 one, I think we'll go ahead and get started. So I am so happy to be able to introduce Zach Drapekin, who is over at Primary Children's in the ED, and who is very passionate about how we communicate in medicine. I don't know if you guys realize this, but we're not very good at it. And, and that's pretty much the hallmark of everything we do, right? It's communicating with each other. It's communicating with patients. It's communicating with insurance companies and we do it in so many different ways. And of course, we're all human and in 10 situations, conflict happens. And I think I know my preferred method of conflict resolution is probably all of your preferred method, which is to ignore it and shove it way down deep inside me. And then usually have it come out at the person I'm not actually having conflict with, particularly like my husband, which I know he really appreciates. Anyways, we're going to learn better strategies for dealing with conflict in the workplace today. And so we're going to start with a lecture and then we will be breaking into smaller groups to kind of put some of these lessons into practice. So for those of you on Zoom, you can actually do like a little zoom chat if you wanted to or you can feel free to Okay, excellent. We've got breakout rooms on Zoom. So if you would like to participate on Zoom, you will still be able to do that as well. A lot of these scenarios are things that we encounter in everyday life. Some of them were with input from you know, the people that run a number of our divisions. And so these are things that we're actually dealing with here at Moran. And then a lot of them are also just things that you may encounter over the course of your career. So I've talked too long already. Zach, thank you so much. Thanks so much. And thanks so much for having me. I really appreciate being here. So I just want to first off start by just doing a big disclaimer. This is about managing interpersonal conflicts and medical setting in the goal of achieving good patient care. This is not an HR talk about how to deal with mistreatment or harassment and stuff like that. That's a completely different issue, different topic. And this is not what we're doing right now. So I want to start by just telling a story about why I'm here today talking about this because this is kind of an odd topic to be talking about for most people in medicine. When I was I did a ER residency, then I did a Pete's fellowship. I was feeling pretty good after I finished my residency, loved my job. I was doing I felt like I was doing great in fellowship. And then I got my first set of feedback. And it turns out I was a dumpster fire to work with, like the nurses, the techs, everyone hated working with me. I was like way too intense. I was not I didn't create a good working environment. I got a lot of feedback. I was not expecting and I was causing a lot of conflict in medical settings. And it really took me by surprise. That's not how I viewed myself. So I was fortunate to have some mentors who are really helpful. And I approached them and asked them, like, what do you do in these situations? How do you deal with this conflict that comes up every day? And my boss now, Howard catish gave me the best advice I heard in this is that no one's naturally good at dealing with conflict. It's not a innate skill that you're born with it to learn skill just like everything else we do in medicine, just like doing a physical exam, taking a history, seeing the fund is whatever it is, it's something you learn by practice and deliberate practice and actually learning the skills. So I went in a deep dive after that and and really explored how other specialties address dealing with conflict. And I learned a lot from by taking like a law course, I talked to people in business in the HR talk to people in medical specialties that routinely deal with conflicts like palliative care and child youth pediatrics, red books on hostage negotiation, all sorts of things and was able to put together some tips and tricks. And the thing I found most interesting about this is that medicine is the thing we think we'd need it the most like we're dealing with people in their worst hours we're dealing with people in stressful situations where they have loss of control conflict is a daily part of our lives. And we don't know how to deal with it. It will like lead us to death by 1000 paper cuts. It's really painful. And it just like you said, it's a burden on you if you don't have the skill set to deal with it. It's kind of interesting me that no one else really taught me in medicine how to deal with this and I did learn it from other specialty. So I had a chance to put it all together in terms like what I thought was the highlights of things I stole from other places and and come up with some tips and tricks that have really helped me out a lot. So I'm really excited to be here. So the key thing this is I'm not good at this. This is all things I learned and when I was learning about conflict, the first thing I learned is I had a George Costanza moment that every intuition I've ever had is wrong. That when it comes to conflict, like I was used to like, you know, this is why I'm right. This is why you're wrong and this is why we should move forward like this. And that's in medicine what we're trained to do, right? Like we're trained to have logic and to be logical people and to convince people that we're right. And that's what we do as consultants. We talk to each other on the phone and we're selected for that when the medical school application process like literally what's selected for it turns out that's just not productive when it comes to the day to day interactions and conflicts that happen. So I what I found is that I was doing everything wrong. Every tuition I've ever had is wrong. I kind of had to start over when I was when I was learning about how to actually deal with this. Like you mentioned, there are kind of three approaches for dealing with conflict. One is the serenity now approach where you just kind of say like, okay, I'm just going to ignore this. I'm going to push it off. And that's okay for the short term. And I would say I use this all the time if I wake you up at three in the morning with a crappy console and you're short with me, I just let it go. It's fine because I'm going mountain biking the next day. I'm cool with that. But eventually, like you said, it does build up in you and you can't hold it in forever. And you end