Grand Rounds-How to be a Better Surgeon, a Better Professional and a Better Communicator

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- Hello, ladies and gentlemen, and thank you again for joining us. We have a very special guest today, Dr. Steve Bogdewic. He's the Executive Associate Dean for Faculty Affairs and Professional Development at my institution, IU School of Medicine. He has also been a great mentor. He's gonna talk to us about a very, very important topic, and that's about being a better person, first, a better communicator, and then a better physician and surgeon. This is a topic that I think as a surgeon, we should pay a special attention to. Steve, I want to thank you for being with us today and please go ahead.

- Oh, you're more than welcome, Aaron. Thank you. As you can see from this first slide, it actually makes the argument that there's a root issue of communication that's critical to being a better professional, which then contributes to being a better surgeon. So I'm hoping that this talk will help everyone to consider some fundamental things that can enhance your professionalism, enhance the practice of medicine. I wanted to begin with this definition, because as much as we use the word "professional," we often don't have a shared understanding of what it is. This definition, professional competence is the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. Now, I've dissected this definition and I want to share with you a way of looking at it somewhat differently. If you look at this, I've highlighted some words. The words I've highlighted in red, communication, emotions, values, reflection, all of those have something in particular in common. They all speak to the phenomenon known as emotional intelligence. Now, what is emotional intelligence? It's not IQ. If you think about it, you're a surgeon. All surgeons have a substantial amount of IQ, or you wouldn't be in the position that you're in. So what IQ doesn't really do is differentiate much. In fact, the students of intelligence would say that it predicts school grades, but it's in fact, a non-predictor of success in life, maybe 6% of job success. So it's necessary, but not sufficient. Peaks in the late teens and only varies a few points over a lifetime. You really can't change IQ. Fortunately, you have it, so that's good. But what about emotional intelligence? In fact, it can be changed. There's no ceiling or limit to how emotionally intelligent a person can become. The definition we'll use then is that, emotional intelligence is an array of non-cognitive capabilities, competencies, and skills that influence one's ability to succeed in coping with environmental demands and pressures. Well, what might some of those pressures be? How about the surgical team that may have some challenging individuals on it? How about a surgery itself that's getting complicated and starts to sort of turn south on you? Or how about just change, change in your institution or in your new practice? How we handle those is a function of emotional intelligence, not IQ. And I underlined the word "skill" because the critical part of the message I want to leave you with today is that these are skills. You have mastered skills. Surgeons are skill masters. So there's absolutely no reason why, as a surgeon, you could not become very effective in your emotional intelligence, given that it is too a skill. What we do know is that self-awareness is the basic building block of emotional intelligence. Now, the challenge with the issue of self-awareness is where do you get it? How do you get it? Because it's virtually impossible to just sit in a room and become more self-aware. It just cannot happen. It happens through relationships. It happens by getting feedback from other people. And when we're talking about emotional intelligence and self-awareness, look at the general ability of an individual to perceive themselves. Here we have a scale of self-assessment, and if you look at the four quartiles, meaning that there would be somebody in the 25th, 50th, 75th and 100th percentile in their ability to assess themselves. Yet when we rate people, we see that the average person would say that they're in the average 50th or better in their ability to assess themselves. Actually, this becomes even more interesting when you look at physicians. And what would be the explanation for this? Why would physicians have such a high perceived sense of their ability? Well, two reasons. One; many physicians, surgeons are highly skilled. They have abilities that are exceptional in many ways. Secondly; and this is the one that I think is most critical, physicians are well intended. You then assess yourself based on your intention, which is honorable. I can only assess you based on your behavior. I don't see your intention, I only see how you behave. So sometimes that gap is problematic. Somebody challenges us for our behavior, and we look at our intention and we can't quite grasp where that concern or criticism is coming from. I wanted to run through five or six slides very quickly, because I think it's important to take this issue of emotional intelligence and argue that emotional intelligence is not just being nice. Look at this slide from the Joint Commission on Accreditation of Healthcare Organizations that says, what are the root causes of sentinel events in all categories? Look at what's number one, communication. And then things descend from there. Let's go to the next slide. Root causes of delays in treatment. The number one? Communication. Root causes in medication errors, communication. Root causes of ventilator events, communication. Root causes of perinatal deaths and injuries, again. Root causes