This follow-up post includes:
- The responses of our medical education experts, Drs. Nadim Lalani, Bryan Judge and Justin Hensley
- A summary of insights from the ALiEM community derived from the Twitter discussion and comments
- Freely downloadable PDF versions of the case and expert responses for use in continuing medical education activities
[su_spoiler title=”Expert Response 1: Difficult Conversations with a Trainee in Trouble” style=”fancy” icon=”chevron-circle”]
Nadim Lalani, MD, FRCPC
Associate Program Director, Emergency Medicine, University of Saskatchewan
Sarah is in a difficult situation. My first thoughts when hearing her story is that David might be having personal or professional challenges that are causing him to act out of character. This response will discuss (1) an approach to “problem learners” and (2) an approach to difficult conversations.
PART 1: The Trainee in Difficulty
I would start by asking Sarah if this behavior is atypical for David. Sarah may not know that the prevalence of struggling medical trainees is 5-10% or have considered that this might be a symptom of a bigger problem.
Defining “Problem Learners”
A problem learner is one who: Requires an intervention because of sufficiently poor performance. The underlying cause of which could be [either alone or in combination] attitude, cognitive skills, wellness, and interpersonal or institutional issues. When previously strong learners like a Chief resident start having problems the first goal should be to identify what changed.
One way to think of the ‘differential diagnosis’ of the struggling learner is through Stienert’s framework:
- Knowledge
- Skills
- Attitudes
- Learner
- Teacher
- System
These problems can be nicely remembered using the mnemonic ‘KSALTS.” It is important to note that the problem is likely multifactorial.
Whose problem is it?
This may become a program issue that the Program Director needs to be involved with. If Sarah and David are not able to resolve their differences it would be the Program Director’s role to gather the supporting evidence and have an intervention with David.
PART 2: The Difficult Conversation
I think that it would be important for Sarah to try and say her piece. Crucial features of this conversation are:
Pre-Conversation Reflection
Sarah can prepare by reflecting on her purpose for having the discussion.
- What is she trying to accomplish? What is the ideal outcome? What are her needs?
- What are her assumptions about David?
- What buttons of hers are being pushed?
- How is her attitude affecting her response to this situation? What has she done to contribute to this mess?
Timing and Venue
The talk needs to occur soon so it does not have time to escalate. It should happen in a private location with no interruptions. David can be seated closest to the door so that he feels less threatened.
The Emotional Side
The result of this meeting may depend on how Sarah handles herself. She needs to prepare for an emotionally charged experience. No one likes receiving negative feedback and it’s natural to feel threatened or attacked. If David is experiencing wellness/family stress this confrontation may exaggerate his emotional response.
Whatever happens, it is important that she does not get caught up in the emotion of the moment. When strong emotions are demonstrated it is important to name them [it’s okay to state that you’re uncomfortable, feeling threatened etc.].
The Ice Breaker
Sarah’s problem may be better received if she begins by inquiring about David’s current life stressors. “David I have asked you to meet because I wanted to talk about the last call schedule, but first – is everything okay with you?”
The Problem
- Sarah needs to frame the dialogue early by committing to listening and respecting David’s opinions.
- Sarah then needs to state the facts and her interpretation of them clearly
- Sarah needs to allow David share his interpretation of the events.
Active Listening, Rephrasing and Acknowledging Eemotions
Rather than thinking up rebuttals, Sarah needs to listen wholeheartedly to what David is saying. By rephrasing his comments and reflecting them back to him she will be able to demonstrate that she is listening and understands what he is feeling.
Move From Positions to Interests
Sarah and David are coming at this from disparate positions, but they do have common interests. They can be used to shift the discussion to their mutual interests by expressing their needs and finding common goals. I would encourage Sarah to:
- Use the “I” word lots. Avoid blaming and making assumptions. Instead of “You’re always so arrogant!” try “When you do not acknowledge my emails, I feel like my concerns are being dismissed.”
- Appreciate where David is coming from and praise honorable behavior: “I admire that you’re trying to raise a young family and at the same time be a resident.”
- Invite David to contribute to a mutually beneficial solution by asking: “How do we get past this?”
Conclusion
If Sarah understands some of the features of struggling learners, reflects on her assumptions, manages her emotions, stays in the moment, and works towards solutions she may succeed at having one of the life’s toughest challenges – the Difficult Conversation.
