Interpersonal Skills Part 3/4 Surgical Core

Interpersonal Skills

1. Interpersonal Skills 3/4 Hayley Howell PGY 1

2. Cultural Diversity Working Through the Barriers of Language and Differing Customs

3. What is Cultural Competence? Developing and maintaining cross-cultural skills Learning verbal and nonverbal cues of other cultures Assessing how the beliefs and behaviors of the cultural group affect individuals Acquiring knowledge  Knowing how your culture is viewed by others Reading about other cultures Developing awareness  Admitting and overcoming personal biases, stereotypes, and prejudices toward different groups Becoming aware of cultural norms, attitudes, and beliefs

4. Developing and maintaining cross-cultural skills involves: Needing to make the effort to understand patients’ medical cultural beliefs—both those beliefs that are scientifically based and those that are not scientifically based. Realizing that physicians’ goals and values in delivering care may be markedly different than patients who are receiving the care Understanding how to work with and through interpreters. This is usually done incorrectly.  Reasons why using an interpreter is so difficult Time consuming to arrange Impersonal Difficulty in communicating the meaning of the technical medical terms  Finding an interpreter is not always recognized as a need. Frequently, it is easier to use a family member to translate.

5. Addressing personally held cultural stereotypes about patients who: Overestimate or underestimate pain Arrive in the emergency department at an early stage of illness or conversely, at a later stage of illness Hold strong beliefs about blood administration Have used home remedies, which may have delayed or impaired diagnosis or treatment Will accept care only if it conforms to their value system

6. Addressing personally held cultural stereotypes about patients or families with differing values When confronted by patients who refuse blood administration during trauma, refuse abortion when the mother’s life is deemed to be in jeopardy, or insisting on ritual circumcision in a patient with a bleeding disorder, do the following: Never try to resolve these situations on your own. Always seek help from senior physicians and/or hospital administration. If you are unsure what to do in an emergency, treat the patient to the best of your ability; the other issues will be resolved by others later.

7. Understanding that cultural diversity also includes successfully earning the confidence of your patients with different: Gender identities Sexual orientations Financial circumstances Educational level Political beliefs Morals Social habits Hygienic habits

8. Important cultural skill: knowing how to use an interpreter Focus your attention on the patient, not the interpreter. Speak in the first person. Ensure that you, the patient, and the interpreter are seated so you and the patient (not the interpreter) can maintain eye contact. Explicitly instruct the interpreter to only repeat what you say “word for word.” The exchange will fail if the interpreter begins a conversation with the patient over each question—with you just sitting there.

9. Important cultural skill: knowing how to use an interpreter Prepare a clear and succinct description of common tests and procedures. Deliver information in small chunks. Put yourself in the patient’s shoes (e.g., what would it be like if I were being informed that I had colon cancer in a foreign language [and maybe in a foreign country]?). Check understanding by asking the patient to repeat back to you what they understand.

10. Types of interpreters Family member (usually a bad idea) Friend (usually a bad idea) Child (always a bad idea for many reasons) Staff member Medical student Professional (best; in person or via telephone) 

11. Develop self-awareness about your own cultural influences and biases. One of our biggest challenges is trying to understand our blind spots (i.e., “we don’t know what we don’t know”).  Specifically, we are all products of our upbringing, where we spent our formative years, our parents’ and family beliefs, the media we consume, and those with whom we interact on a daily basis. Despite our desire to learn about others, many of us have simply never been exposed to individuals of varying gender identities, sexual orientations, religious beliefs, cultural practices, and so on.  We must understand that we all have hidden biases based on our experience (unintended bias), acknowledged or not. We all must constantly strive to develop heightened self-awareness as we seek to serve our culturally diverse patients every day.

12. Stress of Surgical Practice – The Signs of Stress, Depression, and Suicide in You and Your Surgical Colleagues

13. Describe and recognize the stressors that exist in surgery. The stress you may feel has important implications, not only for you but also for your marriage, your children, and your surgical career plans. Surgeons often seek help too late—usually after irreversible events have occurred. Stress is a significant threat to surgeons. Surgeons feel guilty—like failures—if they cannot cure their patients, and they feel guilty about complications or mistakes. Coping strategies are not effectively taught during training. Specific training interventions for stress have been effective in the military, aviation, and professional sports.