up taking out other people. It ends up showing in your body language and your nonverbal cues in your tone of voice. It comes out. And also you don't have the opportunity to share your input. So it actually is detrimental ultimately if you use that as your only technique. Dug or not. This is what I was doing. This is where you just put your head down and get what you want. And it can be effective in the short term, not in the long term. You end up creating a bunch of dumpster fires as I learned in your path. And you also lose valuable input from your team. And also you the camaraderie that happens in the workplace is one of the most enjoyable parts of being in a productive work environment. And you lose that. And that I think is a huge cause of burnout. So this will work in the short term, like just waiting to get senior enough to get your way. But ultimately, it's not effective long term. What I learned is that there is a way of going about conflicts where you actually learn skills to empower yourself to deal with them effectively in a way that you can get what you want, but also preserve relationships. And it was a really interesting skill set to me that was completely nonintuitive to me and completely different from anything else I learned in medicine. So that's why I want to talk about today is the skill set that will empower you to deal with these conflicts in a way that doesn't crush your soul. The way doesn't destroy your relationships around you. And ultimately, I think it's one of the major causes of burnout in medicine is that we are not trained to deal with conflict. I mean, it's one of the most we know when it looks forward to dealing with conflict. Once you have the skill set to deal with it, we all like hard things, and it's nice to do hard things when you have the skill set to deal with it. So I'm hoping to give you some of those skills so that this is no longer like something you dread, but something that you're actually able to deal with and kind of look forward to. It's like a psychosocial jujitsu match. So the goals for the session, I'm going to talk about some ground rules of reframing conflict that will be crucial in terms of getting to better results. I want to talk about some common word traps that come up that just completely derail things, and it's fun to identify those when other people are using it, but also to make sure you don't use those word traps. Talk about some Jedi mind tricks that just put people at ease and get things going the right way. And then last, we're talking about an outline for managing conflicts and most importantly, go through some cases that are hopefully are relevant to you guys. So generally, when a pediatrician who works part time is giving a talk about feelings, there's no conflict of interest, and that's the case here. So I want to talk about some misconceptions with with conflict. First one is the one I had is that we're trying to prove that we're right and the other person is wrong. And if you have that attitude, it's just not going to be productive. And again, this is the attitude that makes us successful in medicine because we're used to proving our point and finding the right answer. And it turns out if you're trying to prove that you're right, you're just going to go in circles and not going to get anywhere. People are not very good at being told that they're wrong. So I think the first thing you think about is conflict is not a means of showing that we're right. The other person is wrong. Our goal should really be achieving mutual understanding and finding a path forward. So I think that that's the biggest thing, the biggest like take me remember nothing else. When you're in a conflict with the person, don't think about trying to prove that you're right and they're wrong. Think about how do I understand the other person and how can I help the other person understand me so we can move move forward. One thing that is tough with that is that we don't like being told we're wrong either. And it's really tough on us. And I think that the one of the most liberating things when you're dealing with conflict is to realize that you always each of us, me, everyone contributes to the conflict in some way. It could be that last time the person came up to me with suggestion, I was short with them. It could be I didn't have a good tone. It couldn't be I may be not receptive. I maybe didn't ask what their opinion was. There's something I may have done to contribute to the conflict. And the sooner I just acknowledge that the better. One thing in medicine that we were really bad at is engaging in all or nothing thinking we're either good or bad or competent or incompetent. And you can be a good caring physician and have made an error. You can be a kind person and have hurt someone by your actions. So the sooner that you drop that liberate yourself from that all or nothing thinking and just realize that yes, I've contributed this conflict. I need to understand how I contributed this conflict and acknowledge that the sooner you can move forward and avoid that cycle of just beating each other up. So this is one of the key points is what I like to call the lizard brain. So we all think that humans are rational people because we have an inner monologue that's very complex and tells us things. And we think that we're very, you know, rational. We're used to dealing with logic, especially in medicine. There's been a lot of really cool studies in psychology that have broken the brain down into two thought processes. One is our slow deliberate process. And that is our inner monologue. It's our logic, it's our reason. And the other is our flash judgments, what I call the lizard brain. It's related to the fight or flight response. It's ingrained. It's subconscious. We're not aware of it. And it turns out it has a very large play in our actions and a day to day basis. Our lizard brain has more control than we like to give it credit for because we don't hear we're not aware of it. And when there's a perceived threat of some sort, lizard brain wins hands down. So if there's any sort of threat in the beginning of a conflict, there is no ability to have a rational reasonable discussion. And there are certain things that trigger the lizard brain and again, a perceived threat. And in medicine, one of the biggest things that we have is when you attack someone's character identity. Now I'm not talking about my identity is like a middle age balding dude who likes to play basketball. I'm