Dear Crucial Skills,
I am a physician and I have to admit that, although I am respectful toward my patients, I have great difficulty when I am dealing with fellow physicians and nurses who, in my opinion, don’t seem to know basic skills to care for our patients.
My frustration with their ignorance often manifests itself not necessarily in the words I choose, but more in the way I voice my opinions and in the tone of my voice. I am dealing with people’s lives and am frequently pushed to go too fast. Often I am sleep deprived or emotionally exhausted. These things make it even harder to be as respectful as I would like to be with colleagues.
I totally understand that my lack of respect just makes the situation worse, but I don’t know how to deal with ignorance in people who I think should know better and who often have egos that prevent them from listening very well. Please help.
Dr. M
Dear Dr. M,
Thank you for writing such an open and revealing letter. It’s clear you’ve thought deeply about this concern, and your good intentions shine through. I see three elements to your situation:
1. Crucial Moments: In key situations, you are both emotionally exhausted as well as in the middle of a high-stakes medical issue.
2. Primed Stories: You’ve become especially sensitive to certain problems: caregivers who “should know better” or “have egos that prevent them from listening.”
3. Visible Actions: You show your frustration—not in your word choice, but in the way you voice your opinions and the tone of your voice.
I can imagine I might do the same. And yet, as you note, these lapses just make the situation worse.
You’re already motivated to maintain a respectful relationship and you already control your choice of words. However, you realize your frustrations are seeping through anyway and damaging relationships. What more can you do? Here are four tips you might try.
1. Identify the crucial moments. The more you can do to recognize when you’re in these moments, the more prepared you will be. Take a pen and paper and map out when, where, and with whom you are most likely to experience these crucial moments. Focus on the moments where you are most at risk of being disrespectful to others.
2. Apply the skill “master my stories.” It sounds as if, when you are emotionally exhausted, you are especially apt to use “villain stories“—to interpret others’ actions in a negative way. And when you judge others, the verdict shows on your face.
James Gross, the head of Stanford’s psychophysiology lab, is the leading researcher in a field called “emotional control.” According to Gross, we control our emotions in two very different ways. One way is to suppress them—we rage inside, but keep our faces calm. Gross explains that this approach results in immediate cardiovascular costs as well as a variety of long-term negative impacts. Living your life behind a mask is not good for you. In Crucial Conversations, we call this “going to silence.”
The second way we control our emotions is through reappraising the events that have made us angry and re-evaluating the situation. This second strategy is the “master my stories” approach we teach in Crucial Conversations. Gross says people who use this approach are more successful in controlling their emotions, as well as happier and healthier over the long term.
So, what do you do? Right now, while you’re calm and relaxed, ask yourself the following questions: “Do I really believe the people I get frustrated with ‘should know better’ and ‘have egos that prevent them from listening’? Or are my stories symptoms of the pressure-filled moments and emotional exhaustion?”
If the problems are real, address them using your crucial conversations skills. But don’t wait until the crucial moment, when you are exhausted. Instead, select a time when you can have high-quality dialogue.
If you decide your stories have more to do with the pressure of the situation and your exhaustion, ask yourself how you would like to handle these frustrating moments. Assume the caregivers around you are reasonable, rational, and decent and that they are trying to do the right thing. Then ask yourself, “What can I do to help them help my patient?”
3. Prepare before the situation. It’s always harder to use these skills in the heat of the moment. So establish a rule for yourself and decide now what you will do and say when you find yourself in that situation. For example, if I’m in one of my crucial moments and feel intensely frustrated, I will say, “I know we both want what’s best for the patient. Let’s each share our perspective.” Create a rule, pick the words that will work for you, and write them down.
Establishing these if/then rules in advance is very powerful, especially when the moments you need them involve a lot of stress and competing demands. They work in two ways. First, they highlight the crucial moments, making it more likely you’ll recognize these moments when you’re in them. Second, they help you move from “consciously competent” to “unconsciously competent.” Instead of having to think about and make decisions in the moment, you act on the decisions you’ve made in advance. (Peter Gollwitzer at NYU has published several interesting studies showing how these rules work).
4. Enlist support. Ask your colleagues to help you recognize when you’re starting to go over the edge. An anesthesiologist I respect told his team, “In general, please call me by my first name, Jim. But if you think I’m becoming intimidating or not listening, then call me Dr. Smith. That will be our signal.” I like this cue because it’s subtle and respectful. Making this request is also a powerful way of convincing people that you really want to do what’s right.
I hope these ideas help. Let me know how it goes.
David
I applaud this physician. As a nurse, I haven’t had the experience of working with too many physicians who really try to have productive relationships with their staff/colleagues. Secondly, I really like the approach of the anesthesiologist who requests folks call him by his professional name if he is inappropriate. My husband adopted this approach long ago (we just had our 36th anniversary!) by calling me by my Mom’s first name when I get obnoxious. I think it’s only been 3 times that I can remember that he had to resort to this! But this worked!!
