Approaching the Unprofessional Learner
so
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
be
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
me
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
us
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
it
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
it
through feedback to help somebody
achieve insight
thank you so much
you