question: "What matters most to the patient?"

I can tell you from the experience of working with hundreds of physicians, this question is 99 percent effective at disabling and preventing harmful conversations. Why is it such an effective coaching tool? Patient-centered questions like this help physicians navigate the power differential by putting the focus on patient concerns and helping the team review the medical response in a more thoughtful way. It sends the signal to all those "superstars" out there that your not competing for the smartest guy in the room award or telling the other guy, "I know something you don't".
We don't need hero physicians. We need team players and coaches.

Email me or share your thoughts on our Facebook page.

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WHAT'S NEW @ THE BEDSIDE TRUST

Dr. Brian Wong's highly anticipated book,'HEROES NEED NOT APPLY' releases this spring.

Listen to Dr. Wong as he discusses Heroes Need Not Apply: A Unique View on Accountable Culture Click here to listen>>

Check out the new video interview with Brian Wong, M.D.

to access Dr. Wong's Q&A as he discusses "Heroes Need Not Apply," Click here>>

Exclusive Q&A interview with Brian Wong, MD

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with Brian Wong, MD: Author of the soon to be released book Heroes Need Not Apply

WHEN: April 24th, 2013
1:00PM EST (10:00AM PST)
We'll keep it short for you, 20 minutes.



WHAT: Dr. Brian Wong will be answering your questions regarding specific accountability challenges at your hospital on a conference call interview moderated by Sierra Weese of Innovative Healthcare Speakers

Please email your question to Sierra by April 22nd, and Dr. Wong will respond to as many as possible during our interview. Join us for a rare opportunity to pick the brain of one of the country's foremost healthcare culture experts on April 24th.

HOW: Conference call in info -- 1 (877) 365-2980
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Everyone in healthcare knows the lack of accountability negatively impacts care, and when accountability improves throughout your organization, care improves. What healthcare leaders didn't know until now, was how to improve accountability and why it is so critically linked to improving patient care. Knowing that every hospital has its own specific accountability challenges, Innovative Healthcare Speakers would like to give you the opportunity to get some of your challenges addressed.

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Speaking Engagements:
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Dr. Wong's interactive speaking programs bring the book's key tools and concepts directly to his audiences, where they experience the process of taking the first steps toward having a patient accountable culture in their organizations.

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