So my question is really two-pronged. First of all, how do you deal with the gender biases in this and the disruptive behavior, especially at that cup-of-coffee level, where if you, with that peer-to-peer intervention, you come to realize that it was just totally kind of a bullshit behavior report because it was a woman who was doing it. Yeah. So that would be my, you know, my first kind of, you know, piece to this. And then the second piece is, how do we deal with it in the current political climate where disruptive behavior has been rewarded at the highest echelons of society? If I could, that's a wonderful two-part question. If I could solve the second one, I would. I had an answer for that. Yeah. Man. You'll get a different answer if you, you'd get a different answer if you catch me on a day when I'm feeling really, really sad and frustrated or on a day where I'm feeling really, you know, hopeful. Let me address the first one. I think that as leaders in the space of sort of conflict and disruptive behavior, as you're developing these programs, it's important to recognize these biases that exist. And that's what I was talking about on one of my late slides about, you know, sort of checking yourself. What am I seeing? What am I hearing? Gathering information, understanding what it was that happened, making sure you have all the details before you go to someone, and recognizing, you know, does this pass the litmus test for me as what I would consider disruptive behavior, or is this sort of like two individuals who, like, you know, got into it and one of them is being sort of labeled as disruptive based on some sort of bias. I think if there's inherent bias there, I think that's important that you honor that and recognize that. And that cup of coffee may actually turn into a different kind of cup of coffee. Are you okay? I'm sorry this happened. I don't consider this to be disruptive behavior. I can see how hurtful that must have been for you. Let's talk about it, right? And so I just, you know, this happens at all levels, right? We now know that black families are more likely to get kicked out of a hospital as being disruptive than white families. We got to own that, and we need to work on that, and we need to try to understand that and unpack that. And so we need to be careful about the biases, implicit and explicit, that are out there and make sure that we're not, if someone has been been reported as being disruptive, that that doesn't mean they are disruptive. That just means that we need to evaluate it. In terms of the upper echelons, I think sometimes all you can do is just be the best person you can be. And this is not quite as it relates to sort of like that, you know, what you're alluding to, but you know, I live by this mantra that sometimes all you can do on a given day for a patient or family or a colleague is just be present. You can't make it better. You can just be there and say, I understand, and I'm sorry. And I think that, you know, do your best to find those moments when you feel like you can say no or say this is not okay when people are behaving poorly. And we hope that our institutions will be able to support us. And just going to your point, I think in medicine the imperative is that there is good literature that demonstrates that disruptive behavior is a threat for patient safety, period. Right? So I think as clinicians, that's our responsibility. And having experience with a lot of different programs around the country, I think that one of the issues of why disruptive behavior is also perpetuated is because we don't follow the process. We don't take the step to document without judgment what's happening. If you do that over and over again and you empower people to document these things, eventually I've seen the highest paid people in hospitals being removed. But I think a lot of times by not stepping up and following the process, we perpetuate, we allow that behavior to happen. So that's, this is a leadership course. That's what being a leader is. It's stepping up, right? And taking that step. You also can only control what you can control, right? So if let's say the leadership in your hospital is unwilling to sort of call out behavior by people who are lateral to you or senior to you, you can still within your own sort of control, so in my case my section or my ICU, is say this is the standard that we're going to set and these are my expectations as a leader. And that's what we're going to enculture here. I was gonna ask a question, maybe take it down a level from what was just asked culturally, but what happens when you don't feel supported by your immediate superior? So you are recognizing or identifying the behaviors and reporting them, but then not feeling like you're supported in that process and then subsequently not seeing changes occur. Kind of how do you deal with that? It may be a similar answer to you can only control yourself and be the best person you can be, but I think that sometimes happens as well when you feel stuck. Yeah. I mean this is the definition of moral injury. Moral injury is when you identify an action that needs to be taken and you are prohibited from taking that action. And so it's an incredible source of burnout and frustration and moral injury is this idea that like you are reporting events as they're occurring, you're trying to be part of a cultural change and the person's senior to you is just not interested in being a part of that. You just keep howling at the moon, you just keep pushing on that wall, and you hope that either that individual or someone who supplants them at some point will be more open to it. So I have a question. So the cup of coffee discussion is actually very reasonable when we have a discussion between our peers, but when it actually happens across the hierarchy, for example in this case it was actually an anesthesiologist versus an RT, so in these circumstances is there any empowering words which the RT can actually say back at the same time to prevent injury from happening to her? For example, could she have actually said, do not talk to me like that? Yeah, that's a great question. So you remember my slides in the conflict management about how, like, calling out bad behavior only worsens conflict, right? I think that, like, if the RT starts to be competitive and says, I don't like you speaking to me that way, or can you try, even nicely, could you try saying it in a different way? Or like, you're making me feel uncomfortable, like, it is likely going to escalate conflict. And that's why it's so important for us to be upstanders to support our colleagues. Because the RT is unlikely, in that situation with an anesthesiologist, is unlikely to advocate for herself. She's unlikely to feel comfortable saying something, and if she does, it's just going to cause a big fight, and then she's seen as being sort of part of the problem. So instead, I step in, and I say, this is not happening, right? I'm in a position of power where I can say, this is not okay. But I think, to the best of your ability, when you find yourself on the lower end of the hierarchy, just being able to say, you know, I want to hear what you have to say, but this is making me uncomfortable, I think even that is probably going to be really challenging, when it's not going to be received well by the individual, because they're behaving badly, they're being disruptive. So you almost need to, you need to remove yourself from the situation. I think we're really running up against break. And I'm happy to stand here during break and answer other questions. I mean, clearly, the anesthesiologist really badly performed, but put it on the side. There's a lot of cases where we're in a life or death situation, and we are very firm, and now the respiratory therapist or the nurse is going to consider what you said is offensive or disruptive, and you cannot be efficient sometimes. You mean, if I was an anesthesiologist, I'm going to ask her to move, get out of the room, for example. Would that be considered as insulting? I mean, we are, he is in a life or death situation, and your people around you are not helping you. So speaking politically correct is excellent, but sometimes, you know, you won't get the job done. I mean, there's just a problem here, how are you going to perform in a way where you're not going to upset anybody? Yeah, great question. I would say, this kind of gets back to that question, that was the political question. We're living in a climate now where there is not, oftentimes, not a clear, bright line between who's taking offense to something I said, and when have I actually behaved in a disruptive way. It doesn't have, this is a really fairly obvious. I would argue that it doesn't take the anesthesiologist that long to say, it looks like you're struggling, let me help you. It doesn't have to be physically pushing them and saying, you know, and then after the fact, berating them, right? I think that's the problem. And look, this happens at all levels. I once had a fellow who gave me feedback that said, great educator, really enjoyed working with him, but during codes, he gets a little bit abrupt. I was like, okay, the patient's dying, and I'm just trying to sort of, and then I thought to myself, you know what, the patient's already dead, and everybody's working hard, and I don't need to be really, really forceful to get the job done. I can actually do it in a way that embraces allowing the people in the room to feel confident they can do their job, and that I'm not like barking orders at them. And I adapted my behavior, and so I think that like, it's being sort of like introspective in that way, and realizing that like, you can find ways to say things that people, somebody's going to take offense at some point to something you say, that's just the way it is, but in those moments when it gets heightened, find ways to say things in a little bit of a way that sort of like brings down the temperature of the room rather than escalating it.

gender biases

disruptive behavior

leadership

patient safety

non-confrontational solutions