of wrong site surgery. Root causes of op or post-op events. And we see here that orientation and training slightly nudges out communication, but communication is still very high on the list. So what we're seeing then is that this phenomenon of emotional intelligence, it's not about just being nice. It's about quality, it's about safety, it's about satisfaction, both yours as the provider and the patient's and the whole team. It's about productivity. It's about revenue. It's about the business that we're in. In the definition of emotional intelligence, I pointed out that I'd underscored the word "skill," and I want to come back to this and say that a skill is simply the ability to use one's knowledge effectively and readily in execution or performance. Here then are the skills, each one of which I'm going to briefly describe because these are the skills that comprise emotional intelligence. These are the skills that strengthen professionalism, and the skills that I think can make you a better, more effective surgeon. Feedback, listening, "I" messages, which I'll explain, nonverbal communication, and reframing or choice. So let's go through these each quickly. The first, feedback. What we said about self-awareness, which is the building block for emotional intelligence is that self-awareness can't come in a vacuum, it comes through feedback. Now, herein, surgeons have a problem. The problem they have is that in the hierarchy of healthcare there's a power differential between a surgeon and many other members of the team. People are not going to therefore automatically give you feedback. Rule number one, if you want feedback, you have to ask for it. You have to ask for it in a sincere way, and you have to be willing to receive it rather than be defensive. Because the minute you're defensive, you teach people that you really didn't want that feedback. All of the sub points here are the very things that we teach our faculty in giving feedback to learners, to their students or residents or fellows. It should be related to agreed upon goals. So if you want your surgical team to give you feedback at the beginning of an operation, if you were to say, "I'd really appreciate you giving me feedback on X," on some particular part of what's happening, be specific. Feedback can reinforce positive outcomes and behaviors, can provide guidelines for improvement. Timely, means that the sooner you ask for feedback near the event that occurred, the better the feedback you're going to get. It should be descriptive, not evaluative, and include an action plan. Sometimes the person giving you the feedback is not really able to generate that. That would really be up to you. The second skill, I would say that listening is, without question, the single most important emotional intelligence skill there is. I take my students into the hospital, first week of medical school and give them a room to interview a patient. I take eight of them. At the end of their interview, I say to them, "Before you leave, ask the patient what one thing you should master so that you can be the best doctor you'll ever be." And we go to lunch afterwards, and when I debrief them, I ask them if they asked that question. And of course, they're medical students, they all want to do well, so they all said, "Yes." And then I asked them, "What did the patient say?" And often, more often than not, eight out of eight of them will say, "The patient said, listen." So it's not just patients for whom listening is powerful. It's powerful with colleagues, it's powerful with team members. The particular skill, active or reflective listening is about being able to paraphrase or say back to someone in your own words what you heard that person say. Now, think of the power of that. Think of a child who walks into the home and turns to the parent and says, "I got in a fight today." Reflective listening would simply say, "You got in a fight?" Now think of it. As simple as that was to say, what might the average child hear? "You got in a fight? Don't you know that fighting is not..." That's the end. Once we start down that road, communication is over. There's no listening. The opportunity is taken to chastise or punish and listening ended. So the power of active or reflective listening is number one, it gives the other person a chance to hear what they're saying and think about it. It also indicates to them that you really are paying attention because you're communicating exactly in some way what you heard. It's nonjudgmental. The judgmental statement to the child would be, "You got in a fight today?", as opposed to, "Oh, you got in a fight." And then let the child say, "Yes, it was with this kid," whatever, but they're not going to open up and tell you more if you can't reflect in a non-judgemental way, what you've heard. I'm going to talk a bit more about listening at the end, because again, I think it is the single most important of the emotional intelligence skills. "I" messages. What's an "I" message? I've listed a sample on this PowerPoint to illustrate an "I" message versus a "you" message. Now, the first part of this slide shows you the formula. It's using literally a statement that starts "I," as opposed to one that starts "you." Now think about the "you" message. The "you" message looks like this. "You make me so angry." And nobody likes to have the finger pointed at them. So think about this example, "you make me so mad when you don't call me!" What if you said, "I get worried and upset when you're late and don't call, I want you to call because I want to know you're okay." That has you taking responsibility and not pointing the finger to the other person as if they've done something wrong. Again, under