The courage of leadership is giving others the chance to succeed, even though you bear the responsibility for getting things done.
Impromptu guidance in the workplace
Skilled impromptu guidance is essential to our teams at work
Make it look easy
Back when I was a Senior House Officer, one afternoon I was doing a forceps delivery under the watchful eye of my Senior Registrar, Sue. During the delivery, she whispered in my ear ‘make it look easy’. I heard what she said, but I was concentrating on my angle of traction. Was the baby descending with each pull? When to cut the episiotomy, and all the other things that rush through your mind when you're learning the craft of assisted delivery. The baby came out beautifully, everyone was happy, and of course I was proud of myself. Another new life safely into the world.
A few weeks later, after we had done a couple more together on our night shift, Sue took me aside in the doctors’ mess and said, ‘Danny, when you do assisted deliveries, the face you pull is scaring the parents!’ Whoa! That stopped me in my tracks. An acutely intense mixture of guilt and embarrassment washed over me. She explained and I suddenly got it; my concentration, grimace, biting of the lip, with the inevitable dose of anxiety was on full show for the parents to see. It must have looked pretty painful - certainly not reassuring when I have their most precious thing in the world in my hands. She taught me to hide my concentration in stressful situations, to always smile and reassure my patient that all will be well.
Sue had given me some gentle advice on more than one occasion and I didn’t get it. Her frank approach that evening was necessary. But her bluntness didn’t come in isolation. She had shown me through lots of other interactions that she cared deeply about my wellbeing. She had given me positive feedback on many occasions and invested significantly in my development. She had invited me over to her house to meet her family and was as caring as any mentor could be. She had my back covered.
Radical candour - care personally, challenge directly
Sue’s approach to guidance exemplified what Kim Scott, a former Director at Google, calls Radical candour. Guidance that occurs at the intersection of caring personally and challenging directly.
Scott calls the x-axis above the ‘willing to piss people off’ axis and the y-axis is about how much you care. When we consistently demonstrate to those we are responsible for that we care deeply for their wellbeing, they can deal with our blunt honesty. Because they know that it comes from a positive place.
Radical candour in our interactions with others doesn’t always come easily. We’ve grown up being told that if you haven’t got something nice to say, then don’t say anything at all. Of course it’s easier to let these opportunities slip by, to not take the time to build the necessary relationships. As leaders, however, the truth is that it’s not only our job to do this, it’s our moral obligation.
“The source of everything respectable in man, either as an intellectual or a moral being is that his errors are corrigible…. he is capable of rectifying his mistakes, by discussion and experience. Not by experience alone. There must be discussion, to show how experience is to be interpreted…. The whole strength and value of human judgment depends on the property that it can be set right when it is wrong”
Less satisfactory approaches
So if radical candour is the right way for us to interact with those in our care, what are the unhelpful ways? How do people get it wrong and what should we be looking out for signs of?
We have all known a doctor who is frankly the worst type of leader. The obnoxious aggressive that berates the RMO in front of the whole ward round, the registrar that criticises the nurse in front of the patient. Unfortunately, if this doctor doesn’t get proper feedback and support, when told that these actions are inappropriate, only the direct challenging will be addressed. Unless they appreciate the importance of caring for our team at work, that person is liable to slip into behaviours that are manipulatively insincere.
The vast majority of leadership mistakes occur in the quadrant of ruinous empathy. No-one wants to tell the person that they have a problem; they may care about the individual concerned, but don’t have the courage or skills to confront them openly about what is going on.
How to do it in practice
What other approaches can we use to ensure that our guidance is given with radical candour? Remember the acronym HIP. Guidance in the workplace must be:
Humble
Helpful
Immediate
In person
In private for criticism
In public for praise
and it doesn’t;
Personalise - critique the action not the individual
Keep looking after those around you. Show them every day with small, frequent gestures that you care personally and are invested in their growth. And have the courage to provide the guidance they need when the situation arises. All of us need mentors who do this.
Man is the maker of himself
Man is the maker of his own happiness. Build yourself into the person you want to be. Be deliberate in your actions and make personal development a part of your life. You are the stone, You are the chisel and You are the sculpture. You can mould yourself better.
An 8 ton stone masterpiece in the Sahajanand Hall of the Hindu cultural complex called Swaminarayan Akshardham in Gandhinagar, Gujarat. Visitors to the complex are inspired by 14 experiences from the life of Lord Swaminarayan, this is Experience 1.
Could rudeness in the workplace increase patient mortality?
Sounds extreme? Many of us will have experienced inappropriate behaviour in the workplace. In fact, two thirds of operating room staff have witnessed rude behaviour and nearly one half have been on the receiving end of it. But could it result in increased patient mortality?
RCT of medical rudeness
A recent study ‘The Impact of Rudeness on Medical Team Performance: A Randomised Trial’, published in Paediatrics last September suggests this may indeed be the case. Researchers found that a rude comment from a third party doctor decreased performance of doctors and nurses by more than 50% in an exercise involving a hypothetical life-or-death situation.
“We found that rudeness damages your ability to think, manage information, and make decisions,” said Amir Erez, the author of the study. “You can be highly motivated to work, but if rudeness damages your cognitive system then you can't function appropriately in a complex situation. And that hurts patients.”
For the experiment the researchers gave 24 medical teams - each composed of one doctor and two nurses - an hour to diagnose and treat a simulated case of necrotising enterocolitis. The researcher told the teams that an expert from the United States would be watching their progress via webcam. At the start, the ‘expert’ was conferenced in and a pre-recorded message was played to the teams. Half the teams received a message that said the observer had been watching other teams and was ‘not impressed by the quality of medicine in their country’. Control groups were simply told that he had observed other teams, without any rude comments. Ten minutes into the simulation, another expert recording was played, telling the control group that he hoped the simulation was helping them improve as physicians. The other teams, however, were told that the physicians and nurses he had been observing ‘wouldn’t last a week’ in his department.
