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Chapter 5. Cultural Transformation in Professionalism
Jo Shapiro, MD
The Center for Professionalism and Peer Support (CPPS) at the Brigham and Women’s Hospital (BWH) was founded in 2008, growing out of a sense that a cultural shift within medicine was needed. We were seeing more and more over-worked, stressed physicians facing a steady increase of responsibilities and expectations, often without the resources to support them. We first formulated the Center’s mission: to encourage an institutional culture that values and promotes mutual respect, trust, and teamwork. We then developed several core initiatives to support our mission. These include: peer support following adverse events, unanticipated outcomes, or other emotionally stressful events such as caring for trauma victims; disclosure coaching; defendant support; teamwork and effective communication training; wellness programs; and a professionalism initiative. Our professionalism initiative1 is the focus of this chapter. We feel strongly, however, that the support and training offered through all of our programs is central to enhancing a supportive and cohesive professional culture within our institution.
Changing institutional culture is a lofty goal. We approach this challenge with the understanding that the culture of an institution is something that we define and redefine every day. It is not primarily about what is written in a policy or a code of conduct. While those things can be vitally important, we recognize that the culture of our workplaces is organic and is expressed daily though our actions and values. To make meaningful culture change we need to be present and active with both support for and education around professional behavior.
Professionalism education and training
We define professionalism as behavior that helps build trustworthy relationships. This means all relationships—between a clinician and patient, a physician and nurse, any health care team member and a student—are important.
In building our professionalism initiative, we understood the importance of setting expectations as well as providing education and training. In order to raise awareness about behavioral expectations as well as about our training and support efforts, every physician at BWH from intern through senior faculty is required to participate in our interactive simulation-based professionalism training sessions. We partnered with Employment Learning Innovations (ELI), an employment law company, to design the curriculum using video scenarios with an accompanying workbook.
One of the video vignettes features Dr. Mills—a well meaning (we assume) surgeon who finds himself significantly under-resourced. We have all had moments when we feel highly stressed for multiple possible reasons such as having to be in two places at once, feeling as if those around us are under-performing, needing lab results that are unavailable, or not having access to important patient information. This is where Dr. Mills finds himself, and he behaves in a way that seems completely inexcusable and horrendous. During the session participants identify the disruptive behaviors being exhibited—what specifically Dr. Mills did that was unprofessional—and we talk about how he could have handled the situation differently. In addition, we role play giving Dr. Mills feedback about his behavior. In facilitating these discussions we acknowledge that it’s very easy to sit in any training session and believe that we ourselves would never behave in this unprofessional way; we point out that most of us are, in fact, capable of this kind of behavior. Given a situation with stressors such as poor resources, sleep deprivation, or overwhelming responsibility, most of us are at risk of behaving somewhat—or even completely—unprofessionally.
These professionalism sessions are just the beginning of an institutional conversation. Our Center has other resources for ongoing professional development, such as training in conflict and stress management as well as workshops to help clinicians develop skills in giving feedback.
In addition, we emphasize that when interacting with a colleague who is exhibiting disruptive behavior, there are other options beyond reporting the behavior. Ideally, we’d like to be training people to address bad behavior when they see it—to have a clear and respectful conversation with the person about the behavior at issue. Yet we recognize that in a hierarchical environment it will not always be or feel safe to have these direct conversations; we therefore must have a process in which people can come forward and voice their concerns. While our institution has a hierarchy of responsibility, we do not have a hierarchy of respect: we are all equal when it comes to deserving respect.
Handling professionalism concerns
We cannot expect people to behave respectfully or feel supported in a culture that does not hold people accountable for their behavior. If anyone has a concern about a physician’s unprofessional behavior at our institution—the person with the concern (the reporter) can be a student, nurse, secretary, faculty member—that person can address the concern through the Center. We first meet with the reporter to listen, discuss, and decide together on a plan. One of our guiding principles in handling these concerns includes being as discreet and respectful as possible to everyone, including the person about whom the concerns are reported (the focus person).
As a next step we generally like to speak with other people who work with the focus person, and we make sure that the reporter is comfortable with our doing that. We explain that this inquiry is not a 360° evaluation—this is a very important point. We are specifically investigating one aspect of someone’s professional behavior. If the reporter agrees, we solicit the names of people he or she recommends, and we then perform multisource interviews. We assure the reporter and the people we contact subsequently that we have a safe system that focuses on the specific problematic behavior. We gather data and then bring this information to the focus person’s supervisory physician, such as a chief or chair, to get his or her perspective.