Suggested Resources
- Back AL, Arnold RM, Baile WF, Edwards KA, Tulsky JA. (2010). When praise is worth considering in a difficult conversation. Lancet. 376: 866-7.
- Bernstein,S. , Atkinson A.R. and Maria A. Martimianakis. (2013). Diagnosing the Learner in Difficluty. Pediatrics 132:210-212
- Canadian Mental Health Association. Fast Facts About Mental Illness . (2013). Retrieved on November 1, 2013.
- Fernandez CP. (2008). Managing the difficult conversation.J Public Health Manag Pract. 14(3): 317-319.
- McGraw, R and S Verma. (2001). The trainee in difficulty. CJEM. 3(3):205-208
- Reamy BV, Harman JH. (2006). Residents in trouble: An in-depth assessment of the 25-year experience of a single Family Medicine residency. Family Medicine. 38(4): 252–257.
- Ringer J. 2006. We Have to Talk: A Step-By-Step Checklist for Difficult Conversations. Retrieved on November 15 2013.
- Steinert Y. (2008). The “problem” junior: whose problem is it? BMJ, 19; 336: 150-153.
- Steinert Y. (2013). The “problem” learner: whose problem is it? AMEE Guide No. 76. Medical Teacher. 35(4): e1035-1045.
- Tiffan B. (2009). Dealing with difficult people. Physician Executive. 35(5): 86-9.
[/su_spoiler]
[su_spoiler title=”Expert Response 2: Crucial Conversations” style=”fancy” icon=”chevron-circle”]
Bryan Judge, MD
Program Director at the Grand Rapids Medical Education Partners Emergency Medicine program (affiliated with the Michigan State University College of Human Medicine).
The simple answer would be to have Sarah talk with David one-on-one to resolve the issues. While this approach may prove successful, the potential exists for emotions to run high in these situations. It is a high stakes situation because, if unsuccessful, further breakdown in communication and their professional relationship could occur.
A Crucial Conversation
This situation calls for a crucial conversation1, but it is one that should be held in the presence of a third party – in this case the program director. This gets each stakeholder at the table to share their insights. It would give David the opportunity to explain himself, let Sarah express to David why she was upset, and allow the program director the opportunity to hear both sides, aid them in developing a solution, and affirm that the program’s accreditation is at risk if scheduling releases continue to be late.
Focus on the outcome
I would advise Sarah to remain focused on what she really wants during the discussion. Does she want an explanation? An apology? A stronger commitment to the role of chief resident from David? I would tell her that she needs to be direct with David in terms of how it has affected her on a personal, professional, and emotional level.
Listen
At the same time, it is paramount that Sarah listens to David so that she can empathize with the circumstances that led to his behavior. As former US Secretary of State Dean Rusk once said: “the best way to persuade someone is with your ears… by listening to them”. Meeting in the presence of the program director should provide a safe atmosphere in which to discuss the issues.
Bring Solutions
Finally, Sarah should come to the table with possible solutions (e.g. regular chief meetings to discuss scheduling issues, different approach to divvying up scheduling) instead of just complaints. Their program director could assist with shifting the conversation into action and results – ensuring accountability by defining who does what by when.
Conclusion
As a program director myself, I know this is the approach I would take. David and Sarah should view this as an opportunity to come to a mutual agreement, move forward, and strive for a better working relationship. In the end, opportunities like this can really strengthen a working relationship by helping people to articulate their positions and problems, and increase their understanding of one another.
Suggested Resources
- Patterson, K, Grenny, J, McMillan, R & Switzer, A. (2002). Crucial conversations: Tools for talking when stakes are high. New York: McGraw-Hill.
[/su_spoiler]
[/fusion_builder_column]
Justin Hensley, MD
Assistant Professor of Emergency Medicine at Texas A&M Health Science Center/Christus Spohn in Corpus Christi, TX.
He also is an avid blogger who writes at his blog EBM Gone Wild.
This situation illustrates the ever-present conundrum in medical education. There is a body of work that needs to be done and a finite number of people to do it. Anything that one person doesn’t do, somebody else has to do. So who regulates this?
As a society we generally try to avoid conflict. We don’t usually like being perceived as aggressors, and will often end up doing the work ourselves instead of fighting. Sarah demonstrates this at the beginning of the scenario by simply doing the schedule herself without arguing.
