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Managing Physicians 101 or Your Work on Becoming a Chief

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Managing Physicians 101 or Your Work on Becoming a Chief Resident Incoming Chief Residents Workshop May 21, 2008 Gerry Goodrich, JD, MPH Weill Cornell Physician ... – PowerPoint PPT presentation

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Title: Managing Physicians 101 or Your Work on Becoming a Chief


1
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

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

4
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

5
The Work of Chief Residents
6
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7
Management is
  • getting people together
  • to accomplish desired goals

8
Maybe management is like this
9

  • or this

10
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?

11
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

12
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
  • ???

13
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

14
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

15
Managing people, building relationships
16
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

17
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18
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19
Some relationships seem really strange
20
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21
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22
Some people even categorize relationships !
23
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

24
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?

25
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?
  • ?
  • ?

26
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?

27
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?

28
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

29
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)

30
Who will your colleagues be?
Residents in your program?
31
Who will your colleagues be?
Other chief residents?...
Med reconciliationHarder, faster!!
Whats wrong with these guys?!!
Both ?
32
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

33
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

34
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

35
Break
36
Managing conflict and negotiating to results
37
Conflicts are inevitable Conflicts can be good
38
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

39
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)

40
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

41
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)

42
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

43
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?

44
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

45
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

46
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

47
Microskill 5- A negotiation
48
Making groups and teams work
49
Teams and groups
50
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

51
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
52
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

53
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

54
Microskill 6 Managing up
55
Leading Some ideas and concepts
56
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57
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

58
Leadership styles differ
  • Autocratic
  • Bureaucratic
  • Charismatic
  • Democratic leadership or Participative
  • Laissez-faire
  • People-oriented or Relations-Oriented
  • Servant
  • Task-oriented
  • Transactional
  • Transformational

59
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60
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

61
Some tools to help with next microskill exercise
62

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.
63

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

64
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?

65
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
66
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

67
Microskill 7 Managing down
68
Wrapping up
69
Working with across generations
70
Work life balance
71
In closing what we have talked about
  • The work of chief residents
  • Building relationships
  • Managing people teams and groups
  • Managing conflict
  • Negotiations
  • Leading

72
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.)
73
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.

74
(No Transcript)
75
Appendix
76
Groups and teams 5 dysfunctions
- Absence of trust - Fear of conflict - Lack of
commitment - Avoidance of accountability -
Inattentive to results
77
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.
78
Situational Factors in the Normative Model
Adopted from Rimar, Stephen, The Yale
Management Guide for Physicians
79
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?)

80
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.

81
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

82
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.
83
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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Cohen A, and Bradford D., (1991). Influence
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Wiley Sons. Ericsson KA. (2004). Deliberate
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Fisher R, Ury W, Patton B. (1991). Getting to
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A. (2007). Better A Surgeons Notes on
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Goffman, E. (1959). The Presentation of Self in
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self-change of smoking Toward an integrative
model of change. Journal of Consulting and
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