How the supervisor responds is variable and determines our next steps. Sometimes he or she is well aware of the problem but has not taken any action to remediate it. Generally the supervisor does not know how to address the problem. It stands to reason that supervisors have had trouble giving the focus person feedback in the past, as few leaders have had training in giving difficult feedback. We then agree on a plan that generally involves our meeting with the focus person together. This meeting accomplishes two things. First, it provides on-the-job training for the chair or chief to see how to conduct these difficult feedback conversations. Second, the focus person responds differently when his or her supervisor is there to support the importance of having this conversation and of holding the person accountable for his or her behavior. A critical point that we stress in this conversation is the unacceptability of any retaliatory behavior on the part of the focus person.
We have developed an algorithm for giving frame-based feedback2 that provides the basic format for this meeting with the focus person. First we state the specific types of behavioral concerns. It is important to remind the focus person that this is not a performance evaluation. We are not suggesting that this problematic behavior is all that defines the person’s career. After clearly stating the specific problematic behaviors and why they are concerning, the second step of the algorithm is to elicit the focus person’s frame—how she or he understands the problem. The third step of the algorithm is to match the discussion to the focus person’s frame.
The central tenet of this feedback technique involves using the principles of autonomy support—having the person tap into his or her intrinsic motivation to change behavior. We may try to draw out the focus person’s empathy by saying something like: “This is how many people feel when they work with you. Did you know that this is the impact your actions have on your team?” Sometimes this leads to a discussion of systems issues that the person feels are contributing to his or her behavior patterns. We communicate clearly that we do understand the difficulties, but that these do not obviate personal accountability for the behavior. This is not to say that systems issues are not real or contributory, and we do not ignore them when they are. We have to be willing to advocate for people in addressing systems changes, but at the same time people need to understand that they still must behave respectfully despite real situational challenges.
The focus person might, alternatively, frame his or her angry or disparaging behavior as trying to get better patient care. In fact one of the most frequent reactions to a discussion of unprofessional behavior is: “I am a patient advocate and I need to behave this way in order to protect my patient.” We respond to this by explaining that we understand and respect that commitment to patient care, and we recognize the person’s reputation for being a patient advocate. We point out that what the person likely doesn’t realize is the correlation between unprofessional behavior, problematic teamwork communication, and negative patient outcomes. We explain that the individual’s behavior actually puts patients at risk; that this is a safety issue. We explore the fact that the impact of that negative behavior is in direct opposition to the person’s intent. This is an example of how we match the discussion to the focus person’s frame as a way to encourage intrinsic motivation for behavior change.
Another example of matching the discussion to the focus person’s frame is when the behavior in question involves sexual harassment. Sometimes the person’s response is defensive, denying responsibility. For example, the focus person might explain why the behavior has nothing to do with him or her; he or she explains that it is really about someone trying to retaliate for an unfairly perceived slight. We respond by explaining that regardless of why the person thinks the behavior was reported, the important point is that the behavior can never happen again. We will then send the focus person to outside counsel for a discussion of the extensive legal trouble that can result if the behavior continues. This approach generally motivates behavior change.
With this same complaint, a different response we may see is embarrassment and apology. The person thought he was being friendly; his frame might be that he was simply making a clumsy attempt at connecting with a colleague. Yet upon reflection, he understands why the behavior is unacceptable. Our response to this frame is quite different from our response to the person who does not accept responsibility. To this person we explain that while we do understand his intent, the behavior made a colleague very uncomfortable. This level of discussion and intervention is generally enough to correct the problem; outside counsel is used just to reinforce the legal ramifications.
One challenge in giving difficult feedback is the unpredictability of people’s reactions and the reality that we cannot control these reactions. The challenge is to work with whatever comes up and be flexible in the response, depending on the focus person’s frame. Our process is therefore both generally consistent and completely personal, depending on the person’s frame and reactions to the feedback. In responding, we also must take into account how egregious the behavior is and how long it has been going on.
These examples demonstrate that we hear a somewhat familiar pattern of responses from people when giving feedback. Regardless of whether the focus person has personal insight, our job is to explain that that person must change his or her behavior if he or she wants to stay at our institution. This must be the bottom line. The person does not have to agree; our job then becomes managing people who do not recognize the importance of changing their behavior.
Most importantly, we all must be held equally accountable. Not holding everyone to the same behavioral expectations allows for a double standard that can be more damaging than doing nothing at all. Our accountability process is, among other things, designed to address egregious or repetitive unprofessional behavior. Without remediating this kind of behavior we cannot take our work to the next level—working to promote healthy team dynamics and helping individuals communicate effectively with one another. The reality is that there simply are some workplace bullies—people who do not respond to feedback and do not recognize the destructive effects of their own behaviors. These people—a small minority—tend to only respond and begin to change when they are threatened with external consequences such as losing their positions. When presented with the need to change their behavior some people refuse to accept personal responsibility; they respond with denial, anger, and threats that can be extremely demoralizing and damaging to an institution’s professional culture. This is why our process must account for both types of individuals. In order to feel confident that our program could manage the full spectrum of problematic behavior it was, and still remains, critical that we have the unwavering support and backing of our institutional leadership. Dr. Gary Gottlieb, BWH President at the time of the Center’s founding, as well as our current President, Dr. Elizabeth Nabel, have been unequivocal in their commitment to stand behind our work.