Conflict resolution is among the many roles of a chief resident. In this scenario, schedule creation is a task that needs to be performed. Failure to get it out on time can cause problems with the powers that be and create havoc for the residents. That said, as she correctly notes in this vignette, it doesn’t mean Sarah has to do it all by herself.
So, how should Sarah approach this? Here are some of my suggestions:
1. Make time to converse with your colleague
The scenario Sarah ends with saying the correct thing: she needs to talk to David. One of the first things I ask people who come to me with a problem with a third party is, “Have you talked to them about it?” It would be inappropriate for faculty to jump in and “fix” this problem without giving Sarah an opportunity to manage it herself. All conflict resolution has to start somewhere and Sarah can make the first effort.
2. Be clear going in, and coming out
I would tell Sarah that she did the right thing by getting the schedule done, but that she needs to be clear with David that this is an unacceptable delegation of a job that he was supposed to perform. She may just want validation that her leadership role allows her to tell other people they aren’t up to task. Alternatively, she may not have skills in conflict resolution, and need advice on performing this role. It is important for her to do it appropriately because mistakes like creating a judgmental or adversarial mood will create more conflict, not less.
When she brings it up with David she should clearly state the problem so there are no misunderstandings about what is being discussed. Sarah needs to remain positive during the discussion of the problem and be willing to listen to David’s side. They both need to offer suggestions for improvement. After all, they are not opponents, but partners.
Personal attacks or ‘scapegoating’ will not help the situation so there should be no tolerance for those behaviors. Both people accepted the leadership roles given to them, so I would expect that they would be able to put aside their emotions and work to fix the problem for the betterment of the program.
3. Have a colleague help you to think through the other person’s situation
A form of constructive venting, sometimes your mentors or close colleagues can act as a sounding board. If I was Sarah’s confidant, I would also maintain objectivity and offer validation for David. Perhaps there really were extenuating circumstances behind why he didn’t get it done. Taking Sarah’s side without hearing the other would simply extend the conflict and hinder resolution.
4. Find ways to prophylax against conundrums
This whole situation might have been avoided if Sarah and David had been given clear expectations by their program director – or set them for each other. If the schedule for chief duties was written out in advance, his failure to complete his task is unacceptable. All too often, though, the reverse is true. Often in medical education, jobs are not well described: They have vague terms of reference or confusing job descriptions. If it was not delineated, then this is the time for this to happen. Too often problems arise from unspoken agreements about the division of labor. This can then create conflict between colleagues job isn’t performed when it needs to be done.
5. When in doubt, ask for help
As chief residents, it can seem that you’re the ‘senior’ now, and you should have things figured out. But this is simply a fallacy. If Sarah is unable to come to a resolution by herself, or if David is unwilling to participate, then their program director (or his/her delegate) needs to get involved. Too often mentors fail in this regard and tell the residents to fix the problem themselves – and in some ways, they should probably TRY to fix things first. But realistically, we all need help sometimes. If they knew how, then they wouldn’t ask for help to begin with. As a mediator, my role would not be to let one side “win”, but instead to fix the problem in the way that is best for the program. I would be there trying to steer the process, not offer a solution that suits my needs.
Suggested Resources
- Berg DN, Huot SJ. (2007). Middle manager role of the chief medical resident: an organizational psychologist’s perspective. Journal of General Internal Medicine. 22(12): 1771-1774.
- Biese K, Leacock BW, Osmond CR, Hobgood CD. (2011). Engaging senior residents as leaders: a novel structure for multiple chief roles. J Grad Med Educ. 3(2): 236-238.
- Conflict Resolution Network. Retrieved on January 30, 2014.
- Hafner JW, Gardner JC, Boston WS, Aldag JC. (2010). The chief resident role in emergency medicine residency programs. Western Journal of Emergency Medicine. 11(2):120-5.
- Jensen, K. (2013). Why Negotiators still aren’t getting to Yes. Forbes. Retrieved on January 30, 2014.
- Myatt, M. (2012). 5 keys to Dealing with Workplace Conflicts. Forbes. Retrieved on January 30, 2014.
- Williams, FK. (2013). A Textbook for Today’s Chief Medical Resident (The Toolkit Series), 21st Edition.
[/su_spoiler]
[su_spoiler title=”Curated from the Community” style=”fancy” icon=”chevron-circle”]
The ALiEM community came up with 10 steps to guide Sarah as she addresses this problem.
1. Calm down
Sarah should cease any unnecessary communication (in person, by phone or through e-mail) about this issue until she has calmed down. Some strategies suggested for de-escalating included writing an e-mail to David but not sending it and venting to someone in her support network.
