Professionalism in the Medical Profession: Challenges and Strategies

Dr Gavin Nimon: 0:29

The medical profession involves different areas of medicine, both from learning how to examine a patient and assess them, as well as interacting with a patient and giving them advice and treatment options. One area of medicine that goes under the radar is professionalism, how to interact both with patients and with staff and other colleagues. It's a very important aspect of medicine. It's really important to actually maintain a professional attitude in a profession, and today we're going to learn more about it. Welcome to Aussie Med Ed. G'day and welcome to Aussie Med Ed, the Australian medical education podcast, designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field. I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and I'm broadcasting from Kaurna land. I'd like to remind you that this podcast podcast players and is also available as a video version on YouTube. I'd also like to remind you that if you enjoy this podcast, please subscribe or leave a review or give us a thumbs up as I really appreciate the support and it helps the channel grow. I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the Elders both past, present and emerging. I'd like to remind you that all the information presented today is just one opinion and that there are numerous ways of treating all medical conditions. Therefore, you should always seek advice from your health professionals in the area in which you live. Also, if you have any concerns about the information raised today, please Please speak to your GP or seek assistance from help organisations such as Lifeline in Australia. Well today, we're lucky enough to be joined by a panel of experts on our Aussie Med program. We're joined by Professor Ben Canny, Director of Medical Education from the University of Adelaide. Professor Gerry O'Callaghan, Intensivist and a Professor of Public Health. Dr. Maura Kenny, Director of Staff Wellbeing at the Royal Adelaide Hospital and Central Adelaide Local Healthcare Network. And resident Patrick Kennewell. A resident who's going to give his advice about interacting with patients and colleagues from a resident's perspective. Welcome to Aussie Med Ed, all four of you. Thank you very much for joining us on the panel. I'd like to start off with Professor Ben Canny. Perhaps you can tell us about how Adelaide Medical School deals with such an important topic.

Prof Ben Canny: 2:38

Thanks Gavin. Well, professionalism and leadership is an important domain of the Australian Medical Council, or AMC, defined graduate outcomes. And this actually comes in as domain number two and that's significant to think about that number because, , it represents the second highest number of graduate learning outcomes as defined under the AMC Graduate Learning Outcomes. And these tackle a range of issues to do with clinical and cultural competence and ethical conduct of doctors. So under that general framework, there are a range of skills, attitudes and behaviours that we're really interested in the students being able to incorporate, because they are in fact registered members of the profession from the time they enter medical school. And , these skills cover a whole diverse range of things. However at the school, we're probably as interested in what is the specific culture that makes up the profession, and therefore leads to professionalism. And a definition that we're keen to use, I came across it in an article written by John Funder and written by Peter Wright, who is a judge of the High Court of Ontario. And he wrote that a profession is a self disciplined group of individuals who hold themselves out as possessing special skills derived from education and training, which they are prepared to exercise primarily in the interests of others. So in addition to these skills and attitudes and behaviours that the AMC define for us, we are really interested in students being able to incorporate that culture and therefore us being able to produce a range of graduates who will be able to serve the community.

Dr Gavin Nimon: 4:24

Excellent so obviously entering a profession is a really important part of the process but once you become a professional and actually enter the profession. How does it actually lay out in real life? I'll pass that question over to Gerry O'Callaghan.

, Prof Gerry O'Callaghan: 4:37

thanks Gavin., of course we all have a definition of professionalism that we like to use and,, the one that I guess I use on a day to day basis, is that medical professionalism signifies a set of values, behaviours and relationships that underpins The trust that the public has in us,, as practicing, doctors. So, to, I guess, put that in the context of working in a big busy public hospital, providing a range of services to the community, it, it really is reflected in how you interact with the other members of your team, how you interact with patients and their families and how you look after yourself and prepare yourself on a day to day basis for that interaction which we know requires us to work on ourselves and to maintain a currency of knowledge and to be prepared to be available not just to consumers, patients, and families but to be available to each other as colleagues when when other colleagues need our help and support in providing care and in making decisions and in looking after themselves.