The rudeness experienced by half the teams had a profound effect on the outcome. Those who were exposed suffered a severe drop in performance, making incorrect diagnoses, struggled with communication and teamwork, asking for incorrect drugs, demonstrated poor ventilation technique and failed to ask for help at an appropriate time. Overall, the rude comments led to a 52% difference in success at diagnosis and 43% difference in treatment success. The assessment was made by 3 independent assessors who were blind to the study’s thesis. In real world situation, as Erez pointed out, these performance deficits could be the difference between a patient living or dying.
Postponing emotions
Erez expected that the more experienced staff would bounce back from the rude comments and keep working as a team, especially as the situation was an emergency one. “But we found consistently and dramatically that rudeness isn't something people can easily get over,” he says. “It's not something that you can postpone emotionally to a later time because it affects the cognitive system.” You don't even have to be the target of the bad behaviour - merely witnessing rudeness results in cognitive decline.
People spend time and energy processing why rude comments were made to them, and how it affects them, taking crucial mental resources from the task at hand. This lack of focus could literally be life threatening to the patient involved. Previous work by Erez has revealed that rudeness can spread through teams like a virus, resulting in a culture of negativity threatening patient safety.
Call to action
We all need to be aware of the direct and indirect effect this negative behaviour has on our teams, both immediately and - in the longer term - on team functioning and culture. It is our responsibility to not only model positive behaviours, but to call out others who are rude, or think that it is OK to behave in a way that is harmful to our colleagues, teams and patients.
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George the Poet
FHPC: 4 ways to make the world a better place
I'm a firm believer of embracing creativity in life. That is creativity both as a pursuit outside of medicine as well as approaching the challenges of our work in a creative way. 'We've always done it that way' is one of the most dangerous phrases in the English language.
George Mpanga is a spoken word artist from humble beginnings in inner city London. He began rapping as a teenager, went on to study politics, psychology and sociology in Cambridge. He subsequently won a social enterprise competition and used his $30,000 prize money to fund a series of secondary school poetry workshops for underprivileged children in London.
'I think rappers are primarily expected to make money for the industry and provide party soundtracks, but obviously there are exceptions and grey areas. The poet’s 'role' is usually to provide thoughtful social commentary'
George provides us with a framework for life in the video below, urging us to consider 4 things before we speak or act.
Is it Fair? Is it Honest? Is it Positive? Is it Creative?
If you can answer yes to all four, then your words and actions are likely to be sustainable and lead to a better world.
'Do you ever question your plan of action; or are you just on a quest for satisfaction?'
More on his website or Facebook page.
Organisational culture
As a leader, you are building the culture every single moment of every single day in your organisation. Your behaviour more than any other single thing creates the culture of your workplace. People look at you and say 'OK, that's what he or she expects'
If you're a junior doctor, the medical students learn from you, if you're a registrar both the medical students and the RMOs are watching how you behave and will emulate the words you use, the way you approach workplace relationships and how you treat others. As a consultant, will be expected to have the courage to both do the right things and pull up those whose behaviour is unacceptable.
Leadership character starts with you.
Seeking fulfillment and happiness?
How can you be happy in your daily work? What makes your job fulfilling? Wouldn't it be amazing to have a job where you gain fulfillment every day. Where you feel a bond with those around you and you know that you are working to a common goal. The irony is that in a world where we are becoming less physically connected - the answer lies in the PEOPLE we spend our days with, not the actual work we do.
Fulfilment and happiness in life comes not from what you are doing, but the fact that you are helping someone else. Giving and gratitude are the keys to happiness. Sounds corny I know, but stick with me on this one!
When you get a thank you card from a patient at work, or when they gush over you the next day, thanking you for your successful operation or the medical intervention you did, how good does that feel? Don't you go home and feel good about yourself, happy that you have done something for a fellow human being and that it has been acknowledged. Even when it's not acknowledged or the patient doesn't seem particularly grateful, you still have that warm feeling inside - not because you did a technically sound procedure (OK, well maybe a little bit of that) - but because you know you have helped someone.
It's not just about our patients; when you take the extra 10 minutes to teach your medical student, you can see they are hanging on your words and how grateful they are; when you ask a colleague if they need a hand with their job list because you finished yours. The irony is that you have more to gain by helping them than they do, because helping others makes us happy.
Give feedback
As leaders, we have to help others understand that team working isn't only good medicine, it's happy medicine and work satisfaction. We have to find ways to bring people together and help them recongise the benefits of doing so. If you are the team registrar, that means making sure your medical student and RMO have the opportunity for ownership of their work, and to give them feedback and support that acknowledges their contribution.
Every single day look for opportunities to recognise and reward individuals of your team for the good that they do. We don't do it enough and it's profoundly important to their development - and the strength of our teams as a whole.
Dealing with compliments and criticism
Feedback can be one of the most difficult and sensitive processes within any team, but it's something we all have to deal with - after all, everyone's answerable to someone. When we are on the receiving end of feedback, compliments can make us complacent and criticism can damage our self-esteem.
Introduce your your team to the concept that when they receive feedback, not to see it as a simple two dimensional result, rather ask what they can DO with it. In other words, what needs to stay the same as it is now, and what needs to change?
M Krogerus & R Tschäppeler
When you get feedback, don't just think about what went well or what wasn't so good. You have to consider how you are going to react. Organise the feedback you received under the headings of the matrix above. Which criticisms prompt you to take action? Which suggestions can you ignore?
By doing this, you'll be able to take the feedback in the way it was (hopefully) intended & come up with a considered plan of action. You can also use the matrix when constructing feedback for others.