the larger umbrella of emotional intelligence and effective communication, an easy way to open up a channel between you and the other person is not to use an accusatory term like "you," but to use an ownership term like "I." "I" messages are simple to use, a skill when practiced that can become very common for you. The next is the power of the non-verbal dimensions of communication. Words only are a small part of a given exchange. Now the exception to that is in clinical medicine, where words are technically important and technical jargon carries a great deal of meaning. When someone uses a particular medical phrase. But in routine communications, say with your nurse, about how that particular operation went, the tone and body language you use is 90 plus percent of what that person will hear. Well, let's use our little example here. The sentence is, "I did not say she stole the book." Look how easily we can change that with just some tonal changes. "I did not say she stole the book." I mean, someone did, it wasn't me. Or "I did not say she stole the book." We all know she's a crook and stole something, but it just wasn't the book. So the power of how we punctuate things with tone and body language can often determine primarily the outcome that we get. And so, while you may be thinking about the words that you used, the other person is responding on a subconscious level to your tone and body language. Moving right along. I talked in the list of emotional intelligence skills of reframing or exercising choice. Now here we have an illustration of an action that then leads to a consequence. I illustrate this using a common humorous example. My father. I claim that my father is very well known because he invented road rage. So here's the action. Somebody violates his space on the freeway and what's the consequence? He gets very angry. And if you were to say to him, why are you so angry? He would look at you like, what do you mean? This person was shaking their fist at me and blowing their horn. I mean, that made me angry. And I said to him one day when he was 70 years old, "I don't think it works that way." And he looked at me with that fatherly smile and said, "well, then how does it work?" And I helped him to appreciate this next graphic, which is, it's not the action that results in the consequence, it's your belief about the action. Now, in the example I gave you, what would my father's belief be? My father's belief is this, no one has a right to violate my space on the freeway. Now, if that's his belief and his space is violated, he'll get angry. But we discussed the possibility of upgrading his belief to, I would prefer my space not be violated on the freeway. That's probably going to happen occasionally. He incorporated that and months later, when we talked about this, he found himself laughing over the fact that he was able to take something that he had been believing for so many years of his life and only when someone made it clear to him, he had a choice. The reality is we always have a choice. If we point the finger outside of us and claim that that person or that situation made us feel a certain way, we've surrendered all choice and empowered that person or that situation. We can regain that power. We don't have to be jerked around by some situation or person as long as we're willing to accept the fact that it's my belief, it got me into this difficulty, not what occurred out there. This too is a skill and with practice you can become quite good at it. I wanted to bring some closure to this then by going back to the notion of active listening and amplify it just a bit. I've put in this quadrant here, active silence. Think about it. Eye contact versus rolling your eyes. Facial expression, not frowning or grimacing. Head nods, an open posture. All of those can be an invitation for someone to talk more. I have encouraging invitations. Sometimes these are called minimal encouragers. Just saying something like, "Uh huh, I see." The one I use all the time with colleagues is "please say more, say more." Just that phrase alone, it invites someone to continue talking. It shows him that you are interested in knowing more. We talked about paraphrasing or reflecting. "You got in a fight, oh. You got in a fight today." And then reflecting feelings. You seem anxious. You sound sad. Giving the person chance to comment on an emotion they may be feeling. Again, I would say that listening is without question the most effective of all the emotional intelligence skills. So let me draw a summary then to all of this. First, emotional intelligence enhances professionalism. Actually, I'd go so far as to say, it is the core of professionalism. It is a skill. And what do we know about a skill? A skill takes time and discipline to cultivate. There's nothing intellectually rigorous about the concept of emotional intelligence. Just like there's nothing intellectually rigorous about physical fitness, but if you want to be good at either one, you must take time to discipline yourself to cultivate it. If you want feedback, you have to ask for it. Listening is the most powerful of the skills. Most communication is or has a large non-verbal compliment to it that we have control of. And lastly, in the ABC example, we always have choice in how we interpret things. Nobody makes us interpret something a certain way. Exercising that choice can impact our ability to effectively interact with colleagues, teams, everyone. So communication and professionalism using the concept of emotional intelligence, I believe could contribute to becoming a better surgeon. With that, I'll ask my colleague if he has any questions that might allow us to further discuss this.