Dr Gavin Nimon: 5:45

So really, being part of the profession is actually really important to have both medical knowledge, medical skills, but also being able to actually present yourself in the correct fashion. And I know from the legal perspective, you are judged as part of your peers. But there's a lot of stress to put on someone. I might put this to Patrick Kennewell, one of our residents here, and ask him how he actually copes with the stress of both being able to deal with their long hours, The difficulty and concerns about missing a diagnosis, but also behaving in a professional way. Is there difficulties that you may face, Patrick, that you can advise about as a young resident coming through the

Dr Patrick Kennewell: 6:17

process? I I think becoming a junior doctor is often a challenging time for people as they move out of medical school, which is a very sort of controlled environment, and move into the workforce. And The way that people deal with the variable workload in different jobs, I think, um, often challenges people and everyone has different coping strategies for how they deal with things. I think, to give some broad tips for junior doctors coming into the profession I think one of the key things is being able to switch off when you're outside of work and ensuring that You know, you can take some time outside of work to do the things that you enjoyed to do before you started in the profession. And I think that's particularly valuable. One of the things that I think is really important that I tell all of the interns that join my team is that the hospital has 24 hour coverage. You've got support on site 24 hours who can help with sick patients. As an intern, you shouldn't be taking those sort of issues home with you. And so one of the things that I suggest for people entering internship is that they should not have the EMR app on their phone because that, you know, I think leads them to, can lead people to open that and want to check in on how their patients are doing 24 hours a day, when I think you need to sort of make that separation for, having time for yourself and having time to and having work time. I think for me as well getting out, in the sun is one of the very important things when you're outside of work, and so going out for walks and, doing some sporting activities as well that maybe aren't as formal and organised as what you did in medical school, that are a bit more flexible around your sort of working life, I think are really important too. So going to gym classes and those sorts of things I think are really important. A lot of things that my colleagues do in their off time to try and improve their wellbeing and help how they can, navigate their professionalism at work. Excellent tips

Dr Gavin Nimon: 8:13

there. One of the problems though in entering medicine is that most people that do become down, go down the path to medical school and then become a doctor have got a personality that makes them perhaps triple A and more of a worrying and caring sort of nature, you'd hope. And certainly sometimes it's very hard to switch off. I might put the next question to Dr. Maura Kenny about How you cope with staff who are struggling with all the stresses, is there certain things or certain tips you can also come from the hospital that helps these staff in this scenario? Thank

Dr Maura Kenny: 8:39

you Gavin it's such a good question. I think it's one that we've been really slow to address as a profession. In fact that flow of compassion has always been out to other people and not really back into ourselves and learning how to look after ourselves. With permission to look after ourselves, with permission to switch off our phones, with permission to not think about patients all the time, with permission, in fact, to say no when you need to say no. I don't think we're very good at healthy boundaries. But that kind of, that self care piece, if you look at the literature around what really facilitates staff wellbeing in a big organisation if you think about a circle with three pieces, three equal pieces, The personal resilience part, if you like, the personal self care, I prefer to think of it, is just one small part. If you really want to look after your staff and get the best out of them, you have to address the culture of the organisation, and the things that get in the way of people's efficiency of practice. Healthy teams, connected teams, compassionate teams, and things that don't massively get in the way of us being able to do our job. They actually account for more. of the outcome for people being able to stay healthy and professional then all of the exercise and the meditation in the world might do.

Dr Gavin Nimon: 9:55

I've found both one of the aspects of professionalism isn't actually just purely just dealing with staff but also actually helping the the person in the street or being involved in other good and respectful attitudes and activities such as helping someone on an aeroplane. The actual process of being professional gives you self reward and actually helps guide you towards a good approach. Do you think that's a good way of proceeding as well?

Dr Maura Kenny: 10:21

This is the part about boundaries which I think we haven't really articulated particularly well when we educate and train and supervise our doctors. That if you think about the hidden curriculum of medicine, the hidden curriculum of professionalism, there's a bit of a hero martyr kind of approach that's It's not spoken about, but which is clearly modelled to us and it can lead to that sense of excessive responsibility for patients. You know, you're going on holiday, you're on the plane, you want to relax and switch off, somebody gets sick. Now, of course, we'll help if we can but, the thing is that it's actually really hard for us to ever say no. And there's something about, Learning that, to do that well, to do that wisely, needs to be talked about more. Because there is this kind of myth, I think, that if you say no, if you can't do things, people will think of you as not coping, you were never fit to be a doctor in the first place because you've had to say no to some things. And then it never ends, there's no end to what can be asked of you. So some of the work that, that I'm doing is around helping the profession learn how to Skillfully say no and enact good self care. But also to ensure that the organisation isn't inadvertently asking that of people as well. Because we were all, we all grew up kind of keeping the health profession going by working ridiculous hours sometimes. And that's just not bad, not, not good for anyone. Especially not for our patients. Because if we're tired and burnt out, then clinical outcomes suffer.

