Approaching the Unprofessional Learner

everybody let’s talk about

professionalism

and think about that word my profession

what is your profession what is your

profession

what do you do what does it mean

because i teach new doctors i teach them

how to operate on patients

eyes and would you like your eye doctor

to be professional

what about everybody else you meet it’s

fundamental

and so what i want to share is some of

my experience in the last five years

of helping people learn the lessons that

i needed to learn myself

and so many others so that we can model

that professionalism

that defines our profession

let’s start with feedback and i want to

start with something that i think is a

fundamental statement

feedback is hard it’s hard because of

the way we

are we are not objective about ourselves

we do not take critique easily

we are sensitive we are this we are that

um who’s talking to me do i like that

person do i dislike that person how do i

perceive that message depending upon

how it’s being given whom it’s giving

given by under the context that it’s

being given

complicated and so before we get into

everything else

i want to show you a little bit about

feedback and i believe that the road to

giving good feedback is a bit convoluted

and i’m a sucker for a good background

it’s amazed i have spent time learning

how to give feedback

i have learned that screaming at the

person

is not an effective form of feedback

they remember the anger

they remember the way i said it they

have no idea what i said

imprecise words weird stuff

good job not effective bad

job what do you mean and finally

it’s important for the person perhaps to

learn what makes their feedback

effective

it’s also important to know that not all

feedback starts with

i’m giving you feedback and that’s true

both from the educator standpoint

and the learner

and it gets harder there are certain

types of things

with feedback that are easy if you have

a low test score

that’s somewhat easy because you might

need to study more

you might need to study better you might

need to study differently

but we’re not talking about the score

the validity of the score

is felt to be accepted we’re not saying

the test was bad

do you see the difference now what about

professionalism because that’s where

we’re going

how do i what objective measure of

professionalism is there

there’s not i saw this i was told that

you wrote this a patient said that

how do i give feedback based on little

bits of knowledge

that are not holistic i haven’t spent

all day with you or maybe i have spent a

day with you is that enough for you to

feel that i can give you a critique

that i can give you something to work on

and now we get to professionalism

because we’re going to use feedback to

try to change

unprofessional behaviors and so we have

to start by what is an unprofessional

behavior

and this is my sort of ad hoc

measurement of professionalism the real

on overt on professionalism is easy

these are the people that come in

intoxicated

they show up late they get so mad that

they need to use expletives

and anger to focus their argument

that’s easy because even if there’s not

a regulation

there’s some societal norm i can go to

to say i don’t know that the expletive

helped you in this particular moment

intoxication is bad we can work on those

things

and and to some degree that’s important

and we’re going to get to that but more

important i want to get into what i

consider insidious on professionalism

these are the people that we may know

it’s

little things and you say well what is

it about that person well i mean

i mean there’s nothing that they do that

nobody else does but sometimes it’s in

combination and what they do is they

little by little earn themselves a

reputation of cold

my doctor was uncaring poor bedside

manner

i mean that’s put that on a google

review see how it goes

these things matter because the people

they got up that day

they got dressed they’re here to work

they’re here to see your problem

and truthfully sometimes they’re right

but the way that they made you feel

didn’t help and you’re not going back

the reason i use insidious i thought

about innocuous various you know

i like words insidious to me is because

over time

there’s a bad outcome and we’re going to

get to that too

so now we need to change professionalism

with feedback and i’m going to tell you

all roads lead to insight

the most important thing that you will

take away from this talk

is that with insight comes judgment

if they don’t know that they had a

choice

when they made an unprofessional action

then the next time that opportunity

arises

they won’t see that choice they won’t

make the better choice

they need to know

that there’s a choice and it’s really

difficult

sometimes for them to have insight that

there was a choice

and that they didn’t make the correct

choice the two ways that i

achieve insight are through always

letting them save face

and a sense of perception versus reality

then we’re going to talk about each one

i love

this word escalation in this sense and

if you look at this slide you will see

how we start with something simple

conversation

what was that and then you work your way

up work your way up and finally

these people are getting close to being

dismissed if there’s a permanent record

in life it’s your medical license and if

you need to write on there that you have

professionalism problems and that will

carry you forever

that’s a permanent record mark you don’t

want and people will get

very close to that before ever having a

sense that maybe i have an anger problem

never underestimate the power of denial

and so

really what this talk is about is how we

can use

insight or help somebody achieve insight

to through feedback to become

more professional strategy one

1936 dale carnegie hit it it’s perfect

and you don’t need to read the book you

can go on wikipedia like everybody else

does and i did too

it’s outstanding the concept of letting

them save

face this is from the educator

standpoint you’re in my office

you’ve done something how do i make you

feel how do i approach the issue

because if i start screaming at you are

you listening to the finer points

no you’re in pure defense mode

either you’re curling up a little ball

or you’re ready to fight

it’s so part of it is setting the right

tone

constructive it’s good to see you it

looks like we need to go over something

part of it is giving them a moment to

speak

what were you thinking how did that go

and if you’re screaming at them

what were you thinking

they’re not listening they’ll remember i

mean unless it’s something so

simple but there’s almost always more

than that and any time

that we’ve been on the other side of

such a conversation there’s almost

always several events that the main

person is not aware of and that’s what

we want to let them

say what were you thinking and give them

a chance

challenge them to do better but

give them a way out it sounds like that

didn’t go very well