talking about my identity as someone who's a caring physician, someone who works hard, someone who's a good educator. If that gets attacked, I want to get real defensive. I want to shut down and I'm going to get nasty. So one of the first things we have to do is we have to realize how can we deactivate our own lizard brain so we can be rational and how can we deactivate the lizard brain of our counterpart so we can have a rational discussion moving forward. So reframing conflict. This is a really cool example I read in a book that I really like. So let's say that you are going on vacation and a beach and you're swimming and you're taking some snorkeling class and all of a sudden you see a 22 foot long basking shark come up, swims by you, checks you out, it swims away. What's your response to that experience? Was that? Get out of the water. Fear. OK, so I'd have the same response, right? I'd be afraid, fear, terrified, mind blown. What if I would tell you that that 22 foot long basking shark is the second largest shark in the world that feeds on plankton. It's completely harmless to humans and seeing one is a once in a lifetime opportunity. There's no danger to humans. How would you describe that same experience? Yeah, so some people still say fear. Some people say super cool. Some people say excited. Some people post on Instagram, whatever. It's a completely different experience based on that one little fact. It's the same basking shark. It came up to you the same way. It had the same set of events, but you experienced it completely different because of your background because of your knowledge. So I think that it's important to remember that everyone perceives experiences differently. And we have to work to understand how our counterpart perceived a given experience and try to understand them, understand them and rather than trying to explain them how they should be seeing it. So I think that that's the key thing is that everyone has their own basking shark moments. Everyone experiences things differently and we need to understand where they're coming from in order to understand how we can be forward. Another problem that we do is we are really quick to write a story when we're having a conflict. We're quick to call someone a jerk. We're quick to call someone incompetent. We're quick to call someone lazy, whatever it is. And here's an example I read from a book also that I really liked. Say that you're driving to work and you get stuck in traffic because there's a Maserati double parked in front of a nice restaurant. All the cars are stopped and you're now 15 minutes late for work. What story do you tell yourself about the driver that Maserati? They're entitled, they're jerk. What else? They're an asshole. Yeah, for sure. All these things, I would be saying the same things, right? Now, say as you're driving by, you see it's actually a physician and they've their post night shift and they're providing first aid on someone who claps on the street. What story do you tell yourself about that person? OK, so you're just as inconvenienced, right? You're still late for work. You're still inconvenienced. The person is still double parked and stopped traffic. But you've called the completely different story about the person. The truth is we don't know what people's intentions are. We only know about the actions we know about the impact it had on us. We don't. And so when we focus and we blame people for the problems at hand, we're prone to cause conflict that just escalates and again gets into people's character identity and activates the lizard brain. We're free to talk about the actions. We're free to talk about what happened. But when we assume what people's intentions are, which is so easy to do, it is so easy to get into trouble. So I think that one of the key things we want to separate people from the problems at hand and focus on the problems. We want to focus on actions rather than what people's intentions may or may not have been because the truth is we just don't know. And the last thing is we want to focus on interests rather than position. So this is a concept from mediation in the business world. Interest is the why. So and a position is the what? So say if I'm in the ER, someone comes in saying, I'm demanding an MRI of my child's brain like right now. I'm not leaving to like an MRI. That's a position. I can't do anything about that. I can't get an MRI in the middle of the night is I just I just can't. But if I get the what the why? I'm worried my child has brain cancer. We can have a discussion. We can go somewhere. We can get somewhere with that. So I think one of the key things we have to figure out is not what the person is saying or counterpart saying, but what is the underlying issue at hand? All right. So those are some just backgrounds in terms of reframing conflict. I feel like this is one of the most high yield slides in this talk because it's something that we all do all the time. And once you become aware of it, you realize how often you see it happening. These are words that just have a magical ability to activate people's lizard brain and cause them to freak out and does the same thing for me. When people say these things to me, I lose it. So it's really helpful to identify these things so that you know to avoid them and also realize when you've been triggered and your lizard brain is taking back over. So some of the words that really cause problems and conflict are always and never. There's a couple of things wrong with always and never. First off, they're almost never true when you say that and it creates a cause for debate and also you take up what is a problem or an action and make it about someone's character identity. So you've activated their lizard brain and you've caused just an argument over something that really doesn't need to be an argument. So using always or never are very often detrimental. But I'm sorry, but you really can't do that. When you say but you just invalidated everything you said before then. So just mean you just be realized that if you're if you're apologizing, if you're trying to get somewhere and use the word but that's a word that you're just displaying to the other person that you really don't really mean what you just said. So just be very careful when you use the word but I do though my wife all the time she hates it. You. So this is a tough one. When we say you, we are prone to assign a judgment to a person or tell someone what to do. So you