14. Recognize that surgical residents are usually incapable of recognizing the signs of burnout, stress, and suicide in themselves Self-reflection is usually absent in residents who may be in these emotional states

15. Recognize that surgical residents are usually incapable of recognizing the signs of burnout, stress, and suicide in themselves

16. Burnout Depression Signs include long-term exhaustion and diminished interest (depersonalization or cynicism) without symptoms of depression or substance abuse. These signs are limited to work. If you recognize these, it is time to take a break. Signs include little interest or pleasure in doing things and/or feeling “down,” depressed, or hopeless.  If you or another resident has one or both of these signs over a period of 2 weeks for more than 50% of the time, this might be depression. You must take action.

17. Suicide Annually, there are 30,000 suicides in the United States—approximately 1 per 8,000 populations. The suicide rate in male physicians is 40% higher than the general male population, and in female physicians, it is 130% higher.  Unfortunately, residents/physicians are far more effective in carrying out suicide than the general population. Warning signs include: Sense of inadequacy, failure to help patients, and failure to live up to senior resident/attending expectations Being alone in a new high-stress environment with little support (being single and having no children is linked to higher suicide rates) Making a mistake that causes a patient’s death (personal guilt)

18. Signs of stress or dangerous behaviors in colleagues include: Alcohol on breath at any time Change in work habits Change in appearance Change in demeanor Cries for help—new risky behaviors (e.g. buying a motorcycle or starting to hang glide) Your program director has the authority to require a resident to submit to an immediate urinalysis, breathalyzer, or blood test.

19. Responsibilities to your spouse and/or significant other You did not know what you were getting into, so your significant other likely did not. Independent versus joint decision-making is a consideration. What happens if your marriage is in trouble? Divorce affects 50% to 60% of you. Do you regard your significant other’s career as important as yours? With joint careers, who gets the geographic choice?

20. Responsibilities to your children Should I choose a “mommy/daddy track” first job? How do I deal with not attending soccer games and school plays? Should I bring my kids to the hospital? Encourage them toward a career in medicine

21. Responsibilities to yourself What happens if my marriage is in trouble? What happens if my child is diagnosed with a learning issue? What happens if I decide I cannot stand my life as a surgical resident? What do I do if I cannot make ends meet financially?

22. common pitfalls surgeons may encounter with the stress of surgical practice.  Not taking advantage of resident support resources Program director Department chairman Trusted member of the surgical faculty Psychiatrist for all house staff (usually engaged by your institution’s Graduate Medical Education committee). Use this resource. Coping strategies are not effectively taught during training.

23. common pitfalls surgeons may encounter with the stress of surgical practice.  Failing to see an accurate picture in the mirror   Stress is a significant threat to surgeons. You have to be honest when looking in the mirror: You may blame yourself for patient complications or deaths. Realize that you did not give the patients their disease; you are just trying to help them. All surgeons have shared these personal and professional stresses. Most surgeons have more than one job in their careers, so you do have the ability to redefine your professional circumstances. Seeking help is a sign of strength.

24. common pitfalls surgeons may encounter with the stress of surgical practice.  Ignoring what is happening around you in the hospital and at home Understand your professional responsibilities to your family; “going with the flow” will probably end in divorce. Resolve the conflict between time with your spouse and/or children and the realities of your schedule. Allocate time in relation to your priorities, and do not let others do it for you. Try not to bring anxiety about patients doing poorly home to your significant other and family.

25. Managing Your Career – Making the Professional and Personal Choices That Define You

26. Choices all surgical residents must make during their training Junior Residents Academic practice. Involves a faculty appointment at a medical school and responsibilities for clinical practice, educating residents and students and developing an area of research or scholarly output. Many find the varied components of such a position very fulfilling, while others do not wish to have so many competing demands at once. Community practice. Working in a community hospital has important rewards professionally, personally, and financially. Surgical research. Building a laboratory, seeking grants, and running clinical trials as part of an academic practice may give great satisfaction. Nontraditional work. A nonsurgical path toward involvement in government/public policy, a “biotech” company, or business may be attractive to the right surgeon.

27. Choices all surgical residents must make during their training Junior Residents Should I pursue a year or two of surgical research during my residency, if offered, even if it means a year or two extension to my training? Should I pursue another degree (e.g., Master of Science in Clinical Investigation [MSCI], Master of Business Administration [MBA], Master of Public Health [MPH]) rather than research? Should I try to go straight through general surgery, so I can complete training (and possibly fellowship) at the earliest possible time? Should I begin to think about a surgical fellowship after completion of surgical residency? If I want to pursue a fellowship, how can I begin to make myself attractive for my desired fellowship?