Dr Gavin Nimon: 11:55

I'll put it to Professor Ben Canny now about How it might come up through the medical ranks, through medical school. Do you think this culture of actually not saying no and trying to do as much as you can might start an early stage in the sense that maybe the curriculum is a bit too wide and makes it a lot of burden to people? Or do you think it's actually a matter of just learning what's important and just focusing on the keep it simple approach to learning medicine and not trying to get burnt out by learning the intricacies?

Prof Ben Canny: 12:23

Thank Gavin. We always have to deal with the reality that we live in a fairly competitive world and medical school remains a competitive world unfortunately, even though those of us who look at it and say it doesn't need to be. From a medical student point of view, there is that incredible tension about getting ahead and the like and so forth. But one of the things I'm really ambitious that we can do is we can Make sure that our students and therefore our graduates actually attain some psychological literacy and in psychological literacy they should develop the ability to recognise in themselves when help is required, when intervention is required, when saying no is the right thing to do, when they don't have the robustness and resilience and that should be a range of behaviours that carry with them no stigma whatsoever. In fact, we should be celebrating when someone does acquire those skills and abilities. So we're striving in our curriculum to be able to provide students with the opportunities to develop that insight because we want them to be healthy, because we want them to keep on doing things in the interests of others. And if they're not healthy, that can't happen.

Dr Gavin Nimon: 14:20

If we look at professionalism And we've talked about different concepts of professionalism. What really makes up a professional individual? What are the individual aspects of it? And perhaps I could just ask for two different concepts from the panel and see what people think. It's not just about being courteous and being respectful and doing the best, but also looking after themselves. Let's make up the different things that would also make you proud to be a profession. Professor Gerry O'Callaghan.

Prof Gerry O'Callaghan: 14:47

So, there's a lot of of work that's been done over the years in defining, if you like, the characteristics or the competencies that make up a well rounded, holistically professional, um, doctor, surgeon, healthcare professional. And there's a number of different frameworks that are often referred to the most The most widely used is one called CanMades which came from Canada. But the kind of competencies or characteristics that, of an individual that are described are they're respectful to other people. They have a high degree of technical and cognitive competence. Self awareness, and I think the self awareness is important because that speaks to self regulation and it also speaks to the privilege of being a profession who are regulated as individual and autonomous practitioners. They're good in teams, they're effective communicators, and they're available. They're present in discussions and they're available to their colleagues, to consumers, and they're available to the community, that the choices that we make as professionals. In how we spend our time in our education, meet the health needs of the community and the population. And as a profession in our kind of broader sense as a profession that we we address the challenges of the social determinants of health, the challenges of our community in meeting and designing and planning for the health needs of the

Dr Gavin Nimon: 16:14

population. Brilliant summary there. I wonder if Dr. Mora Canny would actually add anything to that. Is there anything else you would think that would actually add to a definition or how someone should behave as a professional person?

Dr Maura Kenny: 16:28

I think I'd like to say something about compassion and what the research is teaching us about compassion. Compassion is different from empathy. Often you hear the term compassion fatigue, which is actually a misnomer. People get empathic distress, which, and empathy is where you're really attuned to the suffering of someone else, but you haven't. necessarily got the skills or the resources to do something to help, and that's what burns people out. Whereas when you train people in compassion, and they're trainable skills, and they're not difficult, and there's a script as well you actually get better patient outcomes, but it's also protective for the doctor too. And there's something about learning about the flow of compassion. So there's the flow of compassion out. There's also allowing compassion to come back in, that means asking for or accepting help from other people. And then there's the compassion we might give to ourselves. Learning how to be aware, learning how to notice when we're not going so well, when our resilience has dropped, when our capacity to manage things has dropped, and when we need some help or we need some time out or we need something. Specific. I think it's really important to know and remember that healthcare professionals and doctors especially are more resilient than the general population by definition. They wouldn't have got to where they were if they weren't resilient. So it's not a failure of resilience which is often what people think it is. It's just circumstances are such or the demands are too high and too long for them to keep coping. So the self awareness has to be not a judgmental self awareness but a compassionate self awareness. If that makes sense.

Dr Gavin Nimon: 18:07

Very much and that's an excellent thought provoking aspect as well. Patrick, perhaps you can just outline more a bit. Anything else you'd like to add to the whole, how you'd like to behave as a professional person, working in a profession that you're very proud of?