are unprofessional. You were late. You were not related. Okay. Cause that's that's actually an action, but you were inconsiderate. Those things create an argument about what is unprofessional, what is inconsiderate and also attack someone's identity. So when we do that, when we assign, when we were telling someone how they're behaving rather than what actions they did, it triggers a lizard brain and they will shut down. Likewise, if you tell someone you need to do this. Oh, teenage brain takes over and teenage brain is almost bad as lizard brain. People don't like being told what to do. So we can have a conversation about how we can move forward. But when you tell someone what to do, it doesn't work that well. Why? Why is a tough one? Because we want to get at the why we want to get at the interests, but when we sometimes start it by phrasing why do you why are you worried about this that comes out as questioning their logic, questioning their experience. Oftentimes it's a little more it's a subtle difference, but what about this has you concerned? What would you like to see different moving forward? These type of things can come at the same issue without seeming like we're questioning the other person. Just and only. Just and only is a good way of minimizing the other person experience, which again will trigger lizard brain and they will get very defensive. You're I'm only running five minutes late. This is just one extra assignment to do. These things will minimize their concerns, minimize their experience, make them feel like they're not heard and people will shut down when they hear this. Calm down. It doesn't work. Telling someone to calm down just doesn't work. You don't get to tell other people how to feel when you tell other people how to feel lizard brain feels threatened and you will shut down. You want to see someone not calm down, tell them to calm down. So those are things that can go terribly wrong during a conflict. I'm going to check my time. Let's talk about things that we can do moving for the Jedi mind tricks. And a lot of these things are remarkably simple and we know them intuitively, but just are very bad at doing them in real life. The first one is listening. And I mean really, really listening. I think that we all know about active listening is to sit down, make eye contact, all that stuff, but listening is not a skill. It's a choice. We actually have to listen to understand where the other person's coming from. What we're used to doing in medicine is listening to wait our turn to speak. We're used to listening so we can make our counter argument to the other person. That's not what we're trying to do. We're trying to listen to understand where the other person's coming from. One thing, a couple of choices that a couple of word phrases that are really helpful in this is help me understand. When you get in trouble in a conflict and you always use the word phrase help me understand where you're coming from, help me understand what you're concerns are, it really opens things up. It really deactivates the other person's lizard brain. And one of the most funny things I see is that when I say that and people just like vent at me, usually end up apologizing for all the things that happen like without me asking at the end of it is they just need to get stuff off their chest. That phrase works magic. I'm hearing so I'm hearing and then stating back what the underlying interest is that again, you are showing that you're listening. You're showing that you care about the other person and that will help the other person turn down their lizard brain and feel deactivated. People will not will not listen until they feel heard. So if you feel like you're going back and forth in a conflict, you're trying to explain the same thing over and over again. It probably means that the other person is not feeling heard. And you just need to stop and really listen and understand them and then also validate their experience. I can see why that would be a frustrating experience. Like it really makes a huge difference to say that and you can actually with that phrase see lizard brain just kind of like toned down to human brain be like, whoa, I said some crazy things a couple minutes ago. I'm going to back it down. So these phrases can make a world of difference in terms of helping you with the listening, which is the first step. Because again, no one will listen until they feel like they've been heard. Next is framing this discussion. So this is where we really want to to make it clear that from my perspective, I'm focusing on the problems rather than the people. I'm focusing on actions rather than tensions. And one of the things I find most helpful for doing that is to explicitly say that the problems are the things that we're working with and that I know it's not your intention. And those two things will disarm people and make people willing to listen because no one wants to hurt other people. No one goes into medicine because they like being a jerk and they like causing conflict. But we all do. And if we are if we're called a jerk called incompetent called mean, we will get defensive. We'll argue back. But if someone tells me about their experience that my actions had an impact on them, I'm going to listen. I don't want to be a jerk. And and I'm not, you know. And so I think one of the things one of the phrase I really like to that is I like to share the impact of blank event or blank action had on me. Again, I'm not even saying I try to avoid even saying like the thing that you did. I'm saying that conversation what was said in that meeting stuff like that. It really separates the person from the problems at him and really makes it clear that I'm really want to fix the issues here and not criticize you as a person as a person. Then adding on, I don't know what was not your intention. That makes a huge difference when we acknowledge that people's intentions, we don't know what they are, but we just want to focus on the actions that impact it has on us in a relationship. Lastly is don't get defensive. We all contribute to conflicts. So the sooner we acknowledge that, the better. There's this idea of drop and rope that if you feel like you're in a tug of war with another person and you're going back and forth and not getting where it just dropped the rope. Just get on the other person's side and say and try to find a common common goal. Acknowledge how you contribute to the conflict and that will make a