EP57 | The Curriculum We Never Had – Teaching Conflict Management in Medical School

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That's j o i n gt.com. [music] If you work in healthcare, you already know this. Conflict is everywhere. In the O, [music] in labor and delivery, in committee meetings between physicians, nurses, administrators, and teams that are all trying to do the right thing. But here's the problem. Most of us were never trained to handle conflict well. We learned procedures. We learned diagnostics, but we didn't learn how to [music] navigate the moments when few

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>> [music] >> In every operating room, in every ward, in every clinic and every team meeting, a silent battle bruise, conflict, negotiation, identity. Welcome to the scalpel and sword podcast where I, Dr. Lee Chararma, [music] physician and conflict analyst, explore the hidden negotiations beyond modern medicine. Let's trade burnout for boundaries and learn the art of healing with precision [music] and power. Hello my peaceful warriors and welcome to the scalpel and sword podcast. I am your host Dr. Lee Chararma, physician and conflict analyst and I'm going to ask you a question. What if one of the most important skills in medicine was

Podcast Introduction and Guest Introductions 3:34

never actually part of your formal curriculum? What if one of the biggest things that was going to make you really effective in the practice of medicine in working in a team at communicating with your patient was not something that you were ever formally taught. Thankfully, I feel like this is changing in our system of medical education. And to get into this, I'm so excited to have two wonderful guests on the podcast today. So, Caroline and Rachel, would you like to introduce yourselves? Yeah, I can go ahead and I am a first year medical student at the University of South Alabama. I'm originally from Opelica, Alabama. Went to Auburn for undergrad and biochem. Just really got into medicine cuz I wanted to help people. it in the end, especially being a woman who has been to a doctor myself and stuff and hearing experiences from friends and stuff, I learned that we have a lot of need for expanding healthc care for just about everybody honestly and then having compassionate providers in that space. So, that's kind of what drives me.

>> I love that. Thank you for being here. Rachel, tell us about you. >> Well, my name is Rachel Carter. I am a thirdyear medical student at the University of South Alabama. I also went to Auburn for my undergraduate education. I got my degree in neuroscience. I worked in a lab for a year before medical school. That's actually where Caroline and I met. And I'm interested in pursuing neurology. I was originally nursing and I started working in healthcare and kind of realized that I really enjoyed the doctor role. I think also just being a woman. I have an aunt who's a nurse and I just assumed women take the caretaker role. And yeah, once I kind of realized that I have more options available to me as far as jobs in healthcare, that's whenever my eyes really started to open. >> Wow. You guys, first of all, I'm so excited you're both here. I do want to say that the reason this all started is I was fortunate enough to meet Caroline and Rachel at our state medical association meeting. And Caroline and my daughter went to high school together.

They were both in marching band. So, I was very excited to see her again and connect. And I think as a parent, it's really beautiful for me to see you guys on this journey. I feel like in some ways that those of us who are in medicine are kind of big sisters to all of you and that's why we get so happy watching you just flourish. And so I'm really grateful you both are here. So Caroline, you're also a third year, right? >> No, I'm a first year. You're a first year. Okay. I knew there was different years. So, this will be really interesting because I feel like we're going to get some really cool perspectives on being a third being versus a first year and sort of how that experience of conflict has been for you.

Rachel, do you have any kind of memory of the first time you really encountered conflict in healthcare? >> Well, I started working in healthcare whenever I was like 18. Rental load, not fully developed. I guess I just witnessed a lot of culture behaviors that you're not necessarily accustomed to in the outside world. I think healthcare is unique in the fact that we are exposed to everyone in the population and we just have a unique mix of characters within the healthare system. But I certainly dealt with conflict during my undergraduate education like working in an emergency department and I was also a patient safety assistant and worked as a unit clerk. But I think institutions that are more focused on education, they

Early Conflict Experiences in Healthcare 7:00

typically have just a better culture surrounding how to communicate and how to get along with your peers. There's a lot more cohesiveness and teamwork whenever you're working at like an academic institution. So, I don't know. I was just very young just getting into the experience, but I've definitely learned more in my medical school education about how to navigate conflict. That's really interesting that that's sort of the first time and I love how you say that like Fredal Lo was still developing so you were still very young and experienced in this but also too I think those experiences are probably even more impressionable given the fact that you were so young when you encountered them. I also love how your observation of being in an academic situation you maybe saw more teamwork or maybe more structure in terms of working with conflict as opposed to maybe in a private hospital. And I think that's something we're definitely going to get into later on. But I think that's so cool that you noticed that. So really, really interesting. Caroline, I mean, you're very young in this journey, but you've also worked in a lab and you've also had that experience. Do you have any kind of memory of the first time maybe you witnessed some of this conflict in medical education?