Dr Patrick Kennewell: 18:22

Yeah, thank you, Gavin. I think, as a junior doctor, we see professionalism demonstrated through the way that people interact with their patients and how they interact with their peers. And I think this really shapes how you view someone's professionalism. The situation that I see quite often is When someone picks up the phone to phone through a consult for another, for a patient on their team. And the attitude of the doctor on the other end of the line often can determine how effective that consult is. And, when people are quite sharp or quite brief or don't understand that people would have a different level of knowledge in their specialty. You find that you get worse patient outcomes, and the junior doctor who might be making that phone call would be less likely to make that phone call again in the future whereas when someone's understanding and teaches and shows some compassion and provides useful input, you're going to be far more likely to engage that service again in the future, and I think the same goes in the hospital setting when you're dealing with as a junior doctor dealing with nursing staff and allied health staff as well. And about how you deliver care in a holistic model. Understanding that everyone comes from a different background, and has a different level of knowledge. And appreciating their concerns and being able to communicate effectively with them to achieve the best outcomes for our patients. Which we're, is what we're all there for. Excellent.

Dr Gavin Nimon: 19:51

Excellent sort of thoughts there. Professor Ben Canney, what aspects of a medical student coming through as a doctor would make you extremely proud to see them acting in a professional way? What are the particular things on top of what we've already said that are really important aspects that you hope they come through with?

Prof Ben Canny: 20:07

Thanks Gavin. This is a bit of a challenge because the previous descriptions have been outstanding. The thing I'd like to add, however, is I'll use the word respect and I want to, I want The graduates and the profession to be respectful of the incredible privilege one is given as a medical professional. Those privileges extend in a protein of ways. You do have people's life in your hands. You do have the ability to interact with people and change their perspectives on what they're doing and help them. You are entitled. to the most sensitive information. And that's a real privilege. For me what I want the profession to be able to do is to maintain that deep respect and to use that privilege to advance their not only their own lives, but the lives of the community. And The great thing about medicine is you can do that by doing your job well. And that's just a rare and unique opportunity.

Dr Gavin Nimon: 21:21

Brilliant thoughts. One aspect though, obviously all of us want to try and be the best we can possibly be. But certainly under stress, it would not be unusual for someone to err as human. And obviously we want to be respectful, courteous, be in control. When under stress, sometimes things can go awry. What are the individual coping mechanisms, forgetting about the team approach and going for a walk, of course, which are obviously general preventative measures, almost, to try and prevent these things happening, but what about the individual coping mechanism in that particular stressful scenario? This is probably a very good question for Professor Gerry Callaghan as an intensivist. I'll pass it on to him, how he copes.

Prof Gerry O'Callaghan: 22:08

I think in terms of my practice, there's a couple of things I'd like to say. In terms of managing stress I've had the privilege of being, a department and divisional head and being an executive director of medical services. What I have observed and what the evidence tells us is that The drivers of stress in our workforce are primarily as a consequence of systems which are poorly designed and get in the way of how they do their work. So one of the, one of my responses as an individual to things that I find stressful has been to work in these kind of operational roles, to work in, at clinical quality improvement and system design. Because many of those And issues are very solvable and actually make a big difference to the experience of the workforce. And to my experience as an intensive care specialist. And that helps enormously. And the way that is described is intentionally designed systems which produce highly reliable care. And that is a big challenge for us to think about in the next 10 years as our systems become more. Digitized, more automated, and more complicated. And the treatments that we offer to patients become increasingly complex. In terms of my practice, I have to say exercise is extremely important. The intensive care is very much a team based activity. Intensive care specialists have a leadership role in leading that care in the interdisciplinary team. And in order to do that effectively one needs to manage the burden of stress and prepare yourself for work and I find that exercise is very helpful.

Dr Gavin Nimon: 23:55

Thanks for that, Gerry, that's brilliant. More though perhaps individual coping mechanisms in that stressful scenario. If I put through one, one perhaps, one little technique I tend to use when I'm in theatre and if I'm struggling at a different part of the operation, I'll usually ask the nurses who are watching intently. to go and get the equipment that I might need for the next step if I can't get through it. It has the benefit of actually being ready to go to that next step if needed. It also has the extra benefit of actually taking their eyes off me so I can actually relax and focus on what I'm doing. That's my little technique of actually struggling through a difficult part of an operation if I'm in that scenario. There are other little techniques that you might want to use that are, that might be more beneficial on the ward scenario or other situations.

Dr Maura Kenny: 24:35

So maybe just to add to the things that have already been mentioned that are really important I think what you're describing is just taking a moment to come back in to the present moment without being watched or observed. There's no doubt that mindfulness practice has a really strong evidence base for reducing stress and helping us recalibrate and come back to some kind of baseline again. I'm a mindfulness teacher and have a meditation practice of my own, which has been vital for me to not just survive, but thrive in this challenging and wonderful career. And I've taught it to many healthcare professionals, and one of them said to me, he was a surgeon, a bit like what you've described, he said that when something goes wrong in an operation, like it's a moment of high tension, like it's a really urgent situation, he takes a nanosecond to feel his feet on the floor and take one breath out. Just to re center, and then he'll go in and be able to do what he needs to do. As opposed to all of the stories that start up oh this is going to go terrible, what's going to happen, this is really bad, oh my god, oh my god. These kind of thoughts that really interfere with our ability to concentrate and focus and do our job well. So, that mindfulness practice of just coming back to the present moment, using feet on the floor, the breath for a moment we know is effective. And I can personally attest to that myself. Yeah. Brilliant.