let me help you make it right let me

show you the way that you could have

handled that

a lot of this they’re thinking you’re on

their side

insight yeah

that didn’t go very well

and you know what goes great with saving

face a good cup of coffee conversation

this is a visual approximation i think

you’ll see

there’s ways that you can do this the

cup of coffee is not so much for the

repeat offender it’s for the one who’s

just blundered

and we all have our moments we all

say to ours it’s just something happens

and it’s perfect

and so there’s three things that you can

do the first thing you can do

is make it about their time

i’m sure that whatever you said felt

great in the moment all right that email

is hilarious

but you’re going to spend a month

apologizing for that

here we go to the next committee now

it’s going to go again

do you see how that action has caused

such a

reaction that maybe it’s not worth doing

it that way

make it about the patient is that the

way

you would want your family treated is

that the type of doctor you want to be

and finally you make it about the money

now imagine that that patient complaint

is a google review for your practice

now imagine that the person that you

just exploded on

was a referring doctor and you’re in one

small town and you’ve got five referring

doctors and now you’ve got four

it doesn’t happen the problem is in a

lot of these things we’re so used to

moving on

we had college we had high school we’re

now in medical school we’re in

internship we’re in residency with maybe

a fellowship

it’s you have to take the 20-year plan

don’t make long-term enemies

all important things when you’re trying

to get them to have

insight and usually one of those three

time

about the patient the money will get

them to realize

yeah that behavior is not going to help

and then we get into perception versus

reality this was an important

conversation piece for me

and it really came about through i was

telling somebody something

and i was saying look i’ve read your

evaluations and

it just you’re cold you’ve got a

terrible bedside and she said to me

my friends like me my family likes me

i’m not a cold person and i said oh my

goodness you’re right

i don’t know you i didn’t grow up with

you i’m not your parent i

don’t know you that well at all but

you’re right

but let’s change it a second you’re

perceived that way

and rather than shutting down

immediately and saying how dare you say

such a thing to me

if we can say why is it that on these

evaluations you are perceived as being

abrupt with your patients

you might just get that insight that

pause

where they approach that hypothetical

situation from just enough

psychologically safe space to say i

don’t know

i don’t think i’m cold to the patients i

don’t feel that way

but if you can get that then they start

paying attention to things more

because now they have just a moment of

saying

i wonder if this is what they’re talking

about that’s

perception versus reality use it as an

educator

there is nothing more effective than

saying this is the perception

if it’s not accurate change it

because if they can have that insight

now they’re going to use judgment with

insight

comes judgment and from perception

versus reality

and saving face hopefully you can help

somebody achieve insight

through feedback to improve their

professionalism

and so then we get into it i thought to

myself well it’s

nice to be on the other side honestly

but how do i what would i do

if i were me 10 years ago or maybe me

someday in a meeting or something where

i am suddenly

being given feedback that is unexpected

and

shows that i have areas for improvement

and so i want to start with the fact

that you might feel like this

because again most of the time it’s an

insight problem you won’t know you’ll

say hold on as i’m being

there’s a word for that in ophthalmology

blindsided

so what are we going to do how can i

help you

in that situation and so i’ve come up

with a few things

the first thing is don’t panic

get yourself under control if you’re not

being fired then you’re not being fired

you’ll know it comes up and if you’re

not

then you need to listen closely to what

they’re telling you you need to hear

that feedback

some people upon being given this list

of grievances

will curl into a little ball it’s an

imposter syndrome you i

you’re right i am terrible i shouldn’t

exist

and you say hold on a second i’m glad

you exist

i’m glad your parents brought you into

this world i’m glad that you are here

i’m glad that we’re having this meeting

this thing needs to work

because you do a lot of great things but

this is going to overshadow almost all

of them

that’s important that they feel that

that you’re on their side

you need to recognize that the message

is not going to be perfect

you are going to be there and you’re

going to be like a trial attorney oh

the fourth oh see that four things wrong

i can explain that fourth thing i the

whole argument needs to be thrown out

i’ll see myself out and you say hold on

fourth one out there’s still a theme

here generally speaking

there is not a single action that gets

somebody into a situation like this

and it is not the absence of that action

that will get them out

and then we need to get into being the

messenger it’s not easy

to be calm cool collected

thoughtful compassion all the things

that we want if somebody was talking to

doesn’t mean i’m not trying but if my

tone irks you

or you read into it something and now

you’re just mad at the way i’m talking

to you

that’s not helping you either because

now you’re not listening the way you

should be

which means that you should be very

careful in those situations about not

saying things that you’ll regret this is

not the time to imply bias

sexism racism other things

there’s other avenues to deal with that

if it’s true or not there’s other

avenues

not in that moment in that moment you’re

listening

tell me what feedback you’re giving me

thank you for that feedback

take a break this is a lot i have

that’s where we get into at gas for time

i would like to go home and think about

what you’ve just told me

i’m going to have to reflect on that a

little bit can i get back to you

very reasonable and when you do get back

to them show them that you reflected on

show them that you didn’t just dismiss

everything they just said

here’s what i’m going to do to

demonstrate to you

who i actually am and not who you

perceive

me to be and finally

if you’re in that situation and we all

are lean a little bit

talk to your friends talk to your family

get to your support system

i’ve had a bad day but also remember

that their job is to tell you that i’m

completely wrong

and that’s not true either right in the

middle thank them for their support but

pay attention

and if we do all those things both as an

educator

and as a learner we’re going to continue

that culture of professionalism

that we so prize and we’re going to do

through feedback to help somebody

achieve insight

thank you so much

you