Managing Physicians 101 or Your Work on Becoming a Chief Resident

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Managing Physicians 101orYour Work on
Becoming a Chief Resident

• Incoming Chief ResidentsWorkshop
• May 21, 2008
• Gerry Goodrich, JD, MPH
• Weill Cornell Physician Organization
• Rini Ratan, MD, Obstetrics Gynecology, CUMC
• Lyuba Konopasek, MD
• John Encandela, PhD

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Five suggestions for physicians
1. Ask an unscripted question 2. Dont
complain 3. Count Something 4. Write something 5.
Change
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From Gawande

• Ours is a job of talking to strangersOn
  the surface, it seems easy enough. Then your new
  patient arrives
• But consider, at an appropriate point,
  taking a moment with your patient. Make yourself
  ask an unscripted question
• One can of course do this with people other
  than patients
• So ask a random question of the medical
  assistant who checks vitals, a nurse you run into
  on rounds. Its not that making this connection
  necessarily helps anyone. But you start to
  remember the people you see, instead of letting
  them blur together
• If you ask a question, the machine begins to
  feel less like a machine

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Microskill 1- Ask an unscripted question

• Pair up, turn to one of the people sitting next
  to you
• Introduce yourself
• Ask an unscripted question of each other

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The Work of Chief Residents
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Management is

• getting people together
• to accomplish desired goals

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Maybe management is like this
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• 
  or this

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Microskill 2 - Identifying challenging tasks
and how to accomplish them

• Identify three challenging tasks that you have
  observed chief residents undertake?
• What was effective about what they did?
• What was not effective?
• How might you have approached those challenges?
  The same, differently?

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Managing your time and the tasks

• Chief Resident 1
• Averaged, over time average day is 13 hours.
• 15 - Admin Responsibilities
• Core conferences
• grand rounds, manage schedules for grand rounds,
  ( ½ hour/day).
• Setting schedule is work, set for a particular
  component (e.g. the grand rounds schedule).
• 3 - Scheduling for the day (½ hour)
• 8 - Rounding (1 hour)
• 3 - Daily admin meetings (½ half-hour)
• 71 - Clinical responsibilities. (rest of day)

• Chief Resident 2
• 2-3 hours responding to schedule issues,
  phones/emails residents, grand rounds, noon
  conference
• 3 hours on resident conferences, teach and
  prepare
• 1-2 hours actually work on the schedule
• 30 minutes a day planning fun/party activities
  (mostly beginning/ end of the year)
• 1-2 hours in meetings (hospital administration,
  adverse events, hospital operations, discharge
  initiatives, length of stay, etc)
• 1 hour answering pages about patient issues
  (transfers, complex cases)
• Attending of record for floor medical consults /1
  day per/ 1-5 hours case variable
• 2-4 weeks per year as inpatient attendings
  (shared with second chief, alternating
  administrative vs. attending responsibilities

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What do Chief Residents Do?

• Provide clinical care - yourselves
• Oversee others providing clinical care
• Teach
• On the floors, in conferences, 11
• Manage schedules, manage schedules, manage
  schedules !
• Residents, conferences, lectures, .
• Organize events work, learning, fun (moral
  support), food
• Direct, look after, manage colleagues
• Balancing individual needs with program needs
• Report up, out, down, sideways, many times a
  day, all the time
• Be a hospital administrator or at least work
  with them
• Organize meetings, be in meetings, run meetings
• Managing time yours, others
• ???