Our work with the focus person is entirely behavior-based. We have learned not to go down the rabbit hole of trying too hard to understand the potential reasons for the person’s behavior. For example, we do not explore the possibility that the person has a personality disorder or should be evaluated. We found, early on in this work, that this approach resulted in significant distraction from the real issue at hand, and we found ourselves over-referring in an attempt to diagnose the reason behind the behavior. As a result, we have shifted toward a focus on the behavior itself and away from attempting to diagnose. This is not to say that we don’t offer people resources, because we do. And if we find that someone is impaired, this is a different matter: in these cases we are very quick to refer them to Physician Health Services, an outside professional group that evaluates physicians for impairment. But we are much more frequently called in to address repetitive unprofessional behaviors without an obvious underlying behavioral health issue.
Another area of caution, in addition to being careful not to “treat” the focus person as we might a patient, is the concept of cultural relativism. People sometimes point to cultural excuses or explanations for their unprofessional behavior. Our response is quite clear—it’s not relevant that this behavior is tolerated elsewhere; you cannot behave that way here. We describe the problematic behavior to the focus person, explain that the behavior needs to stop, and describe the behavior we expect going forward.
One of the biggest barriers we face in this work is, interestingly, too high a tolerance on the part of supervisory physicians. They may be overly concerned about the focus person’s career; all they can see is a colleague whom they hired and have devoted considerable time and energy into helping develop. As a result, there are times when we at CPPS are “holding” all of the damage and sadness that results from this bad behavior. Our role at that point is to help the supervisor understand the degree of destruction caused by the unprofessional behavior. In this way, the suffering of those people impacted by the unprofessional behavior is made visible to the leadership. We do this with the important support of our chief medical officer (CMO) Stan Ashley, MD, as well as our legal counsel for the hospital, Joan Stoddard. Sometimes in particularly intractable situations it can make all the difference to have the CMO in the room to support our process. We have also formed a professionalism advisory committee that meets quarterly to review cases. At the end of the day, this cultural transformation can only happen with strong institutional support.
Since 2009 we have had 270 individual physicians about whom concerns were raised (and there may have been more than one concern per person) and ten instances of our assisting with team dysfunction. We categorize the problematic behavior broadly as follows: demeaning, angry, uncollegial, shirking responsibilities, hypercritical, unprofessional patient communications, clinical dyscompetence, misconduct, and sexual harassment.
One of the central tenets of this process, and what makes it functional and useful, is that we all must be held accountable. Our goal is not to get rid of people; our goal is to motivate them to change their behavior. Yet we must, at the same time, demonstrate the accountability of this process in our insistence that physicians with repeated and egregious unprofessional behavior cannot remain at BWH. Since 2009, twenty-five physicians have left BWH due to professionalism concerns, and six were demoted from positions of authority.
We recognize that while holding each other accountable, we also need to support one another. People perform best in a supportive environment. We therefore have developed programs in which we have physician and nurse peers reach out to clinicians in times of emotional distress, such as being involved in an adverse event or when facing a lawsuit. The trained peers are there to listen, empathize, and offer suggestions for healing and recovery. One study we performed showed that nearly ninety percent of physicians wanted to talk to a physician colleague, not a mental health professional, after an adverse event.3 If a physician needs to make a disclosure to a patient, we have disclosure coaches who work with risk management to help the physician prepare to have compassionate and transparent conversations with the patient and family, and who also understand the emotional challenges facing the physician.
In this context of supporting and being there for each other, we believe that our professionalism initiative and other support programs are all necessary and beneficial elements of the positive change we seek to make within the institution. Culture is manifested by how we speak to each other, our ability to encourage staff to speak up when someone is not behaving well, and what we do to support one another. Our support and accountability programs demonstrate that the institution values and respects its employees. I will end with a quote from Vaclav Havel about hope, which he believes is “not the conviction that something will turn out well, but the certainty that something makes sense, regardless of how it turns out. The hope of fellowship, and kindness, and service.”
I would like to thank Pamela Galowitz for her invaluable help in editing this chapter.
- Shapiro J, Whittemore AW, Tsen LC. Instituting a culture of professionalism: The establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf 2014; 40: 168–77.
- Rudolph J, Raemer D, Shapiro J. We know what they did wrong, but not why: The case for “frame-based” feedback. Clin Teach 2013; 10: 186–89.
- Hu YY, Fix ML. Hevelone ND, Lipsitz SR, et al. Physicians’ needs in coping with emotional stressors: The case for peer support. Arch Surg 2012; 147: 212–17.
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Updated on May 19, 2015.
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