Crista O’Hana S. Nobleza, MD, MSCI
University of Mississippi Medical Center
Aleksandra Yakhkind, MD, MS
Neurocritical Care Fellow
University of Pennsylvania Health System
Do you have questions regarding your professional life? Is there a conundrum at work that requires an outside perspective?
The Trainee Section and Women in Neurocritical Care (WINCC) Section have teamed up to publish a new column in Currents to serve your professional advice needs. Submit questions to email@example.com, and we will get them answered by a seasoned advisor. We believe in lifelong learning and mentorship, and this column along with our mentorship programs, are tools for your professional success.
We are thrilled to publish our first ASQC Currents submission. Read on for professional advice for senior WINCC members on how to deal with interpersonal conflict regarding hierarchy in the neurocritical care unit.
I am a pharmacist in a large neurocritical care unit. One senior attending who I work with gets offended when I bring up ideas on how to improve medication management. I am polite and try to ensure the safety of our patients. How should I move forward? Should I talk to my supervisor? Should I be less polite?
Your Local Pharmer
Dearest Local Pharmer,
I’m glad that you brought this problematic situation to the attention of all, as you are certainly not the first and will not be the last to deal with a difficult colleague. In our profession, it is of the upmost importance to work together to ensure the best outcomes for our patients, which often is a tug-of-war when it comes to the “art of medicine” and paucity of data in the patient population we treat.
Working with an obstinate colleague can make even the most cool-headed provider frustrated. These individuals are found everywhere in our lives from the work place to PTA meetings. Hopefully the tools below can provide guidance not only at work but in other situations as well.
- Maintain your politeness during your interactions with your colleagues. Composure is seen as a sign of control and respect. Rudeness and snarky comments are off-putting and can drive a further divide.
- Be confident and prepared (with data if available) when making your recommendations. Stick to high level, meaningful recommendations initially and use the opportunity as a teaching point to everyone, including residents, fellows and nurses. Do not use recommendations as a podium to make your colleague look incompetent. This can be effective if the delivery is confident, data driven and not emotional.
- Make your recommendation with the above foundation and then listen. Hopefully your colleague will attempt to provide his or her counter position for not accepting your proposal.
- Ask questions and try to understand his or her intentions. Perhaps the motivation for the lack of acceptance is a different understanding of the literature, as more senior clinicians have experiences to guide their decisions or they are egotistical and dislike others presenting them with different ideas. The latter is much more difficult to comprehend, especially when caring for sick patients. If this is the case or you are unable to decipher the underlying stimulus, reach out to others who have worked with this individual for longer to get perspective. You may find that there is a past situation that has created this circumstance.
- Discuss, in private, your perspective and include your interest in high-level collaboration with this individual. Be honest, not emotional, with how you are feeling with the current situation. If necessary, highlight specific examples, as your colleague may not even realize they are causing this frustration. Hopefully this will help build a respectful rapport that can flourish.
If all else fails and you believe the patients welfare is at stake, escalate to a higher authority for resolution. I would not recommend this approach unless you have completely exhausted all other means. Although this is an option, I have found this approach often creates animosity and can create more tension.
I hope these suggestions help in creating a work place that is healthy and multi-disciplinary!
Theresa Human PharmD, PhD, BCPS, FNCS
Barnes-Jewish Hospital/Washington University in St. Louis
Dear Local Pharmer,
My recommendation would be multi-fold:
If possible, schedule a time to meet with this attending to understand how to partner together in achieving the medication goals when they are rounding. In this meeting, share your perspective that communications during rounds to date suggest your input is not well received. Ask how to best communicate with this attending during rounds. You may want to include your supervisor in the meeting, depending on your comfort level.
Secondly, be sure you are well prepared and focused with recommendations. Choose your battles carefully. It is helpful to organize, focus and define the pharmacy recommendation/concern under a category of effectiveness, safety or costs before raising it on rounds. Most teams can agree to discuss any question formulated from one of these three areas.
Example regarding Effectiveness: Your attending has recommended Antibiotic Y. Antibiotic Y is broad spectrum that covers SPACE organisms, but the CSF and sputum cultures show Gram + cocci.
Step 1 Preparation: Before rounds, formulate a clear, focused question targeting your effectiveness concern. Your recommendations should be well structured and succinct. To be effective with this approach, preparing in advance is essential. It’s best to be proactive by anticipating the issues and follow up questions from the team. Thorough pre-rounding preparations evaluating the medications, patient responses and any other necessary data will help avoid being reactive on rounds.
Step 2 Communication: A potential reply to your attending could be, “Are we concerned about SPACE organisms causing infection in this patient?”
If the attending states no, and you would like to recommend an alternative, your follow up might be, “Is it reasonable to think about switching to antibiotic X in this case because Antibiotic Y is strong for SPACE organisms but is not as effective against Gram + cocci?”
Regardless of the answer from the attending, your question will lead to improved understanding of what the team is concerned about and will also provide insight to them about your concerns.
If there is pharmacologic, pharmacokinetic or pharmacodynamic evidence supporting your recommendation, be sure to state it. This might include, “Antibiotic X crosses the BBB and has better concentrations in the lungs against the Gram + organisms seen on culture”. Similarly, if it is a safety concern, asking the question or stating the need for adjustment based on risks is usually well received. Cost management discussions are always challenging and may require more guidance from supervisors on best approach.
Speaking with your supervisor is always a good idea as they may have individual experience with the attending or similar situations and can provide sage advice for next steps.
Step 3 Professionalism: It is never appropriate to compromise your own professionalism (being less polite) in response to another person’s behavior. Remember that you can only control yourself. At the end of the day, modifying your approach in a respectful manner in order to achieve the ultimate goal of patient outcome is what matters. Most who win the battle don’t win the war.