- Steve, I want to thank you for really a very worthwhile discussion. May I please ask, as someone who has been involved in managing physicians, what is the top three issues that surgeons have been criticized for in terms of their communication skills, personal relationships, in and out of the operating room and how do you feel we should be paying more attention to those details?

- Well, it's a good and challenging question. I would say that the notion of self-awareness and let me explain that. It comes up quite often in my dealings with surgical colleagues. And that is, if you know something about yourself, for instance, if you know that when you are anxious you tend to blurt things out. Knowing that means that if you could brief your team, if you could say, "I know I have a tendency to do or be this way, therefore, I want you to appreciate it's not coming at you as some personal attack. It's very much a way I behave under certain circumstances and I'm happy to discuss it with you after the procedures and all. But I know that about me and I just want to make sure that you're not taking it the wrong way. That's prevention, and that prevention is based on your own self-awareness. So, whatever we know about how we are, communicating that with colleagues is very powerful. The second thing that I think is an area where the surgeons with whom I've worked tend to have difficulty is in the notion of feedback. If something happens and you're not aware of it, you're never going to learn about it unless you literally ask. And I don't think that we have enough of a willingness to do that. If we ask and take earnestly what we learned from that, we can change the dynamic around us pretty quickly, because people really do believe that we're sincere and that's the key. If we're not sincere, it doesn't pay. The third thing that somewhat connects to the first is just that whole notion of tone, body language. We can say things in authoritarian ways or condescending ways, and that can deflate a person very quickly. And so paying attention to the ways in which we communicate, what is the tone we use? What is our body language when we're communicating with someone? A very powerful way to change the dynamic.

- Thank you. I just want to reflect on something you said very eloquently, and that was self-awareness. As neurosurgeons, we make very life-threatening and very important decisions in people's lives. So in our career, we feel that we are right. If we're making that decision for people, that means we know what's right, what's wrong. And that idea that you're always making the right decision for your patient almost becomes a second nature to you. And therefore, any way you talk to others or any beliefs you have are always the right beliefs. And therefore, anybody else's beliefs if they're not concordant with yours are not right because you are the person who's making the big decision for the patient, you have to be right. And because you want the right thing for the patient. So I think self-awareness is a very big issue with neurosurgeons in general. The second issue is the job intensity. When you're in the operating room, you're operating on a human brain, a human spine. There's many things at risk, and we all have a certain attention span. Sometimes we close our eyes and sort of we have this tunnel vision that we're working under the microscope or working on placing, you know, instrumentation in the spine and anything else that happens in the operating room is no longer important. If a nurse is necessarily asking you to do something differently, if a nurse is telling you something in there to remember you would say, you know what... You may even subconsciously don't believe that that's important anymore. And I think that's the second trap that surgeons often fall into. You assume that you're the surgeon, you're in the control of the ship and therefore nothing else is important. You have to keep your horizon open. You have to remember that times have changed. Harvey Cushing was a big role model for many neurosurgeons and still is, but Harvey Cushing's model of neurosurgery of demeaning everyone is not going to be functional in any way. We have to remember that we are now only a small part of a team in the operating room, and everybody else is essentially as important and the hospital and the federal government also believe the same way and we have to keep in mind. Would you say that number one, the self-awareness, the intensity of the job, almost radically change the personality of the surgeons in the operating room and in the hospital and you may meet the same surgeon who's the most spectacular guy if you meet him outside the hospital, but the moment you're in the hospital it's as if you're dealing with a different individual?