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Tasks Summary

• Organizing people
• Solving problems
• Demonstrating professional expertise
• Both through clinical practice and teaching,
• including role modeling
• 4. Representing your program up, down,
  sideways

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On stage, Off stage, Back stage

• On stage
• In public, mostly all the time, elevator talk
• Off stage
• Free, can speak your mind, at home
• Back stage
• Need to have a place that allows group to have
  certain kinds of conversations

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Managing people, building relationships
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Relationships

• There are all kinds
• They come in various shapes and sizes
• Some we ponder over them
• They can break down
• They can be challenging
• We learn from them
• We can build them

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Some relationships seem really strange
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Some people even categorize relationships !
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Emotional Relationships Legend

• Indifferent / Apathetic
• Distant / Poor
• Cutoff / engaged
• Discord / Conflict
• Hate
• Harmony
• Friendship / Close
• Best Friends / Very Close
• Love
• In Love
• Hostile
• Distant-Hostile
• Close-Hostile
• Fused-Hostile
• Distrust

• Violence
• Distant-Violence
• Close-Violence
• Fused-Violence
• Fused
• Abuse
• Physical Abuse
• Emotional Abuse
• Sexual Abuse
• Neglect (abuse
• Manipulative
• Controlling
• Focused On
• Fan /Admirer
• Limerence

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In your new role, who do you relate to?

• Program Director/Associate
• Program Coordinator
• PGYs 1, 2, 3,
• Attendings
• Other chief residents
• Nurses
• Students
• Who else?

• And who is on your list?

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What kinds of relationships will you have?

• Who do you report to?
• Who works for you, anyone, no one?
• Who works for your program director?
• Who do you work with?
• Who do you need ?
• Whose instructions must you follow?
• ?
• ?

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Microskill 3 Building relationships

• Make a list of all the necessary relationships
  you think you need
• Choose the three that you believe will be most
  important to your success as Chief Resident?

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Microskill 4 Building relationships For the
top 3 what should you do, now, before July 1?
Hint Start with program directors

• Know their names !
• Know their job?
• What tasks are critical to them?
• What are they worried about?
• Is this an RRC review year?
• Do they already have a problem person or two on
  they are worried about? Is someone at risk in
  their view?
• What are critical clinical issues for them?
  Hospital, department, important visitors?
• What might you do for them?
• Coffee with them?

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Building relationships with your team

• First impressions as a Chief count
• first meetings, first tasks, first assignments
• On the job / in the hallway
• on stage, off stage, back stage
• be careful, attentive to settings
• Nurturing, building relationships

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Management Getting people together to
accomplish desired goals

• Some things you do yourself (the easy part)
• Getting others to do work
• Doing working in groups
• Managing up
• Managing down
• Managing colleagues (managing sideways)

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Who will your colleagues be?
Residents in your program?
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Who will your colleagues be?
Other chief residents?...
Med reconciliationHarder, faster!!
Whats wrong with these guys?!!
Both ?
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Getting work done

• Some things you can do yourself the easy part
• Some things you need others to do often
• Some things you can direct others to do
  sometimes
• Most things, most of the time, for most of us you
  need others to do tasks but cannot direct them to
  do them
• The problem of influence without authority
• You have the responsibility, but you dont have
  all the authority

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Rules for treating those you wish to influence

• Mutual respect
• Assume they are competent and smart
• Assume good will on their part
• Openness and clarity
• Talk straight provide the information they need
  to know to help you
• Be clear, precise even
• Trust
• Assume that no one will take any action that will
  hurt another
• Others need certainty of you motives
• Mutual benefit
• Plan so that both parties can win
• If you need to dissolve the relationship do so on
  the assumption youll need it again

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Managing People There are only four types

• Those who want to be liked.
• These are the social directors who want everyone
  to be happy, especially with them.
• Those who want to be comfortable.
• They want job security. They will do a good job,
  but dont expect them to stretch or push
  themselves or to respond well to pressure.
• Those who want to be right.
• These people are strong in their opinions and
  will defend their ideas to the death. They can be
  reluctant to accept other points of view.
• Those who want to win.
• They have the drive and tenacity to succeed.
• 
  Robert Toru Kiyosaki, Rich Dad, Poor Dad

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Break
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Managing conflict and negotiating to results
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Conflicts are inevitable Conflicts can be good
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You cant always get what you wantbut if you
try some time you might get what you need.
Mick and Keith, 1969