As an medical professional that has experienced many crucial conversations…or lack of, I feel compelled to comment. I applaud the writer for recognizing that the lack of showing respect can “make the situation worse”. As the study “Silence Kills” shows, these responses lead colleagues (especially nurse/physician relationships) to delay/prevent communication or toward “out of scope practice” that can harm or kill patients. Years of subservient roles and gender domination in the medical professions have led to a culture that can no longer be accepted, in a taxed healthcare system we find ourselves in. Patients are sicker, shortages of nurses and physicians increase demand on individuals, and quick availability of treatment, drugs..etc; along with the push to move patients through faster demands that we hold crucial conversations daily with each other. There is little time to discover and correct errors before they already occur.
As we all master our stories, we realize that many professionals do not feel that they are infallible and really do care for the patient as an individual. Just as many professionals are not “ignorant” of basic skills.. but still have to follow protocol and practice by calling the others at night for what seems like basic intervention. All professionals live on a sliding scale of knowledge, experience, and critical thinking; and we should be sensitive to this.
I like the recommendation in enlisting support, given by the MD; except that as an RN, I would typically have to turn it around and revert to addressing the MD by first name when a signal was needed. I found this to be more sucessful…of course as a male I can get away with it.
William Peoples BSN
Clinical Education Coordinator
My mother, a woman full of wisdom, told me “two wrongs don’t make a right.” It sounds like Dr. M. is justifying his behavior by using his colleagues who “don’t know basic skills.” As a reformed perfectionist and overachiever, I understand Dr. M’s frustration all too well. However, sustaining this attitude will only alienate you from people. You do have to change your stories. If you can clearly see the “ignorance” of the situations, then help your colleagues by sharing your knowledge and opinions. Let them know how much you care. Apologize quickly when you blow your fuse. You will need to master your stories if you want to build meaningful relationships with your colleagues. Doing these things will help you build a better team and improve patient care. Best to you!
On my commute home last night, I was mentally working through the same thing the MD was experiencing when a little voice inside my head asked me “why do you think you know so much more than they?”. Then seeing the reference to Maslows Competence model (“consciously competent” to “unconsciously competent”) this morning reminded me that pride slips in between these two levels and can wreck everything if I let it. Timing on your article was spot on for me. Thanks you. Good read.
Reading the Dr’s letter made me wonder if his colleagues were too tired to do the right thing. Also, is the doctor a perfectionist, or are they threatening the patient’s health? If not, let it go. If so, say something appropriately.
This is a tough one, right? I think what makes it so relevant is that we want to do the right thing, but then–in the heat of the moment–find ourselves violating our own best intentions. The key to doing the right thing in the heat of the moment lies in a.) cuing, so that you can prepare yourself; b.) establishing a plan or rule in advance, so you know just what you’ll do; and c.) PRACTICE! With time, the right actions will become more automatic.
I am a nurse who works with a doctor just like Dr. M and I’d like to give my perspective and how I approached my “Dr. M” successfully. I had a “Crucial Conversation” with my “Dr. M” and talked to him about how each of us on the team has something valuable to offer to the team, we all bring different strengths. I also talked about how the doctor comes with a wealth of knowledge he acquired through his years of schooling, that we don’t share. I asked him to stop and think of us as his patients and to treat us with the respect he gives his patients. I also reminded him of the ultimate business rule of never saying anything negative to colleagues in front of other team members, and especially in front of patients. I reminded him that regardless of how smart or stupid people are, everyone is entitled to be treated respectfully.(We did actually have a good conversation, just telling my part) He has been great since our talk, and actually came up to me 2-3 wks later and told me “thank you for talking with me that day!”
I hope this doctor realizes that if he is dealing with older nurses, they were trained to just bring the facts to the doctor and the doctor makes all the decisions and does the thinking. Or they might be retaliating because he’s treated them disrespectfully in the past.
Having worked in an acute care hospital setting for many years, I have worked with many physicians and health care professionals. Sometimes a physician who believes that others are “ignorant” and don’t know what should be done in a situation, is actually the one who does not know! We had a physician who repeatedly ordered certain treatments for patients with diagnosis “X”. These treatments had been shown to be ineffective and inappropriate for this diagnosis by the medical research in the preceeding five years. Different staff members tried to discuss this with him and he was given the research articles (which he threw away). At wits end, we finally asked if he would provide an educational session for staff on the treatment of this diagnosis. He agreed, and at the very beginning of his presentation announced that he had discovered that he had been using inappropriate treatment and proceeded to educate us on the treatment we had been recommending all along! I think you should have asked Dr. M to make sure that he was up to date on the latest evidence based practice himself, before assuming that he was correct in his assumption that others were ignorant and lacking basic skills.
I like tip #4 in this article. I am not in the medical field but I was looking for a respectful way that my son can communicate to me when he thinks I am not really listening or hearing him. So I think I will adopt tip #4 in that he can call my Mrs. Mom during those times and that will be my cue to stop and listen or at least tell him he was heard and have a conversation about it.