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Workshop teaches how to give bad news by Dick Peterson Public Relations Medical school physicians don’t like delivering bad news to patients. But they do it, because it’s their job.  As teachers, they have a similar aversion confronting their residents and fellows. And all too often, they don’t do it, even though it’s their job “We have trouble giving negative feedback,” said George Arana, M.D., in an Apple Tree Society session, Oct. 1, to help faculty members learn to use reprimand effectively. Arana, who is associate dean and designated institutional official for Graduate Medical Education and Graduate Medical Education’s Franklin Medio, Ph.D., presented “Breaking Bad News to Learners: How to Give Negative or Critical Feedback” as part of Apple Tree’s ongoing effort to serve MUSC faculty with information and techniques to improve their teaching skills. Perhaps it’s the lack of facts to support a subjective observation or third-party complaint. Or perhaps it’s the idea that the reprimand more often than not judges personal performance or may affect a student’s future. Whatever the reason or whatever the effect, a reprimand needed should always be a reprimand delivered. “A mistake is still a mistake and must be corrected,” Arana said. So what’s the goal in delivering a reprimand or correcting a mistake?  “Handle the information effectively,” Arana said. He pointed out how anticipating a resident’s or fellow’s reaction helps keep the process on track and avoids getting bogged down in details and negotiations. “You are inflicting pain, when you reprimand. Expect denial, hurt and anger.” In fact, denial heads the list in a five-step process Arana and Medio presented to the group to help them anticipate—and prepare for—the confrontation. The steps follow closely the Kubler-Ross stages of delivering bad news to patients. “If physicians can follow these stages and deliver bad news to patients, maybe we can teach them to use the same process when talking with learners who are having difficulty,” Medio said.  Following denial: Anger/Upset; Understanding; Bargaining; and Acceptance/Agreement. “If the interaction went smoothly, it did not go well,” Medio cautioned. “You can anticipate a challenge, so plan for it. The process is pretty consistent.” During the initial anger and hurt understand that the anger is inner-focused but outer-directed, Medio said. “Anger and hurt are circling during this part of the process. Don’t respond to the comments coming out of the anger, but stay focused on improving performance.”  In some cases the confrontation is high-stakes and may require following legal protocol, Medio said. “Have them repeat to you the nature of the problem. Asking if they understand, and getting a ‘yes’ is not enough. You have to get them to repeat it back.” Unfortunately, students expect positive reinforcement, not criticism, Medio said. “We have a high price to pay for this in our culture.” He said that continual reinforcement without adequate criticism has made teachers reluctant to make corrections and led students to believe their infractions can be tolerated. “There’s never a good time, bad time, right time or wrong time. Take care of a problem when it happens,” Medio advised. He warned of possible litigation against a medical school if it can be determined that chronic substandard performance had been repeatedly overlooked and led to a serious infraction later in physician’s career.  “Also hospitals are beginning to realize that it’s easier to fire a disruptive physician than replace a good nurse.” Medio said hospitals are becoming less and less tolerant of physicians who put the integrity of their nursing staff at risk. “Practice correcting,” Medio said. “Give them the impression that correcting is your job.” Frequent correction can make many of the high-stakes confrontations unnecessary.  “Residents have been dismissed or have resigned from programs for failure to perform,” Medio said. “We’re talking about chronic, substandard performance.” He said that frequently people will come to a resident’s defense saying he’s such a nice guy. “Well, he’ll still be a nice guy, but he won’t have a medical license.” Medio said there’s knowledge, application of knowledge and behavior to consider. Substandard performance in one area should never be dismissed because of good performance on the other two. He called it the “halo effect”—the idea that because a resident or fellow is bright, talented or a nice guy, his flaws should not be corrected. He also warned of a negative halo effect—one in which a reprimand becomes the resident’s stigma to follow the rest of his days. Medio said that a teacher’s job is to point out mistakes and help the student correct them. “We have a responsibility to the public to see that they do correct their mistakes.” Medio and Arana also listed six traps in the evaluation process and instructions on designing learning contracts.  The Apple Tree Society seeks to foster dialog and activity related to the scholarship of health professions teaching through campus and national partnerships. The goals of the Apple Tree Society are: Expand the faculty development opportunities related to teaching on campus. Initiate programs that recognize and enhance the value of teaching as a scholarly activity. Explore and support innovative methods and technologies for teaching and learning. Promote professional development of current and future educators. All faculty members are invited to attend and participate in the society’s activities and events, including monthly brown bag sessions and workshops such as this one.   Excuses, excuses... He's heard them all by Dick Peterson Public Relations It could be a medical resident’s nightmare in reverse, but hardly a dream.  Just imagine: You’re face to face with College of Medicine Associate Dean for Students Victor Del Bene, M.D., and you are formally reprimanding him for behavior infractions reported to you by nurses. See what I mean—too bizarre to be a dream. Actually, it was a role play at Apple Tree Society’s Wednesday afternoon presentation on How to Deliver Bad News. Presenters George Arana, M.D., and Franklin Medio, M.D., had paired the group— teacher-student, teacher-student—you get the idea. Me-teacher, Del Bene-student. Understand, I’m not a resident; I’m a campus editor. But Del Bene—nice guy that he is—is on my list of people with the ability to make my life at MUSC pleasant or miserable, and so far it’s been quite pleasant. And being on that list carries with it more than a modicum of respect. This little role-play thing was hardly what I expected when I hiked over to Gazes Auditorium to cover Apple Tree’s event. Here’s a loose—from memory and cleaned up to make me look good—transcript of how it went: Me:  I’ve called you in today concerning your interaction with nurses. I have here three complaints—one from a nurse manager—stating that you have verbally berated nurses on the floor, made unreasonable demands and blamed unavoidable problems on them. And I’ve... Del Bene:  Wait a minute. When did this happen? Who’s making these complaints. I’m sure I can give you an explanation for each. I’m not sure it’s even me you’re talking about. I’ve seen other students doing the things you’re talking about. I’m certain it’s not me. Me: I started to say, I’ve observed similar behavior from you that needs to be corrected if you expect to successfully complete your medical education at MUSC. Del Bene: Well... uh, what am I supposed to do? When I see something that needs doing, I have to see that it gets done. I have to tell somebody to do it. I’m only working for the good of the patients. I can’t be concerned about hurting a few nurses’ feelings when the welfare of my patients are at stake. I think you have this all wrong. It’s not me. It’s those nurses who aren’t doing their job. If they would just do what they’re told, .... Me: Those nurses spend more time with their patients than you and they have valuable patient information that could help you with your treatment, if you would just take the time to listen and show some respect for their opinions.  You need to understand that the welfare of their patients is also the nurses’ concern and they are part of the same clinical team you’re on. I’ll be setting up a review schedule to ensure that you are correcting your behavior. I’ll be checking with the nurses on a regular basis to monitor your improvement and I will follow this problem with random checks on your interaction with other nursing staff. At this point the role playing was cut off. Del Bene said that the much of the reaction he gave mimicked what he hears in actual reprimands.               Catalyst Online is published weekly, updated as needed and improved from time to time by the MUSC Office of Public Relations for the faculty, employees and students of the Medical University of South Carolina. Catalyst Online editor, Kim Draughn, can be reached at 792-4107 or by email, catalyst@musc.edu. Editorial copy can be submitted to Catalyst Online and to The Catalyst in print by fax, 792-6723, or by email to petersnd@musc.edu or catalyst@musc.edu. To place an ad in The Catalyst hardcopy, call Community Press at 849-1778.