• But you must try, try and try
• Bob Marley

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Negotiation

• Communication between two or more parties to
  determine the nature of future behavior (Volkema)
• Communication aimed at reaching agreement when
  some interests are shared and others are opposed
  (Ury)

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Different negotiation styles

• Positional bargaining
• Hard participants are adversaries
• Goal is victory
• Search for the single answer The one you will
  accept
• Soft participants are friends
• Goals is agreement and relationship building
• Search for the single answer the one they will
  accept
• Principled negotiation participants are problem
  solvers
• Goal is a wise and fair outcome, reached amicably
  and efficiently
• Focus on interests, not positions, with multiple
  options for answers

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Basic Principles

• Preparation is essential
• What do I want?
• Why should they negotiate with me?
• What are my alternatives?
• Focus on the people involved and their interests
  not on the positions
• What are my interests?
• What are their interests?
• Are there any objective criteria to support my
  position?
• People will not negotiate with you unless they
  think you can help or hurt them (Volkema)

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Solutions

• Consider solutions in preparation for negotiation
• What are options for a solution?
• Invent options for mutual maximum gain
• What kinds of options has this person accepted in
  the past?
• With you? With other people?
• Negotiate for what you need, not what you think
  you can get

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What are my alternatives what is my walk away?

• What is my Best Alternative to a Negotiated
  Agreement (BATNA)?
• An action that you take independently
• How flexible am I?
• What is my range of possible agreement?
• Is the status quo acceptable?
• For how long?
• At what point will I walk away?
• What is unacceptable?

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What if they say

• This is non-negotiable
• I understand thatcould you tell me more about
  why that is? or why you want that?
• Say I just cant help you with that
• If not now, then later?
• What are other options?
• Educate them about the costs of not agreeing
• Dont threaten but warn

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Tips for success in negotiating

• Be prepared
• Practice with a colleague
• Write out a framework
• Find evidence of objective criteria
• Consider your responses to their response
• Stay calm, do not be reactive
• Mirror their style (tone, pace, formality)
• Find points of agreement and state them
• If you disagree, explain first
• Ask open ended questions
• Gives you more info and more time to think

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Conflict prevention

• Clear articulation of ground rules
• goals and expectations established up front
• You need to be clear that you too play by rules
• they watch what you do, not just what you say !
• Repeat, reinforce no doubt as to rules

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Microskill 5- A negotiation
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Making groups and teams work
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Teams and groups
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A way to think about groups or teams

• 1. Forming
• Group not a group, collection of individuals, no
  trust,
• 2. Storming
• Some conflict, jockeying, interpersonal issues,
  looking for trust
• 3. Norming
• Norms and patterns of work begin, group starts to
  cohere, roles emerge
• 4. Performing
• After first three stages, work begins to get
  completed and optimum performance starts
• 5. Adjourning
• Time is up in your case, year ends

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Managing the paradox the challenge of teams

• Embrace individual differences and strengths vs.
  collective identity and goals
• Fostering support and confrontation among team
  members
• Focus on performance and learning and individual
  development
• Balance managerial authority and team member
  discretion and autonomy
• Manage relationship triangle Manager

Individual Team
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Groups and teams require

• Trust
• Ability to have and manage needed conflict
• Commitment to team
• Be accountable to themselves and their work
• Constantly attentive to purposes, results

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Managing Up influence without authority

• Find mutual interest
• Address issue / dont avoid
• Make sure facts are clear (first hand / second
  hand)
• May need to get help / consider consultation
• (Tell the story, explain the parties and
  interests, state possible solutions)
• Is this a major conflict?
• Clinical issue
• Two challenge rule ?
• Get Help / Escalate

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Microskill 6 Managing up
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Leading Some ideas and concepts
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Some Attributes of successful leaders

• Purposeful, mission driven, committed
• Cooperative, works well with others
• Optimistic (few pessimists become leaders)
• Serves as role model, leads by example
• Self-aware able to lead ones own self,
  others can follow
• Aware of environment, so that others seek
  direction
• Empathetic understanding what others say, not
  just listening to how they say it able to walk
  in others shoes
• Possess integrity integrates outward action
  with inner values

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Leadership styles differ

• Autocratic
• Bureaucratic
• Charismatic
• Democratic leadership or Participative
• Laissez-faire
• People-oriented or Relations-Oriented
• Servant
• Task-oriented
• Transactional
• Transformational

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Management and leadership the same?