world of difference because all of a sudden, instead of arguing about who's at fault, you're finding ways to move forward. Last is sharing your perspective. I think this is a hard one because we do have valid perspectives that we need to share. This is not a course and in canning up your feelings and just wait until they explode when you get home. This is about finding solutions moving forward. I saw you laughing at that. So there are effective ways to share your experience and it's important to do these things effectively. So one of the things is I statements and I statements are tricky because we are allowed to say talk about simple, unemotional, undeniable facts and we're allowed to talk about how those impacted us. So an example of my statement is when when that was said during the conversation, I felt hurt because I felt like my perspective was not heard. Moving forward, I would really appreciate if you asked my opinion before we make these changes, something like that. Again, I'm separating the person from the problem. I'm talking about how that undeniable, unemotional action impacted me. What an I statement is not is I feel like you're an incompetent jackass. That's not OK. You're not allowed to label other people. You're allowed to talk about simple, undeniable, unemotional facts and the impact that those things had on you. Not labeling those things, but the impact it had on you. So I statements are tricky because people oftentimes fall into the I feel like you are unprofessional. I feel like you were create an unsafe working environment. Those things create opportunity for argument. We want to talk about simple, unemotional, undeniable facts that a newspaper reporter would say and how it impacted us because no one could ever criticize us or argue with us about those things. The other thing is I wish I wonder I worry. This is a great way for bringing up concerns or bringing up disagreement with someone in a way that is not as confrontational and allows them to empathize with you a little bit as well. So these phrases make a huge difference. So this is what I like to call the four step approach in terms of how to approach a conflict because these are really challenging to deal with. And and I think it's worth going through these steps. And then we're having about another five minutes of didactic. And then we're going to spend the rest of the next 55 minutes going through six examples that are hopefully very relevant and feeling real and probably a little raw to you guys. So the first thing I like to think about when I approach the conflict is what are my goals of the conflict? If my goal is to prove that I'm the alpha dog and that the other person cannot behave that way, that's fine. It'll probably hurt me in the long run, but I'm going to behave very differently than if my goal is to try to understand where the other person is coming from, help them understand where I'm coming from and find a path moving forward. So the first thing is just to think, what is my goal? What am I trying to get out of this conversation? As we different different times, like I said, if I wake you up with a crappy console at 3 a.m. and you're short with me, I'm probably not going to like bombard you with I feel statements. I'm OK with just letting that slide. But if every time I call a consultant and they're rude to me and their staff and make me feel uncomfortable and I value that relationship and I want to change it moving forward, yeah, I need to put the work in. Next step, deactivate your lizard brain and deactivate the other person's lizard brain. So the first step is your own lizard brain. Best and most important thing is just taking space. If you're like mad and revved up and you can feel that your tense and then all those signs that we all get, that's going to come off in your in your nonverbal cues is going to come off in your tone of voice, come off in size and rolling your eyes and it's going to come out. So you need to take space and make sure you're in a space where your lizard brain has not taken over. I mean, sometimes what I do is I sit down. I like vent with my wife. I write an angry email. I don't send it. I just let it sit there and I come back like two days later when I've had a time to mountain bike and ski and feel much better as your doctors do. So first is deactivate your lizard brain. The other thing is make sure you deactivate the other person's lizard brains. And the way to do that is you have to very deliberately with those Jedi mind tricks, separate people from problems, very deliberately separate actions from intentions and then try to get an understanding of where they're coming from. And if you want to bring up something that's troubling you, again, start with simple, undeniable, unemotional facts and how it impacted you. You always have the ability to talk about those. And it's very hard to argue when you say something like those, when you start with those things. Next is to understand where the other person's coming from. That's where that listing comes from. Again, if you start by just explaining why you're right or explaining your experience, people won't listen until they feel heard. So it really, it makes a big difference and it may seem silly, but you need to understand where the other person's coming from. You need to understand how they perceived their basking shark moment and how they perceived your contribution to the conflict. You need to understand what underlying interests are rather than positions and how we can move forward. So just really listening to understand and not listening to wait your term to speak is absolutely key. And if you don't do that, people will not listen to you until they feel heard. Next is bring it back to your goal and share your perspectives. This is where you can use those I statements. I wish, I wonder, I worry, I feel. Those I statements can be really effective in terms of bringing back to your perspective. And one of the things you wanna focus on again is how do you address your goal for the conversation while also acknowledging and finding a solution that involves the other person's concerns? And I think using that phrasing is really helpful. So moving forward, how can we address your concerns while also addressing these issues that I'm concerned about as well? That makes it so it's a collaborative effort and rather than just a negotiation or a boxing match more commonly about who's gonna be right and who's gonna be wrong. So these are some