Dr Patrick Kennewell: 25:53

Perhaps if I can add to that as well for junior doctors, I think that one of the most helpful things is making sure that you take, you know, 10, 15, 20 minutes to have a lunch break in the middle of the day, being on the wards in a, an environment where you're trying to complete jobs while being called about new jobs that need to be completed can be quite stressful and something that I think that was really good when it was instituted was a sort of half hour paging freeze unless there were sort of emergencies that needed to be attended to so that the junior doctors could take a break from their day. You know, do a bit of mindfulness and get a meal with some of their colleagues and sort of share some thoughts on how their morning had gone as well. And so I think that's really important. And if you're in an environment where, or a team where that can't be facilitated, I think, perhaps an intern handing their pager to their resident for a half hour so they can duck out and get some lunch or something like that, can make a really big difference in those sort type of situations. And particularly if you've gone through something stressful like a, a met call that hasn't gone what. Or as planned, then, taking a 5 to 10 minute breather and handing your pager or your phone to someone else to answer some calls for you. I think people are always happy to do that and it's a really good sort of strategy to deal with those high stress moments.

Prof Ben Canny: 27:12

And Gavin, what I'd add from my perspective, and one could argue that how can the world of medical education be stressful? And certainly the time scale is somewhat glacial compared to the requirements in a clinical environment. What I find when deluged with, let's say, lots of decision making pressures is that, um, it's important to try and recognise what are the urgent decisions as distinct from the important decisions. And further, what extra data might I be able to gather to help me make a decision? And very often the really important decisions aren't urgent and they do have some ability of time to be able to arrive at a better decision making place for yourself armed with more data. I think that is applicable to many instances in clinical medicine as well. Not the acute Metcalls and the like and so forth, but there'll be lots of opportunity to employ that sort of strategy.

Dr Gavin Nimon: 28:16

Brilliant. What about though when you do come across someone who does behave unprofessional, someone who you actually have respected or you actually don't mind, how do you actually go about talking to them and actually pointing it out to them? There are obviously different techniques to use this on and there may be different scenarios you can think of. But perhaps we'll start off with, we'll start with Maura maybe, about what the options are for dealing with a person in that scenario and how it actually can escalate further down the track if that's not working.

Dr Maura Kenny: 28:48

You know, this is a really difficult thing to be able to do well to manage conflict like that to manage somebody else's unprofessional communication and particularly if there's a power imbalance or a, you're a junior in the hierarchy to somebody who's been rude to you, you don't have a lot of power to really address it with that person. In fact, you're probably likely not to do that. Because it might jeopardize other elements of your career development. So if that's the case, it's really important that you can go and talk to someone, the importance of peer support, not just like Patrick's saying about handing over your pager, but seeking out somebody in the organization who's a mentor or a supporter, where you can just debrief, be supported, be validated. And then, you can decide what, if anything, you're going to do next. And obviously there's a whole other piece around how we deal with professional behaviours in organisations, which we might get to later, but if you don't have the capacity in the moment, and after all, how many of us are able to come on with a really calm, wise response to somebody who's behaving unprofessionally to us, it's quite a big ask then sometimes you just stay quiet, go away, get some support, and then decide after that how you're going to respond.

Dr Gavin Nimon: 29:57

Fair enough. What about the opposite scenario? What about if you feel you've behaved unprofessional when in the light of day you realise you regret what you've said and how you behaved? What's the next step you do in that scenario? What would, how would the panel deal with that? Let's look at self insight first of all, and then look at how we deal with the person who doesn't have that self insight. So I'll start off perhaps with Gerry. If you had a scenario where it may happen on occasion where you're a bit concerned about how you behaved, what would you do in that situation?