• Differences between the two roles.
• Manager
• Administers, maintains, focuses on systems and
  controls and the short term view, asks how and
  when, keeps eye on results
• Leader
• Innovates. Develops, focuses on people,
  inspires trust, asks what and why has a
  long-term view and an eye for the horizon

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Some tools to help with next microskill exercise
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Giving Feedback The Feedback Sandwich
Ask Tell Ask
Adaptation of The New Feedback Sandwich,
common in patient-physician communication
literature adapted by Lyuba Konopasek, MD, for
use in medical resident feedback settings.
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Giving feedback

• Ask learner to assess own performance first
• Phrase question to encourage meaningful
  reflection
• Tell what you observed diagnosis and explanation
  using specific observed behaviors
• React to the learners observation
• Feedback on self-assessment
• Include both positive and corrective elements
• Ask about recipients understanding and strategies
  for improvement
• What could you do differently?
• Give own suggestions
• Perhaps even replay parts of the encounter show
  me

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SOAP

• Subjective
• What do you/others think and say?
• Objective
• What are the specific behaviors that are
  observed?
• Assessment
• Form a differential diagnosis of the problem.
• Plan
• Gather more data? Intervene? Get help?

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Stages of change

• Pre-contemplation (Not yet acknowledging that
  there is a problem behavior that needs to be
  changed)
• Contemplation  (Acknowledging that there is a
  problem but not yet ready or sure of  wanting to
  make a change)
• Preparation/Determination (Getting ready to
  change)
• Action/Willpower (Changing behavior)
• Maintenance (Maintaining the behavior change) and
  
• Relapse (Returning to older behaviors and
  abandoning the new changes)

Source Prochaska, J. O., DiClemente, C. C.
(1983). Stages and processes of self-change of
smoking Toward an integrative model of change.
Journal of Consulting and Clinical Psychology,
51, 390-395
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REMEMBER There are only four types of people

• Those who want to be liked.
• These are the social directors who want everyone
  to be happy, especially with them.
• Those who want to be comfortable.
• They want job security. They will do a good job,
  but dont expect them to stretch or push
  themselves or to respond well to pressure.
• Those who want to be right.
• These people are strong in their opinions and
  will defend their ideas to the death. They can be
  reluctant to accept other points of view.
• Those who want to win.
• They have the drive and tenacity to succeed.
• 
  Robert Toru Kiyosaki, Rich Dad, Poor Dad

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Microskill 7 Managing down
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Wrapping up
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Working with across generations
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Work life balance
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In closing what we have talked about

• The work of chief residents
• Building relationships
• Managing people teams and groups
• Managing conflict
• Negotiations
• Leading

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How to succeed at being a chief resident
What I wish I knew before I started !Current
Chiefs Top 10 Tips(We asked some of them.)
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Sonyas Pearls

• 1. Approach every problem like youre going to
  solve it.
• 2. Patients best interest should always come
  first.
• 3. Assume everyone has the best intentions.
• 4. Try to make it clear that YOU have everyones
  best interest in mind.
• 5. Recognized that different people bring
  different strengths and skills to the table.
• 6. You input/perspective is extremely valuable
  to others (hospital/attendings).
• 7. For the greater good, you may have to endure
  some seemingly pointless activities or
  meaningless tasks.
• 8. Sometimes a job is work you may not love
  all of it.
• 9. Everyone deserves to be heard but you can
  limit it to five minutes.
• 10. End discussions with a clarifying statement
  around the action plan.
• I will do this, you will do that.