28. Choices all surgical residents must make during their training Junior Residents Carve out time to build strong personal relationships with those who truly understand the realities of a surgeon’s life. Most surgical residents make decisions about a significant other/spouse during residency (if they have not already done so). Remember, more than 50% of marriages end in divorce. This rate is probably higher in surgeons. Like all personal relationships, marriage takes dedicated care and commitment to the relationship. Try to decide about having children while in your surgical residency. It is much better to plan for this possibility than to be surprised. Be honest about your financial goals. What personal lifestyle do you find most fulfilling, and how can you financially support it?

29. Choices all surgical residents must make during their training Senior Residents Decide about your career path: academic practice, community practice, basic science/clinical research, or a nonsurgical path in public policy or business (see Learning Objective 1b). Decide about fellowship choices and apply. Be your own person and make choices with the advice of, but independent of, your significant other, parents, or mentors in your surgical department. Continually rethink your personal decisions about marriage, children, and the timing.

30. Choices all surgical residents must make during their training Senior Residents Contact former chief residents and fellows in your program, who are a wonderful resource concerning practice opportunities.  Talk to senior staff; they, too, often hear of opportunities. Do not be afraid to “sell yourself.” Send “cold” letters to institutions/facilities in places where you wish to live or practice. Contact surgical journals and professional recruiters, who are good sources of hospitals seeking well-trained surgeons.

31. Choices Effecting your future career Understand that you have experienced “delayed gratification” for many more years than your fellow professionals in law, business, and finance.  Realize that the time has come to make difficult choices for which there is no right or wrong answer. Understand that choosing an academic versus a community practice will define your career; each has marvelous but different rewards. Be strong enough to emerge from the expectations of parents and your residency leaders. Resolve the conflict between time with your spouse/significant other (and your children) and the realities of your schedule. Allocate time in relation to your priorities—do not let others do it for you. Assume that you will have more than one practice pattern during your career.

32. Choices Effecting your future career Do I want to live and raise a family here? Who will I be working with on a daily basis? What is the mix of operating room, office, and night coverage? Where will my initial patients come from? What happens if I have to bail out? What will this opportunity be like in 5 years?  (Look beyond your immediate horizon.)

33. Choices Effecting your future career Is my marriage strong enough for me to take a chance on a new community and a new practice arrangement? Should I choose a “mommy/daddy” track first job that might give me more time flexibility (i.e. less than full time work)? How do I deal with not attending soccer games and school plays? Should I bring my children to hospital rounds or the operating room? Encourage a career in medicine? What about maternity/paternity leave? Understand the rules for a junior attending.

34. Elements to consider when negotiating a contract Find a lawyer versed in contract law—not your parents’ lawyer or a law school friend. If you are thinking of joining an academic practice, learn about the promotion and tenure considerations. If you are thinking about joining a community practice, find out about the partnership arrangements.  How long might it be until I attain full partnership?  If I have to bail, what are the separation requirements, including noncompete clauses? Ask about coverage arrangements and call schedule.  Find out about office support (e.g., nurse, clerical help, and billing arrangements). Do not “give away the store.” This is your only moment of leverage

35. difficulties encountered when creating your personal and professional goals as a resident Understand that “going with the flow” (i.e., following the expectations of mentors, parents, and significant others) is usually a prescription for disaster. Do not just blindly agree with your mentors, who want you to follow them into academic practice, or with your significant other, who may want you to practice in a community hospital in a leafy suburb.  For possibly the first time, look in the mirror and decide what really are your “number one” personal and professional goals. This can be intimidating, but there are no bad choices.  Do not fail to understand that many surgeons “have more than one career” in surgery (i.e., they move from academic surgery to community practice). Just because you are a professional, do not hesitate to seek the advice of other professionals as you start out in your career (e.g., lawyers to help negotiate your contract, investment advisers to help with your long-term financial plan).

36. References Jackson, H. T., Ahuja, V., Augustin, S., Briggs, K., Hochberg, M., & Klingensmith, M. (2023, January 18).  Interpersonal Skills, Part 3 of 4 . SCORE | TWIS. Retrieved March 7, 2023, from https://www.surgicalcore.org/moduleContent.aspx?ID=1000799&currID=1&currTopID=786