2. Check your assumptions and biases
Once she calms down Sarah should take a moment to reflect. Hopefully, this will allow her to identify her own assumptions and consider other factors that may have influenced this situation.
Sarah’s immediate reaction suggests that she already believes David is slacking off and/or taking advantage of her. While that may be the case, it is important that she does not start climbing “the latter of inference” (Mark Wahba, @mywahba) to reach assumptions like this.
3. Consider alternative perspectives
Sarah should consider alternative explanations; for instance, David could be having personal or professional difficulties that are making it difficult for him to meet his obligations. This would require a very different response and if Sarah does not consider this possibility, she may worsen the conflict.
Sarah also needs to reflect on the division of labour of chief tasks outside of the schedule. Rob Woods (@robwoodsuofs) quoted his father, saying “In a partnership, our own egos will always make us believe we are carrying 60% of the workload. The problem is that both parties each think they are doing 60% and it can become resentful of each other’s lack of contribution.” Is Sarah carrying the load in all areas? Or has David been picking up a disproportionate amount of the work in another area?
4. Set the stage
Sarah’s discussion with David should occur in person in a private, relaxed environment at a time where they will not be interrupted. David should have some idea of the purpose of the meeting so that he does not feel blindsided when the problem is raised.
5. Casting the players
There were varying opinions on whether others should be involved at this point. Some felt that it would be good to have a neutral third party present. Others suggested that it is important for Sarah to learn to deal with interpersonal conflicts herself. The decision to involve another will depend on David and Sarah’s pre-existing relationship: if this is the first disagreement they’ve had as a pair of co-chiefs, then meeting alone is likely a good first step. On the other hand, if there is a pattern of discord then a third party becomes a reasonable option.
6. Rehearsing the approach
It is important for Sarah to have a plan for the meeting. She could develop one by mapping out her concerns on paper, reflecting on her priorities are for the conversation (eg. ensuring an equal workload, getting an apology, being treated with more respect, etc), and considering potential goals that David would be likely to get on board with. Stella Yiu (@Stella_Yiu) advocated for informally rehearsing some of the key points with a mentor prior to the discussion.
7. Directing the discussion
This is the most challenging part of addressing a conflict. The references listed below were suggested to help prepare Sarah for the discussion.
The effect of gender roles in this conflict was also discussed. A recent Washington Post article raised important questions about the nature of gender and how it may affect workplace perceptions of women in conflict situations. Shannon McNamara (@ShannonOMac) summarized this discussion stating that Sarah should have a “calm but assertive discussion with David about expectations around work responsibilities, while being aware of the risks of being perceived as too bossy, and setting clear boundaries between work and home life.”
8. The opening lines
Sarah should introduce the topic by stating what happened and how she felt as a result. The emphasis should be on the action and not David as a person. With the topic broached, she should give David an opportunity to explain his perspective. Assuming he does not feel threatened, he may share information about personal or professional struggles that have been affecting him lately.
9. Beginning a dialogue
It is likely that there are goals that Sarah and David can rally around. While listening to David’s perspective Sarah should consider where they have common ground to start building support for a solution around their shared objectives.
10. Create a plan together
Once shared goals have been defined a plan should be laid out to meet them. It was recommended that this plan be written down and possibly shared with a third party to ensure that they both stick to it.
Conclusion
Interpersonal conflicts are difficult to handle. It is often much easier to read a case like this and come up with an appropriate course of action than it is to complete this exercise in real life when emotions are running high.
Suggested Resources
- Adams, J. (2010). Pitfalls in Conflict Resolution. Free Emergency Medicine Talks. Retrieved on January 30, 2014.
- HelpGuide.org. Conflict Resolution Skills. Retrieved on January 30, 2014.
- Sandberg, S. (2013). So we leaned in… now what? Ted: Ideas Worth Spreading. Retrieved on January 30, 2014.
- Ury, W.L., Fisher, R. & Patton, B.M. (1992). Getting to Yes, Second Edition. New York, NY: Penguin Group.
- Williams, J.C. Women, Work, and the art of Gender Judo. Washington Post.
[/su_spoiler]
Case and Responses for Download
Click Here to download the case & responses as a PDF.
Author information
The post MEdIC Series: The Case of the Terrible Teammate: Expert Review and Curated Commentary appeared first on ALiEM.