tips and tricks. The next thing we'll do is an exercise and this is gonna take the majority of the time for the session today. I like to call the Jedi time machine. So everyone should have a worksheet. If you don't, we have extra ones here. And in the breakout groups, they will be posted as a link and we'll have breakout groups on Zoom as well. There are six scenarios that are listed here. I'd like you to take 35 minutes to go through these six scenarios. In these six scenarios is a brief vignette and then there is an example response of things gone awry. And what you have to do with that example response is underline the work traps that you identify. Things that will deliberately make this conversation a lot worse. And I want you to rephrase it using the Jedi mind tricks and using these, the four steps, the establish your goals, deactivate lizard brain, understand where you're just coming from and bring it back to your goal. I want you to get into groups of about three and work together because this is not an easy exercise. And I oftentimes will do this when I'm encountering conflict and medical settings is I will run it by other people. I will show people the draft of my email. I will write down how I'm gonna phrase difficult conversations. And it really helps to have that neutral observer, that third person to give you feedback. So I want you to get into groups of three, I'll be circling around the room just to listen in on your conversations. We're gonna reconvene in about 35 minutes. Now it may seem ridiculous that we're gonna take 35 minutes to write six sentences. That's what the effort is. And that's like fast. You're gonna see. So we're gonna do that exercise. I'll circle around the room before we do that. I wanna see, are there any questions or any comments or any concerns with the content of the didactic before we go into the application of it? Yes. That's a lost cause. Yes. Oh, thank you. Thank you so much for reminding me. Please mix it up. So I don't want like all residents, all attendings, all fellows. I would love to have a mixture because these cases are, I'm not trying to paint one group of people as the bad guy. I'll take the hit in the ER. We were printed as the bad guy in one of them. But I wanted to be a mixture. I wanted to show that this is about finding paths forward and understanding where other people are coming from. It's really helpful to have that experience of different levels of training, of different levels of medical hierarchy. So please mix it up into groups of threes and we'll reconvene at 840 to kind of bring it back together. Thank you so much, everyone. I've heard some really great conversations about these cases. I wanna go through just as a big group to kind of summarize the take home points from these cases. And then summarize the take home points from the talk as a whole. So I'd like to start by just going through the cases one at a time and hear the approaches that different groups have come up with and some of the conversations that they came up with. So the first case that we had was the late colleague, the 25 minute late, there's traffic. So could I get a group to volunteer about how they would potentially address the conversation like this? No volunteers, I will volunteer. This group here. Yeah, I think some of the things we talked about were first of all, having this conversation not in the moment when this person is showing up to clinic 20 minutes late and waiting room's full, kind of creating the space to talk about it in more detail. And then there's a role too for making an observation and saying, hey, I notice that you're showing up to work at this time. And there's kind of two parts to that. That you can also talk about, hey, is there something going on that's keeping you late? Like, is there something going on at home? Is there kind of asking more questions of the person of what is leading to that? So they also know that you're not just jumping to conclusions about what's leading to it, but also talking about I statements that saying when you're late or when you can even say it generally, when people show up late, this affects the rest of the team in the way that where clinic doesn't run on time and people are not being seen in a timely manner, making those observations and then kind of inviting them to talk about how can we come up with some solutions for this? Well, that was really great in multiple levels. So thank you so much for sharing that. First, I wanna say that, yeah, people won't listen until they feel heard. So I think that that's key. We don't know, this is a Maserati example. We don't know what is going on in their lives. We don't know about their experiences. We don't know what's causing them to be late and we're not curious about it. People would generally shut down. They won't listen until they feel heard. And in truth, we might get some really valuable information about what's going on in this person's life. They might have just had a divorce and lost their house and we don't know. So being curious is key. And then you are never wrong with I statements where you make simple, unemotional facts when you showed up 20 minutes late. That's an undeniable fact and the impact it has on you. So that's really a great approach to that. Any other discussions that people had about this case? What do you wanna bring up? I love your point about not in the moment because your lizard brain is active. I mean, I get, there's one thing that pisses the hell out of me and that is tardiness. I despise tardiness. And if people show up late, I lose it. When I was a chief, I used to call the other services chief and wake them up so they could yell at their resident if they showed up late to the ER. I mean, it was really bad. But so for me, this really hit at home. But sometimes to address this, I need to wait a couple of days. I need to do my own internal venting and then address it. Sure. Yeah. Yeah, and again, that's not judgmental. It's just I wanna share the impact that this action has. And that's why I like that phrase. I wanna share the impact that event or action has. Again, you're separating the people from the problems. Let's go to the next case. Thank you so much for that discussion. Next case. Oh, the ER. The second year residents are gonna love this case. The crappy consult from the ER. So can I get a volunteer about? I'm gonna go to Dr. Wilkinson because he's my resident on consult. So he's in the thick of it right now. You did. All