Modern Challenges to Professionalism

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Modern Challenges to Professionalism

• James Adams, MD, FACEP
• Professor and Chief, Emergency Medicine
• Northwestern University Medical School

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• Mahatma Ghandi was asked what he thought about
  western civilization.
• He replied that he thought it would be a good
  idea.

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• We could use a little more civilization in our
  civilization

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Professionalism

• ACGME is requiring all specialty societies to
  ensure standards of professionalism
• Does anyone know what this really means?
• Aspiring to altruism, accountability, excellence,
  duty, service, honor, integrity, respect for
  others.
• Everyone thinks they have it

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The model of AristotleEthics is a rough and
tumble business

• Courage the golden mean between cowardice and
  foolhardiness
• Justice Fairness, balancing benefits and burdens
• Prudence Wisdom, from information and experience
• Temperance The mean between abstinence and
  overindulgence

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Poor Penalized Paul

• You are always scheduling me for a shift
  whenever I have some personal plans.
• You give me more nights, more weekends
• You made me work 24 days last month, I hate
  you.
• You always give me the worst schedule.

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Poor Penalized PaulSolutions

• Head this off now
• Set rules, standards,
• Lower expectations
• Ensure fairness.
• Fairness is not exact equality. Do not set this
  expectation.
• Establish expectations of variability
• Never reward bad behavior
• Give the bad shift to the complainer
• They will complain anyway
• Tell everyone that this is the rule

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So Sick Sally

• One resident calls in sick on one weekend shift
  every month. This usually coincides with a
  weekend visitor.
• What do you do?

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So Sick Sally

• Standards of Professionalism
• Inherent ethics, plus
• Rules
• Penalties
• you cannot penalize me for being sick
• Expectations
• your clinical education requires X hours, Y
  patients, Z experiences. We would never dream of
  shortchanging you.
• Follow through.

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The Case of the Reluctant Patient

• A 43 year old African American man came to the ED
  with severe pain from an incarcerated hernia. In
  the pre-operative holding area, he refused
  surgery. He did not want to be discharged, he
  just said that he did not want surgery.
• The surgeon sent him back to the ED to be
  discharged.

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Gain insight first

• How do we display courage, justice, prudence,
  temperance?
• We need more information
• From the patient
• From the surgeon
• Good facts and good ethics will win in the end.
• Negative emotions are a separate problem,
• Do not become part of the problem.

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Trauma Tom

• A tense, but quiet disagreement occurred between
  the ED attending and trauma attending when it was
  suggested that a patient be kept in the ED for
  several hours of observation instead of being
  admitted.
• When the ED attending could not get the trauma
  attending to admit the patient, the ED attending
  said, You are just a big fat f---ing baby.

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Trauma Tom

• Register disagreement respectfully
• Find an opening, a negotiation point, a need
• Ask questions
• Find allies
• Set standards
• Identify accountability
• If you argue, your behavior becomes the issue and
  the real issue is lost.

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Late, libelous Laura

• One ED resident always shows up 15 minutes late
  to clinical shifts. After the off-going resident
  leaves, he then disparages the prior doctors
  work.
• The residents are tired of this and want you to
  make him stop.

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As a practical approach

• Suggest written behavioral standards
• Collegiality how we are going to treat each
  other?
• Citizenship what is our duty at shift change?
• A good retreat topic
• Attach rewards/punishments
• Evaluate each other
• Peer feedback
• Do not criticize facts are facts

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Seek understanding, offer to help

• Do not criticize, seek understanding instead
• Can you help me understand
• I dont know what you are talking about.
• Say This is affecting you deeply.
• What can I do to help? I will do whatever I can
  to ensure that you regain a positive reputation
  and meet the standards.
• Your anger is your enemy
• Having standards avoids you being the bad guy.

The Golden Mean of justice, prudence, temperance,
and courage
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Late, Libelous Larry

• The residency director calls her in for a meeting
  and threatens probation.
• The resident is asked to maintain a log of
  arrival times.
• At the next meeting, every shift arrival time is
  noted to be exactly at the required minute.

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It is not only the crime, but the cover up...

• Watergate
• Clinton
• Enron/Anderson
• The Catholic Church
• and maybe you???
• Even when a little lie looks like the right way
  out,
• NEVER EVER LIE.

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The tipsy tern

• You are on duty and overhear the nurses talking,
  laughing, and joking about an intern, on duty the
  night before, that they thought was drunk.
• He kept sitting with his forehead in his hands
• He smelled funny
• He talked, walked funny
• He seemed confused

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Multiple components

• The behavior of the nurses
• What do you say about the content, place, and
  time?
• Thanks for bringing this up, it could be really
  serious
• I need to hear about this, please take it
  seriously.
• Thanks for bringing this to my attention, I am
  going to follow through.
• Issues with the intern
• Is this your issue?
• Find a trusted superior.

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As a practical approach

• Assess for stress and burnout
• Be sure to care for the caregivers
• What does a person with drug/alcohol dependence
  look like?
• What does a suicidal person look like?
• Sometimes the ED is a refuge

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High Standard Harriet

• The nurses complain that they are mistreated by a
  resident
• The physician states that she never mistreats the
  nurses, they just do not like it when she asks
  that vital signs be completed, that patients be
  undressed, and that basic nursing practice be
  acceptable.

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High Standard HarrietMultiple issues

• Multiple issues
• The requests being made
• How the requests are made.
• How Harriet is feeling
• Solution Inspire your team to higher levels of
  performance
• Through high regard.

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Leading nurses, consultants, team members
requires a relationship, high regard, high
expectations, supportiveness

• How are you doing?
• Thanks for...
• Your work is really important...
• Nice to see you (accompanied by a firm
  handshake)
• Give the person a cookie
• A little bit of relationship goes a long way.

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Gain insight first

• How are your patients
• How are things?
• Can you explain to me?
• How are you doing tonight?
• How is everything on your service?
• What are your thoughts about?

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Challenged Charlie

• Your intern has no clue. She went to see a young
  woman with low abdominal pain, never ordered a
  urine or a pregnancy test, and wants to discharge
  the patient.
• The patient has classic signs and symptoms of an
  ectopic pregnancy

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You say

• Oh my goodness, you need 4 more years of
  education just to get stupid.
• Nothing, just roll your eyes and sigh.
• Why do you hate her? You are obviously trying to
  kill her. Why not go get a gun and make it a
  clean kill?

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Gain insight, offer truth, offer help

• (positive) I know that you are working hard/you
  are trying hard/you care a lot/we appreciate/You
  did X well, but...
• (feedback) But such patients need
• (positive) and your effort/attention is
  appreciated.

Sandwiching
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Be a good winner

• A 24 year old man presented with a proximal
  finger amputation. The resident on the hand
  surgery service did not respond to 4 pages. The
  hand surgery attending was called. The resident
  responded to the ED quickly, but clearly angry,
  demanding to know who called the attending. My
  pager never went off.

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Be a good winner

• My pager never went off. Do you say
• A. You are wrong, I paged you 4 times.
• B. You are a miserable liar, and lazy too
• C. Well, we will see about that (as you approach
  the secretary to prove the pages were sent)
• D. Thanks for coming down.

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• Courage set and maintain high standards. Avoid
  anger. Dont avoid conflict, but dont seek it
  either.
• Justice Be fair, knowing there is no equality.
  Recognize good qualities of others. Redirect
  those who are off course. Hold people in high
  regard.
• Prudence Be thoughtful, caring, wise. Develop
  allies, nurture relationships.
• Temperance Avoid anger. Be predictable, patient.
  Be imperturbable.