- I think that you're making an excellent point. The intensity of the work that is done by neurosurgeons cannot be minimized. As you pointed out, extremely delicate and serious work. And that underscores more than anything the need to have a rapport with the team that you're working with so you can share exactly what you just did. It would be very effective to say, "this is a very intricate and delicate procedure that we're about to do. I know that I will get very caught up in it because a lot rests on my shoulders, but I'm not in here alone. We are a team. I need your help too, as we accomplish this. And when it's over, I really do want to hear about the things that went particularly well and anything that would make us do better the next time." You're admitting then at the outset, this is hard and it's intricate and you're going to get very focused and you need their help. And their help is not to correct something or to offer an opinion out of the blue. Their help is to at the end of this, be able to share with you things that may have made it go even better.

- I agree. I know this discussion is not in any way related to anger management, but if I may ask you to give us three thoughts about a surgeon in the operating room doing this procedure, and somehow feeling angry about somebody in the room for some reason, and it could all be related to the intensity of surgery. It's not going well. And somehow you're building this sort of emotional, volcanic sort of pressure. And Sally a nurse does something not exactly on time or a surgical assistant doesn't do. And then that volcanic eruption occurs. How would you say one surgeon at that point, within the most intense points of surgery, things are not going well and suddenly somebody who's not catching up with what you're requesting or doesn't do what you asked for because he or she is involved in too many different things at the same time. What do you recommend to the surgeon to deal with his or her frustration at that moment?

- Well, I'll give you one thing that I think you could do right at the moment, but I'll also mention some things prior to going in there. The thing you can do at the moment is it's actually physiologically impossible to have two states going on within us that are opposite. So for instance, I feel this anger or even rage starting to build the simplest thing I could do right then would be to pay attention to my breathing. It is impossible to breathe in a deep and rhythmic way and allow that anger to build. You can try it anytime you find that intensity starting to rise, just check yourself by breathing in a deeper way, a little more rhythmically, and you can check that anger and deal with it later, it works very effectively. The second thing is you can almost imagine that occasionally some instance such as you're describing is going to happen. What if you imagined before you ever went into the operating room, something like that and imagined how you might respond effectively. That sort of mental rehearsal, the mind actually doesn't know the difference. If you're mentally rehearsing handling it a certain way, your mind would see that as reality because the mind is inside of us. The mind, whether it's a literal thing happening or an imaginative thing happening, we can program some of our thoughts. So if I imagine, if I rehearse, how I might handle something like that effectively, I can then do it. Mental rehearsal is just as effective as anything in being able to address something like that. The third, I think goes back to ABC. There are phrases that we can tell ourselves about what's happening that can modulate the intensity of what we're feeling. We start to feel this anger building, and we can learn to say things to ourselves like, "I recognize that this is upsetting and I have an expectation of this individual that exceeds what they appear to be capable of." And so you can deal with this later, instead of saying to yourself, "they should and must know how to function better than that." They're not functioning the way you need them. You may as well just say that to yourself rather than on a subconscious level thinking, "well, they should be functioning exactly how I want them to." That's a belief that's crazy. The same belief is, they're not, I wish they were, but they're not. And maybe when this is over, we can have a discussion of that. So you can learn to breathe. You can learn to rehearse. And you can learn to come up with statements that you can use to tell yourself things that will keep this from continuing to escalate.

- Steve, I want to thank you very, very much. This was very helpful.

- Well, thank you. I hope it was. And I think it's marvelous that you've elected to focus on something that probably is not all that common in the surgical world. And yet I think it is necessary to do what they've committed their lives to doing and do it even better.

- I agree. Thank you.

- You're welcome. Thank you.

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