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Appendix
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Groups and teams 5 dysfunctions
- Absence of trust - Fear of conflict - Lack of
commitment - Avoidance of accountability -
Inattentive to results
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Prochaska and DiClementes Stages of Change Model
Source Prochaska, J. O., DiClemente, C. C.
(1983). Stages and processes of self-change of
smoking Toward an integrative model of change.
Journal of Consulting and Clinical Psychology,
51, 390-395.
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Situational Factors in the Normative Model
Adopted from Rimar, Stephen, The Yale
Management Guide for Physicians
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Running a meeting Some people are good at this,
others not, it can be learned

• What is the purpose of the meeting? (Dont have
  it if you dont need it).
• Written hand out is best, if not say it, follow
  it,
• Start on time
• Finish on time
• Let everyone have their say, sort of
• Dont avoid conflict, manage it, if need be
  park it
• Some groups/teams need regular meetings (same
  time, same duration, standard process)
• Meetings can be short 5 minute daily huddles
• Learn to park contentious issues
• If you park an issue, know that it must be
  returned to, it likely wont go away
• Recap at the end, making clear follow-ups,
  specific to dos.
• Leaders learn to read the people and the group
  in a meeting.
• Not all of the groups work is done in meetings,
  but if some of a groups work must be done in
  meetings, or the group will wont be able to get
  work done
• Define group, and the duration of its life (one
  year?)

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Communications issues

• Sending
• Present message clearly in detail, with integrity
  and authenticity.
• Receiving
• Able to actively listen, seek clarification, able
  to trust
• Delivery method
• Suits circumstances of both the sender and the
  receiver.
• Content
• Needs to resonate and connect with the values and
  beliefs of the receiver.

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Words can matter

• The trouble with talking too fast is you
  may say something you haven't thought of yet.
• Ann Landers
• Words are, of course, the most powerful drug
  used by mankind.
• Rudyard Kipling
• It seemed rather incongruous that in a society
  of super sophisticated communication, we often
  suffer from a shortage of listeners.
• Emma Bombeck
• Remember not only to say the right thing in the
  right place, but far more difficult still, to
  leave unsaid the wrong thing at the tempting
  moment.
• Benjamin Franklin

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Different negotiation styles

• Positional bargaining
• Hard participants are adversaries
• Goal is victory
• Search for the single answer the one you will
  accept
• Soft participants are friends
• Goal is agreement and relationship building
• Search for the single answer the one they will
  accept
• Principled negotiation participants are problem
  solvers
• Goal is wise and fair outcome, reached amicably
  and efficiently
• Focus on interests, not on positions, with
  multiple options for answers

Fisher R, Ury W. Getting to Yes. 2nd Ed.Penguin,
NY, 1991.
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Taxonomy of Leadership Styles
Area of freedom for group
Influence by leader
0 3 5 7
10 Decide
Consult Consult Facilitate
Delegate
(individuality) (group) You make
the decision You present the You present the
You present the problem to
You permit the group to alone and
either announce problem to the problem to the
the group in a meeting. You
make the decision within or sell it
to the group. You group members group members
act as a facilitator,
defining the prescribed limits. The
group may use your expertise in individually, get
in a meeting, get problem
to be solved and the undertakes the
identification collecting information that their
suggestions, their suggestions
boundaries within which the
and diagnosis of the you deem relevant to the
and then make the and then make the
decision must be made.
problem, developing problem from the group or
decision. decision. Your
objective is to get
alternative procedures for others.
concurrence on a decision.
solving it, and deciding on
Above all, you take care to
one or more alternative
ensure that your ideas are not
solutions. While you play
given any greater weight
no direct role in the groups
than those of others simply
deliberations unless
because of your position.
explicitly asked, your role is
an important one behind the
scenes, providing
needed resources
and encouragement.
Adopted from Rimar, Stephen, The Yale
Management Guide for Physicians
84
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