>> Yeah, absolutely. Although it was it like Rachel, I didn't start working in medicine until a little bit later in life, but I took two gap years and during those two gap years, I worked either in a clinic or as a tech in the hospital for pretty much the entire time >> and definitely experienced what Rachel's talking about. And I feel that a lot of our healthcare workers are really tired and especially nurses and techs and EDS workers >> feel very tired, very underappreciated, probably underpaid and it just comes out in conflict sometimes and it comes out against each other and that's mostly what I experienced. And although that was a tidy tangent just responding to Rachel, but I do actually have a memory of the first time I had a solid conflict with co-orker although it wasn't in healthcare but it was graduates not my graduate program. The lab that we both worked in I was an undergrad and working with graduate students and is this related enough?

>> Yeah. Okay, great. So kind of along the lines of graduate education actually because my PI was the one who kind of diffused the situation. We had a situation where one of the graduate students took on an internship and we were so excited for them. But we noticed that summer that they had the internship, they did less and less and less in the lab and eventually it got to the point where we were like, "Hey, we're so excited that you have this internship. Please just do a little bit of work. Yeah. And also they would come into lab stressed because they were pressed for time and stuff. So it was a tense environment to work in. And my PI emailed her real fast and we met that day. And I explained the situation to her and that he was being kind of standoffish and that we were having tension in the lab. And she was like, "Did you try talking to him?" Asking like why he's acting this way or what's going on or what you can do? And I was like, "I sure did not try that at all."

So that really diffused it honestly was just being open and honest and just talking to each other about the way you feel. And it doesn't really feel like much of a professional thing to do, but in the end, you're two people period. So, like you have to have those conversations sometimes like no matter how much you want to wear that professional hat, someone's going to hurt someone's feelings some point. Oh my gosh. Okay, there's so much I want to get into. One of the things that I think is really interesting about your story, Caroline, and again, it's one of the things that's great about having both of you here in different phases of your education is this concept of hierarchy.

You had somebody these were graduate students. You were an undergraduate student Caroline and you were in this conflict and this was something definitely was about resources about the amount of time being invested in the workload that was being divided and you know the fact that there was workload that expectations was not being met but what I love about that story and why I think it's so cool that that was one of your earliest memories of conflict is not only was your early experience of hierarchy but the person who was at the top of that hierarchy was the one who number one was receptive to you engaging when you asked and gave you a very practical lifelong solution.

Did you talk to him? Such a simple thing, but what a powerful piece of advice. Yeah, unfortunately I didn't talk to him about that situation. It kind of just fizzled out. But I worked in that lab for a good bit longer and practiced that over time. When something would come up, when he would be late or something and have an excuse, I'd say, "Okay, I understand what you're trying

Learning Conflict Through Lab and Clinical Training 12:00

to tell me, >> well, okay, so it would be an interaction between two graduate students that I was watching >> and they'd be kind of getting into a tuffle because of the lateness and then the response and the snarkiness or whatever." And I'm like, I understand what you're trying to say. You're trying to say that you have a good excuse. How about we say, "Hey, so sorry I was late." And just learned how to have uncomfortable conversations and say like, "Hey, this is something that I would have rather heard." And being able to have the conversation. And I think that's a great skill that you learn very early on that sometimes the best conversations that we have are the ones that are most uncomfortable, but they're the ones that we need to have. And so you got actual practice doing that even before you in medical school. I think that's incredible. And if you still have your PI's email, you should still email her and go, I was on a podcast and I talked about you and this life skill you taught me is really awesome because I think the people who have that behavior modeled for them very early on like Rachel was saying before we have our funal love developed, you had somebody show you how to do conflict well. And that's not something we get a lot in medicine, is it? That's not something that a lot of us had as an early experience of having people do conflict well. You were both talking about working in medicine very early. My first job in a hospital, I was 16. I was a hospital secretary and my office was outside the doctor's lounge and literally I'm at my desk and typing and I hear boom is here and they're throwing chairs and things like that. And that was my first experience of watching doctors in conflict was watching chairs and hearing the words fly. And I mean I still remember that. I still remember like I was sitting in my desk. I can still sort of see and hear and all that experience.