Prof Gerry O'Callaghan: 30:23

I have definitely been that person., you know, in moments throughout my training and throughout my career. Um, I mean, I think that one of the key components of being professional is self awareness. And I think in those moments when you realize that you have behaved in a way that you're not proud of or that doesn't reflect the values that you hold as an individual or that you share in an organization. I mean, I think the sensible thing to do is to have a conversation with the people around You know, who, who shared that moment with you and, and apologize. The, the issue is one really of understanding what the threshold is, and that's often hard because other people may have a different view, and of course that changes over time as society changes. But I think on balance, if we regularly ask for feedback from our colleagues, they will give it to us. I think we do get feedback from patients and families all the time. And I think actually asking people whether or not, having conversations regularly when you work with the team to say what worked well? What could we have done better? Is there anything I could do better? I mean, becoming used to having those conversations in which one is vulnerable as an individual, but in that moment of vulnerability, when you, when you're in that zone that's not quite so comfortable, that's when you're learning. So I think that, that's how I do it, and I have apologised to people for being abrupt or being late or discourteous over the years. And, uh, you know, I hope I don't have to do it too many more times, but, you know, if I do and I certainly hope that, you know, my colleagues will hold me to account as they should. That's a

Dr Gavin Nimon: 32:00

brilliant revelation there, Gerry, and obviously, I think most of us can actually feel that scenario as well. Maura, how do people take it when they actually receive an apology having been dealt a blow in an abrupt situation or discourteous or unprofessional behaviour scenario? Does it, is it worth, is it worthwhile or does it fall on deaf ears because the damage is already done?

Dr Maura Kenny: 32:23

Well it can definitely be worthwhile if it's done authentically. So we all know the difference between someone who says I'm sorry you felt that way, which really is sort of saying, is code for, well you got upset, but that's your problem. As opposed to, I'm genuinely sorry, I wasn't very skillful I'm tired. Not that that's an excuse, it's a reason, I'm sorry. That, you know, just a simple sorry can really go so far to repairing things. I'm sorry, I messed up, I was rude I'm sorry. And that kind of genuine, brief apology can just work so well. But, from my perspective, it's really hard for us to be perfect all the time, so we're going to make mistakes, we're going to be irritable and grumpy, it's really important to repair. But we're not very good at that as doctors because we're such perfectionists, we don't like to admit failure. But it's actually much more Like, if you can make yourself do it, it's actually incredibly connecting with another person and rewarding. I apologised to my secretary last week because I was really tired and busy and a bit off with her, and I went in the next day, I said, sorry, I had such an awful day yesterday, I'm sorry if I was a bit off. And she almost teared up when she said, thank you so much for saying that. It was, like, and it really has repaired the relationship, it's so important.

Dr Gavin Nimon: 33:40

Thanks, Maury. Yes, that's really important, I think, to be quite honest in that scenario. What's the training medical officers experience in this scenario? Do they have any ideas of what happens in a unprofessional behaviour setting? Is it worthwhile speaking to your colleagues and trying to repair the relationship?

Dr Patrick Kennewell: 33:57

Well, I definitely think it is, Gavin. And I think these are people that you're going to be dealing with for a large majority of your career. And relationships and how you deal with these people now might shape how you deal with them throughout the rest of your career. Something that's really interesting when you talk about the JMO space is the medical training survey which ARPRA puts together every year. Which has a lot of professional standards that are in it that are reflect how JMOs go through, go about their work. So The sort of things that are outlined in there is that one in three trainees across Australia at the moment either experience or witness bullying, harassment, discrimination or racism in their workplace. And that's clearly an area of professionalism that, we need to make sure that we're dealing with appropriately. The medical training survey also shows that 48 percent of trainees had a heavy or very heavy workload. And these are the sort of things that can impact on people's professionalism. And I think is why, something like this is so important. And ensuring that we can address both the people's professionalism on an individual level and how we can make those system based changes. I think it's really important for us to ensure that we're working in an environment which allows people to be their best selves and be professional people is really important too.

Dr Gavin Nimon: 35:17

It must be difficult when there's a group of people brought together in one environment and they have to mix the whole time. Particularly so in the hospital, but even more so in the medical school. Do you experience scenarios that Patri outlines at the medical school? Professor Ben Canny, what's your thoughts?

Prof Ben Canny: 35:35

Medical students certainly are under a degree of pressure from time to time, though and we need to remember that and we need to remember that it's a different environment and different generation of when we did our training. We do see unprofessional behaviour between students and among students and the school is lucky that it's able to work closely with the student body to both Call those instances out and work with the student body to be able to address those. With the introduction of a new curriculum at the University of Adelaide, we've been able to completely reconsider the way we're addressing the assessment of professionalism and the way that we are able to identify instances which might be unprofessional and bring those to the fore to be able to discuss with students. Progress or assessment decisions aren't taken lightly and they're always taken after that opportunity to discuss and work our ways through them. That gives us the opportunity to develop some of those earlier skills I was talking about. Can someone develop insight? Can someone understand Can someone show remorse and respond appropriately as Maura has said? And they're the things that we will accrete and information about that behaviour which will help us make the best decisions in helping someone

Prof Gerry O'Callaghan: 37:06

develop.