right, Dr. Wilkinson's team. All right. So we talked about starting with kind of acknowledging kind of your shared concerns, see some sort of statement along the lines of like, I see that you're concerned about this patient and then explaining kind of your interests and why you want more information. So explain that we cover multiple hospitals. I've got a long list of patients. I need to figure out how to triage these patients. If we could get a few more things on exam, that'd help me kind of prioritize who to see next. But I think that's completely valid. Like everything you said there is completely valid. And it's hard to argue with that, that you need this information. It's not that you're a bad doctor. It's that I need this information is what you're saying. Any other discussion that happened on that case? Emitory statement. Yeah, that's fair. Like sometimes it's gonna be tough and that's depends on your goals are. What are your goals of the conversation to get through this consult and just get through the night or is it to have a relationship? One other point I will say with this is one thing to always remember is people won't listen until they feel heard. And if someone is behaving badly, they feel threatened. Their lizard brain is activated. They just don't know that. And so one of the best things you can do in that situation is to figure out what from their experience what was their basking shark moment? What made this experience tough for them? So it's something simple. I stole this phrase from a resident who used it on a tough interaction with a nurse they had was, hey, it seems like this was a tough interaction. Tell me more. What can I do to make this interaction better? And people will just vent. They will unload and they'll usually apologize like immediately after. But once they have a chance to feel heard, it makes a huge difference in their ability to listen. Two hands, yes. To that effect, I was thinking of this sentence to perhaps de-escalate and maybe establish a shared goal saying something like, I can see things are really busy in the emergency room and I really want to help you. And so that way we can all just realign ourselves. And then the next thing I said was something like, when I don't have enough info about the patient it's really hard for me to give good advice and then following with what Sam had said later on. I was gonna say actually the same thing and that was kind of out of a discussion with this group over here where Jordan was like, one of the things that drives me crazy is when it's like, well, the person on the phone's like, I'm just trying to advocate for this patient and the assumption is of course that then you are not advocating for the patient. So something that like what Tony was saying puts you both on the same side. Like we are both 100% working to make sure we are taking care of this patient. I know that that is your number one priority. It's my number one priority. I can't do that unless I get this information. So... I like the shared goals and the moving forward statement. So I understand that this has been a frustrating experience for you because oftentimes you feel like you're belittled by consultants or whatever information you got from listening. I also need to get some information to make sure I can take care of the patient with both the same goal of taking care of this patient. Moving forward, how can I make sure that I address your concerns about how I talk to you while also getting some critical information that will be important for me to treat this patient? Brown was saying, kind of setting somewhat of a boundary and saying like I'd appreciate if you don't speak to me that way. Cause I mean, at some point, especially if it's like repeated behavior, you know, residents who are on call, don't have post-call days. It's hard when like multiple people are calling you and if they're speaking to you in a rude way, I think at some point it is maybe necessary also to just set a boundary and so how would you do that and when do you think would be like best to address that so that you're not still getting their lizard brain? So any thoughts from the groups? I'm sure other groups had that kind of discussion. What ideas have you had about setting boundaries in a situation like that? I saw a hand go up here. Yes, totally agree. So I think that that's a perfect use of an I statement. Say, hey, when you said just see the damn patient, that's an undeniable, unemotional fact that I'm just like a newspaper reporter. When you said just see the damn patient, it made me feel like I was not being valued as a colleague and like I was being in, made me feel incompetent and inconsiderate, whatever emotion you wanna label for yourself. Cause again, you are always out of liberty to discuss simple, undeniable facts. You're always out of liberty to talk about how those simple, undeniable, unemotional facts impacted you. Moving forward, how can we make sure that we are most effectively communicating together, both me in terms of talking to you on the phone to the consultant and also communicating a way that's respectful and doesn't create these tough emotions. I think that's totally valid. We don't need to, this is not a talk about how to take it. This is a talk about how to move forward. Any other comments on that case, the ER case? Sorry to the two people on call right now. Yes. What? Perfect. Let's go to the next case. This is the one about the, which one was this, is it the OR? Yeah, you add on the OR. Any volunteers about how you'd address this add-on case in the OR, the person in the OR desk rolling their eyes and making a comment under their breath? All right, Teresa choose. All right, Dr. Wong. So as far as this scenario, our goal, cause it sounds like the decision has already been made to add the case on, we decided that our goal was to like try to improve our relationship with the OR staff so that they wouldn't be trying to fight us in our goal of taking care of patients in the future. So our first statement that we came up with was, I'm hearing that it's a tough situation, you're getting home late, and then just trying to express like openness to hearing things to. So we said, help me to understand the impact that this add-on is having on you. You can just, you can see it in the body, like that they're just like, oh God, I really shouldn't have done that. I don't care if it's part of the relationship with that. Yeah, and then I think just like apologizing, like I'm sorry