And I think your insight Rachel in the fact that academic hospitals sometimes do this better than private hospitals is because teamwork is not less essential in those situation but it's more ingrained in academic medicine which is not something we always see in private practice. >> Rachel, do you feel like you got any kind of formal training in conflict early on in your medical education? Yeah, I was going back and kind of looking at my notes from like clinical skills sessions and ethics sessions. And there was this one session in particular during my first year of medical school.

It was a professional identity formation lecture. And it's the first session that really dawned on me of, oh, I'm not just a participant in the health care system. I'm training to be a leader in the healthare system. And what do I want that to look like? Who are my role models? What do I want to emulate? How do I want to be perceived to the team? and you know how to navigate that. So that was like the first time that I was like, "Oh my gosh, I have to put my big girl pants on. This is getting real." But we just kind of started to talk about situations that we may encounter in healthcare because this was prior to us going into the clinic and stuff for our first year. So they're just kind of preparing us saying, "Hey, there may be a disconnect between what you're learning in the classroom and what you see emulated in clinical practice and that's okay." And you know, how do you deal with that dissonance? it's I don't like this way of practicing. I would like to do it a different way or just trying to identify who you want to be as a provider. So that was my first like big woohoo moment. >> I love that. I can tell you that was never something I had. And the idea of professional identity if you were lucky enough I think to have a physician that you shadowed or a physician in your family a lot of times I think those were the sources of professional identity.

because you looked up to those people and they were definitely role models in you practicing medicine. Like my professional identity was very much influenced by my mother and my father who were both physicians. So very much of the way I practice I feel like is hearkening back to the way I knew my parents were. And I think that's really cool that they got you to physically think about what do I want this to look like? But you said something else too that I want to get into. they went ahead or in your mind you were already visualizing yourself as a leader when you thought about what that professional identity looked like you saw yourself as someone who was leading in healthcare and the fact that you already were thinking about that as a first year medical student that is so powerful do you feel like that's something you're even as a third-year medical student able to start to manifest that identity >> oh absolutely because I mean we work with so many different people so we get exposed to so many different ways of being a doctor. Ways of interacting with the team, ways of interacting with patients. So, I just kind of silently take notes on things that I like. Maybe even it's like a joke that they make with a patient. I'm like, "That's a good one. I'm going to write that down. I'm going to put that in my tool box." It's just kind of keeping that in the background of your mind. Just observing the behaviors that you want to emulate in your own practice. That's kind of been just a really good groundwork for third year and observing physicians. >> That's cool. I don't know if this is something that your attendings encourage, but do you ever have a chance to say to them, I really like that you did X and I'm going to emulate that or do you have a chance to have that kind of interaction with your attendings?

>> Yes. Well, virtual feedback is like something that's like a cornerstone of medical education at this point. You get feedback on your feedback. So like we have to fill out a survey and write information about all of our preceptors, but also just like your preceptors are human and you can just talk to them at the end like what kind of things did I do well and then you know you can obviously tell a physician like whenever they've done something really good and I have in the past before good and I think that's important as well because I think one of the trends that's happening right now in medical education is the way especially third fourth year medical students interns residents are getting that feedback back. The way and the schedule in which that's being done, I think has definitely changed. And I think the generation of doctors coming up has had such a strong influence on that change. I always say that, you know, the only feedback we ever got to see if we did something wrong. If you got something wrong, you got yelled at. And if you did it right, we just never heard anything. And that was your feedback. And I do not think that's something that would be acceptable currently in this current climate. And unfortunately, there's a lot of people who grew up my age, really old, who look at the way we got feedback and think that we were right or what we got was correct. And as we have younger physicians coming up who are wanting more of that real-time feedback, we're like, why are they asking for this