Dr Gavin Nimon: 37:07

One of the issues though can be aberrant behaviour, can get learned responses so people can behave poorly and then become worse and worse with time. What's a way of addressing that scenario if you start seeing behaviours which aren't being improved upon? What's the sort of different techniques you can use to approach this? I think, Gerry, you've done some work, as the rest of the team has here, on different pathways to actually address poor behaviour and how it can be improved in an escalating fashion. What are your thoughts?

Prof Gerry O'Callaghan: 37:37

So, I think there are two kinds of poor behaviour. There is low level incivility. That happens at a relatively high frequency in large, complex organizations where people are under pressure. And that kind of behavior can be, you know, speaking about people behind their back in an unkind way, excluding people from decisions in which they have a legitimate interest, not inviting people to meetings, being recurrently late or rude. And that has a significant effect. Both on team culture and the experience of healthcare workers and drives disengagement. But more importantly, we understand now that there is a strong evidence base which connects unprofessional behaviour with poor patient outcomes and poor safety outcomes in an organisation. Much less frequently there is, egregious or significantly poor behaviour in organisations. That is very infrequent. And that is normally well dealt with by organisations. But it, this sort of incivility and unprofessional behavior, which is not really suitable to refer to a complex, human resource process, is much more common and much more of a problem. And excuse me, in, in Central Adelaide, what we've done is we've worked in partnership with Vanderbilt University in the United States to implement their peer professional accountability program. And what that is when a peer Observes a behavior that they deem to be unprofessional. So the standard, if you like, is set by the group of people with whom you work. And they feel that this behavior does not reflect an appropriate professional standard. In our organization they can make a private and confidential report of that behavior and a peer of that individual will provide some feedback. It is feedback with the intention to That the individual will exercise self regulation and understand that their behavior was unacceptable to their peers and colleagues and that they will manage that themselves. And that program has has a strong evidence base behind it. We're in our second year now of that program in Callan. We're evaluating our progress as we go. We would expect that it would take, some time in order to I guess articulate or be effective but we're we're pleased with our progress so far and it is very inclusive Patrick and Maura are very very well aware of the program and we have trained over 250 messengers within our organization who are willing and they're demonstrating their commitment to the organization and to their colleagues that if an event occurs. They will provide that feedback to a peer, and we're very careful and thoughtful about one, the information is only available to the individual who's going to provide the message, the feedback, and the other thing is, of course, that person is a peer. So if it's an intern, it will be another intern. If it's a consultant, it will be another consultant.

Dr Gavin Nimon: 40:39

Brilliant. Rather than the old aggressive sort of paternalistic type of model, which is more of a feedback sort of development sort of process in trying to improve people's behaviour. Does that work every time? Or does it have to go to the next level before it actually progresses?

Prof Gerry O'Callaghan: 40:53

Well, I guess nothing works 100 percent of the time. The intention of course is for the individual to reflect on, on that occasion and to to manage their own behaviour in the future in a way which is not unacceptable to their peers and colleagues. Very infrequently, less than 2 percent of the time in the evidence base that's available to us individuals recurrently behave in a way which upsets the people around them. Under those circumstances further feedback is provided to them again by a peer. And that feedback really is to say, look, your experience in terms of the way you're interacting with the people around you is different from your peers. And in large health systems there is a, there is information and evidence which can, benchmark or compare individual specialties so that, people have a sense of, you know, well, actually it's not just because I do a particular kind of job. Actually, you are still different from people who do the same job in the same kind of circumstances but are not experiencing that feedback from their peers. But the intention of the program is at all times To provide feedback to professional colleagues and let those colleagues reflect on it and to understand how they can address that and change the outcome in the future.

Dr Gavin Nimon: 42:09

As a Director of Staff Wellbeing, how well is it received? Is it received in a better fashion or a worse fashion in past times?

Dr Maura Kenny: 42:16

I wouldn't actually know the answer to that because, as Gerry's outlined, it's a highly confidential process, which is so important to protect people's dignity and not be publicly shamed as they learn to modify behaviour. So, I can't speak from personal experience, I'm certainly aware of the literature that shows behaviour when they're given that kind of feedback. Most of us do try and be reasonable, decent people in the world, and when you get that. an outlier and you've gone a step too far. People do often self correct, that's what the evidence shows. Um, it's, we're always trying to learn and improve in medicine. It's one of the tenets of professionalism and so that can also happen in the, what are often seen as less important skills, like how you communicate with your team. I think The world is changing. People are much more aware of how important that is these days and being the old, terrifying, chief nurse or, head consultant doesn't cut it as an excuse anymore. The world has moved on from that kind of view. People expect to be treated fairly at work and I think that's really appropriate. From your experience,

Dr Gavin Nimon: 43:25

Patrick, has it been well received? You've given some feedback to other medical officers in the Royal Adelaide. Has it been well received and taken in the right fashion or has it been a hard task to do?