I'm running behind, I had an unexpectedly difficult case and just saying that in the future, I will try to come up with a plan to avoid this kind of running late in the future, whether it's like canceling a non-urgent case when I do have an add-on or scheduling fewer cases so that we have room for add-ons. The other thing I want to add to that though, you don't need to take it, but you don't need to have people characterize it as scientists, like eventually you don't need to take it as scientists, and you don't need to take it as well. You're probably, sometimes it's appropriate to accept it. I have no idea, because I feel like that's like normal and I just accepted it. So I'm just going to pass this to someone else who feels like they can't accept rolling the eyes and grumbling. Dr. Petty, I'm going to ask Dr. Petty. Dr. Petty, how do you set boundaries? As someone who's, you're probably asking me because you know I'm not great at setting boundaries. You know, that's a really good question. One thing I really like that Nana just briefly referenced, but he said it again in our small group discussion is, it's not the person's fault that we don't train everyone on ophthalmology. And it's just such a lovely way to create some empathy in the situation. And from there, once you're thinking about that individual, that invitation to, hey, maybe we can do the exam together if you've got a moment, or at some point getting to the point where you could comfortably say, this is actually something that'd be really helpful for you to know and understand. Maybe you don't have time now, but I'd be happy to follow up and find a time that I can teach you this and you can have this skillset moving forward. And so I think part of it is growing in to the competence to set a boundary, but it has to start from a place of empathy. Otherwise, the boundary becomes more about you and your needs and less about them and what would be helpful for them. I think that's a great point. The other thing I think it's always good to go back to as well when it comes to setting boundaries is you are always at the liberty to talk about simple, undeniable, unemotional facts and how it impacted you. So, hey, I noticed that when we spoke, you said under your breath, I'm never gonna get home in time. I just wanna share the impact that that had on me. When I hear that, I feel hurt because it makes me feel like I'm not a caring member of this team and that really impacts me negatively. Moving forward, how can we address the concerns that you brought up from that conversation we just had? While also finding a way that we communicate that doesn't impact me like that. And you always make it about you and how it impacts you. We talked about this a little bit is that I sometimes don't understand the logistics of how it affects someone else. And I think as a consultant, sometimes the person who's consulting you doesn't understand the logistics either. Like I'll turn this on the residents when I'm on call and I'm taking a transfer call and I'm like, Ashley, what do you think about this? And it's mainly like, I don't exactly know what to do with this patient. Do they need to come? Can we do an outpatient thing? Cause I don't deal with the logistics of the situation and someone in ER doesn't deal with the logistics of a lot of these situations either. I love Jeff's point of like involving them in the care, not just like doing a consult and then telling them what you think, like involve them and help them understand like how you're thinking about it. I think it's really, really empowering. Yeah. I totally agree and having the approach that we're all in the same team and I'll have different strengths and I'll have ability to improve including myself and everyone that having that attitude and showing that attitude as well, showing your openness to hear feedback will make other people open to hear feedback. We don't have time to go through the rest of the cases. I do want to real quickly as a closing thought. Okay. Closing thoughts. These are some things, some comments that come up. Is that one, conflict management is not conflict resolution. We're not always going to get a resolution. Our goal is not to prove that we're right is to find mutual agreement. So it's a sort of find an understanding and find a path forward. It's not necessarily agreeing on the right answer. So our goal is to understand heard a lot of great conversation about picking your battles that this as we saw the rewriting six sentences took like 40 solid minutes. That's a lot of effort. This is not going to be every battle that we're going to pick but for the ones we care about where it's going to impact our wellbeing longterm it is worth putting in the effort. And it's worth like, I mean, when I do this I literally pull out that cheat sheet and like happen from me when I write an email and run it by my friends and run it by my wife and stuff like that, get feedback on it. We all make mistakes. And I think just acknowledging that we will make mistakes and we'll say things like, oh, wow I really screwed that up. But that was embarrassing. That's okay. We're human and we're always trying to be better. So we will make mistakes. We have made mistakes. We will make mistakes in the future. And lastly is power dynamics do complicate things. Medicine is very hierarchical, hierarchical. And it's hard if you're a resident to have these conversations with your attending with your division chief, et cetera. One thing I will say with that is that the same skill set applies when you're using your allies to help you. So if you talk to your program director and you're using effective I feel statements talking about how it impacts you you're gonna be a lot more effective moving forward and finding solution with your allies who can help you address those power dynamics. So even though power dynamics complicate things it still is helpful to apply these skills when you're using your allies to help you through these situations. So any other questions or thoughts? Cause I have now run out of time. All right, great. Thanks so much. Appreciate you having me. I do just wanna say this was not born out of any like any issue or complaint. You guys are all doing an amazing job. This was just an opportunity came through and I know that has given this talk at a number of other departments and it's been so incredible that we just were able to get him here. But you guys all do a great job doing this all the time every day.