Messy moments: Disputes over care

The infectious disease MD specialist is really angry over how his patient is being treated in the ICU. Everyone ignores his orders.

• He blasts the nurse in front of the patient’s family.
• He asks how the situation happened then talks right over him – leaving no room for explanation.
• He insists loudly that the nurse start a different treatment immediately.
• He treats the nurse – and other caregivers – like they are the patient’s enemy, not the virus.

An MD colleague passing by takes the specialist aside. He suggests his behavior was disrespectful. It prevents him from hearing information about his patient.

The specialist says,

“I’ve got this. They did it wrong.”

He walks off in a huff.

What would the specialist like to happen here? To create the best care possible for his patients

The specialist deeply cares about being an excellent doctor. So he cares about getting it right.

• He also feels ignored or worked around.
• The nurse undermined his expertise and authority.
• He now distrusts everyone. He has to do everything himself!

AND

Extraordinary workloads and soaring uncertainty, complexity and turmoil make it impossible for any one person to do everything. The specialist depends on the care group to bring their smartest, most attentive and most generous selves to his patients.

<what might the specialist do now?> It’s time to care: Steps toward better quality patient care

1. PERSPECTIVE-TAKING: What was that situation like for that nurse?

• He (and likely others) feels disrespected and threatened.
• If staff don't feel safe from negative consequences, they won’t ask questions or voice concerns.
• They feel their autonomy threatened. They may fear for their jobs.
• They withdraw and withhold potentially critical information about the specialist’s patients.
• It’s tinder for resistance and for medical mistakes – endangering patients.

2. BUILD better relationships. They’re critical to your patients’ welfare.

a. The next time one of your care group says something to you:

• Stop, take a breath, look them in the eyes and show them you’re listening. Then truly listen.

TIP: Do this every time you want to tell those in the care group something this week.

b. The next time you want to say something to one of them – particularly if it’s criticism - ask if they have a moment to talk.

• If so, take them to a space with privacy. If not, arrange a time and place.
• Clarify in a non-judgmental way the problem you saw.
  • “I’d like to talk with you about the patient’s concern about…”
• Ask (before you speak!):

• Notice what if anything happens in that moment with the other person.
• If you are willing, apologize to this nurse. Genuinely.

TIP: Do this often so people come to expect that you want to know their perspective. It will take a while before they believe this.

c. Call a care group huddle before the next patient care shift. A meeting is a powerful way to change expectations of a group.

• The huddle starts with everyone saying their first name, role and the way they feel right that moment. This brings their voices into the room and introduces them to one another. The specialist goes last.
• Introduce the new expectation(s):
  • Tell them how you depend on them as a group and as individuals
  • Apologize if your previous behaviors may have pushed them away or hurt them. It may not be easy. It is powerful.
  • Tell them that you appreciate and truly want their full participation.
    • Have already decided what one thing you will do THAT shift that will better show that you want to hear what they have to say. Even a small phrase or gesture changes things.
• Continue with huddle ‘business’ reviewing patients on the schedule, possible problems and solutions.
  • Appreciate each person when they first say something. I’m glad you brought that up.” “It’s good to know you are thinking about X.”

What does this do for the specialist?

• He’s more likely to get candid, critical information from other corners of care
  • The specialist’s barbs and bossy behavior bemeans others and triggers difficult emotions - embarrassment, anger, shame. Others certainly feel disrespected. They feel demoted. That can spoil their ability to work effectively with others.
  • Rapport with the care group proves vital to gain candor and timely information
• He knows people will contact him when it’s important.
• Patients’ care will improve even more if the care group feels valued and part of the care project. They’ll pitch in despite their overwhelming to-do lists. Fewer things fall through the cracks.
• He improves the patient experience.
• When the care group believes the kinder behaviors are really the norm, they want to work with him. That matters hugely in a moment when clinicians are ‘quiet quitting’ and leaving in droves.
• He gains greater peace of mind because he knows the group is attentive to his patients when he is not there.

Nance Goldstein, MDc, ACC, PhD, partners with physicians as a leadership coach to find ways through today’s tough times and enjoy medicine more.