Dr Patrick Kennewell: 43:37

I've found that when I've delivered feedback it's been very well received. Often people have reflected on the situation and it's given them a chance to speak with a peer about a situation that was probably quite difficult for them in the workplace too. I think more broadly the program has been excellent at allowing Medical officers and now the whole of Kyle and almost the opportunity to be able to report in instances of both unprofessional and professional behavior and offer a feedback model for people who are being, doing exceedingly well on a professional basis or, going out of their way to help other people out as well as, those who have provided unprofessional behavior. It gives people an opportunity to point that out and feel like, that will be addressed then. So I think the program's been well received and it'll be really interesting to see the data reflected in the MTS survey over the coming years to see if it really, shows a change in those things that I talked about before in trainees experiences of bullying and harassment. Okay,

Dr Gavin Nimon: 44:40

well, that's brilliant. Look, I think we've covered a lot of ground today and I hope this has been useful for the listener. I'd like to start off by putting through and thanking my panel for coming on board. Thank you Professor Ben Canny, Dr. Patrick Kennewell, Dr. Maura Canny and Professor Gerry O'Callaghan. Look, thank you very much for all being a part of this. I'd like to finish off with some closing thoughts, perhaps we'll start off with Ben and work our way down. Ben, have you any thoughts about what we've talked about today?

Prof Ben Canny: 45:08

Thanks Gavin. Several thoughts. It's a privilege to be able to talk about this. Hold my own professional identity very strongly and I think it is about what you can do to be able to give back to society and the community that has given you so much as an opportunity and I'll go back to that commentary about privilege as well. The other thing I'd like to reflect on, I think this is a really incredible opportunity for health services and universities to work more closely together. We do so much together but we don't often think about how do we create the commonalities of culture between our organisations to ensure that we get people who are fit and able to be able to contribute to healthcare.

Dr Patrick Kennewell: 45:56

I guess my comments, Gavin, would be it's great to work in a workplace that we can actively see the culture is changing. And we're making strides and improving the way that working conditions are for junior doctors. And, I think that's reflected in how people demonstrate their professional behaviour. I guess my closing comments would be I think it's really positive that changes are happening in this field and that behaviours that were previously taken for granted are no longer tolerated. Brilliant.

Dr Gavin Nimon: 46:31

Maura?

Dr Maura Kenny: 46:34

Thank you, yes, I think medical curricula of the future need to specifically teach the skills that we need to be. Kind, compassionate, altruistic professionals, like we spend a lot of time teaching about content of illnesses and how to diagnose and treat them. I think we need to put the right amount of emphasis on getting those skill sets up as well.

Prof Gerry O'Callaghan: 46:58

I've got two very brief remarks. One is, I think most professionals actually understand professionalism very well and understand in those moments when they fail. I think also, We know now that we need to intentionally design systems to help people do their work. And that's probably the most useful thing we can do to support professionalism and professional behavior. And the last thing I want to say, Gavin, is what you're doing with Aussie Med Ed, as an orthopaedic surgeon, talking about lung cancer and diabetes and professionalism in medicine, is actually a great example of professionalism where you're giving back to the community and giving back to the profession beyond. Just your specialty and your scope of practice.

Dr Gavin Nimon: 47:41

Thank you very much. I'd like to finish off and say, I know Gerry's been waiting for me to say this all the whole time, is the quote from Higgins from Ted Lasso, when he talks about how Roy's trying to strive towards being a perfect person, and he said, no one can be perfect, we can just keep striving in that fashion, and as long as we keep moving forward, we're heading in the right direction. I think that's a great quote from a great series. So thank you very much everyone for coming on board. Once again, thank you very much to Gerry, Maura, Patrick and Ben. Thank you very much.

Prof Ben Canny: 48:11

Thank you, Gavin. Thank you very much for listening to our podcast today. I'd like to remind you that the information provided is just general advice and may vary depending on the region in which you are practicing or being treated. If you have any concerns or questions about what we've discussed, you should seek advice from your general practitioner. I'd like to thank you very much for listening to our podcast and please subscribe to the podcast for the next episode. Until then, please stay safe.