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Candid reflections on bad behavior

Posted Nov 18 2009 10:00pm

by Dr. Kenneth H. Cohn

I have been thinking a lot about the 2009 ACPE Doctor-Nurse Behavior Study, which surveyed 2,124 physicians and 696 nurses. It found that nearly 85 percent of respondents experienced degrading comments at work, including yelling (73 percent), cursing (49 percent) and refusing to work together (38 percent).

As I wrote in my first book, Better Communication for Better Care, confronting a physician creates fear, but in retrospect, we all benefit from early intervention to avoid lapses in patient care suffers and even burnout. The reason why I use the term "in retrospect" will become apparent after I relay my own humbling experience (from a previous century):

I was a third-year surgical resident in the Emergency Department at a busy urban hospital. I had been on duty for 20 consecutive hours when a man who had been working on his car was brought around 3 a.m. with battery acid covering his face and eroding his skin.

Calmly, I asked the triage nurse where the nearest eye-wash station was located.

"We don't have one," she replied.

"Where is the nearest shower?" I asked.

"We don't have one," she replied.

"Then, I will take him to the changing area in the operating room (20 yards away), where they have a shower to wash the acid off."

"Dr. Cohn, our protocol does not allow an acute patient to be transported out of the ED," she countered.

That was when I lost it. Instead of saying, "Let's take care of this patient's acute needs to get the acid off his face and discuss revising the protocol in the morning," I let her know what I thought about her protocol and took the patient to the OR changing room shower.

When I returned with the patient, I learned that I had been reported on for swearing at a nurse in front of a patient. I counted at least five bleary-eyed administrators with clipboards taking statements from the triage nurse and everyone else who had been nearby.

I cannot remember the number of times that I apologized for my behavior and how many times I was admonished and reminded about how, in times of crisis, the team leader needs to remain calm. I felt that my behavior was under a microscope for the next year. It was truly a low point of my residency.

I responded by changing my behavior and relating that humbling incident to teach incoming residents why they should not fight at night.

A few decades later, I learned about Marshall Rosenberg's Four-Step Model on how to give and receive feedback in conflict situations. I summarized it in a chapter of my book entitled, "What Physicians and Administrators Can Learn from Nurses" as follows:

1) Observation: "Yesterday, there was a problem with..."
2) Emotional response: "I am feeling concerned about..."
3) Needs: "Because I need..."
4) Request: "In the future, would you be willing to...?"

I feel that the predominant leadership behavior I witnessed during medical school and residency centered on command-and-control, win-lose interactions. Not until MBA school did I learn that women are socialized to value relationships and that leadership styles described by Daniel Goleman that involve vision, coaching, and democratic and affiliative approaches build teamwork better than the approaches I had witnessed.

As the current ACPE CEO Barry Silbaugh wrote: "Because of our traditional roles in the health care hierarchy...physicians need to be role models of effective teamwork and leadership under stress for physicians in training, for other members of the healthcare team, and for our patients."

What do you think?

* Do you agree with Goleman that emotional intelligence matters at least as much as IQ in predicting career success?

* Do you believe that conversations can be our most effective weapon in eliminating disruptive behavior among healthcare personnel, as described by Joseph Grenny in a manuscript that accompanied the ACPE study, entitled "Crucial Conversations: The Most Potent Force for Eliminating Disruptive Behavior"?

* Finally, do you agree with the seriousness of this problem, as exemplified by the 2005 report Silence Kills, in which more than half of the healthcare workers surveyed witnessed coworkers break rules, make mistakes, fail to support, demonstrate incompetence, show poor teamwork, disrespect them, and micromanage, and yet only 10 percent felt confident of their ability to raise concerns with co-workers?

I welcome your thoughts and comments.

Ken Cohn is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations.

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