Professional Identity and Feedback Culture 18:30

feedback? Why do they want this so often? And I think this is a real big disconnect that part of the reason why I'm really happy you both are here is I really think this is something that needs to get discussed is the idea that we have generational change in the way that feedback and education takes place. Caroline, have you already gotten this lecture that Rachel's gotten about physician identity, professional identity? Have you already had that? >> Yeah, I have. Yeah. >> What was your response to that? How did you feel when you really started to think about the idea that you were establishing a professional identity? I guess I had already come to terms with the fact that it was a professional identity, but I had a lot of time to stew on that invite gap years and being a tech and being like, okay, at some point I'm going to be a doctor and I'd like to do things this way, that kind of thing. What I was really impressed by in those little classes was the way that they set us up to practice immediately. Um >> so we have pre-assigned small groups that we all meet in regularly throughout the semester for various things. It could be curriculum or ethics. I mean ethics is curriculum but like it could be core subjects that kind of thing. So, I want to say our first ever session in those groups, they immediately were like, "Okay, these are your co-workers. Like, these are your professional peers and let's set up some group norms. Let's learn how to give feedback. Let's learn how to let the quiet ones speak up. Let's learn how to receive feedback like immediately." And we would practice that every time. And at the end they would have us write down like something we could improve upon, something that we didn't do too well, something that we did do well. And then at the beginning of each session, we would revisit it and like add some stuff to it. And in the moment, it was you're an overwhelmed first year trying to figure out how to do med school and you're kind of like, ah, is this really necessary? But once I like stepped foot in a clinic for the first time, it was like, oh yeah, it's necessary. Oh, yeah. And especially we were with those groups for the entirety of that semester and just off the bat having those conversations I felt just put us in such a good spot to practice our conflict.

>> Yeah. And it's so cool because the best way to get better at managing conflict is to practice it, is to roleplay apply it, is to get comfortable sometimes giving uncomfortable feedback. You know, we talked about having uncomfortable conversations. Well, how do you get better at those? You practice them. And so, I love that you had an opportunity in real time to be able to do that and do it in such a way that since you are with those people the entire semester, you probably got to a point that you felt safe doing that. And I think that's huge in terms of creating those safe spaces.

Do you think in medicine we're getting better at creating safe spaces for learners where you guys really feel comfortable asking questions? Sometimes questions that's like this might be a dumb question but I'm going to go ahead and ask it or even sometimes you're the person who's being the voice of safety for the patient. I mean sometimes that role does fall on the medical student. Do you feel like we're getting better at creating that environment? >> I absolutely think so. And kind of going back to what I was saying originally about academic medicine versus maybe private institutions, I don't even necessarily know if it's academic versus private, I think it's just the role that I'm in. So whenever I was a tech, I was 18, so my co-workers were in their 60s.

You know, you're not going to communicate with me, a brand new 18-year-old in the ED, the same way that you're going to communicate with somebody who's experienced. So I think kind of having this baseline we're all in the same class together, everybody having the same expectations of what their knowledge base is and what they're learning, then that just like facilitates better communication because we know what the goal is. We know where you are and so then we better know how to communicate for those situations.

Also, I just wanted to mention our clinical skills course at South Alabama is like actually really incredible. I know like during the first two years like whenever you're studying in the classroom it can be really hard to take yourself out of that and go to clinic and you know do all these clinical skills assignments and sessions and things but it builds upon each other. like whenever you get to your third year, you're so much more prepared to navigate situations with your peers and with your patients because we also had sessions where it was like they would give a difficult clinical encounter. And so then we'd have to discuss with our small groups like how we might attack this and then later in your third year you'll have SP encounters, standardized patient encounters where you'll actually go in independently and talk with the standardized patient through an encounter like that. and then you watch it on video, everybody critiques you. It's medical school. It feels like you're under a microscope sometimes. I was really worried about that going into my third year. But I think because feedback is so normalized, it's like nothing at this point. Somebody saying something to me about my performance is not a comment on myself. It's not a comment on who I am as a person. It's just a comment on how I performed that day. And it really takes the pressure off of it. I want to add on to that from the other side. Now, of course, I can only speak for South, but South also emulates that what they want to see in us as far as seeking out feedback goes. We at the end of every single module, which I think this might be Rachel, did y'all do this the A&E feedback? Yeah. Oh crap. Gotcha. At the end of each module, they send out this long survey. So, and so they could say, "Here's what I thought worked. Here's what I thought didn't work." And they may or may not change things. But from that, and then also professors always saying like, "Let me know if this new format works. Let me know what you think about it." That kind of thing. They're really good at receiving the feedback as well as giving the feedback. So, I feel like they really teach you how to do both sides and also show us how to receive feedback with grace. So, you see this modeled as much as you see this encouraged and taught. And that's really massive, right? You're having this behavior modeled for them. It's not just being told this is we're

Conflict Resolution as a Core Medical Skill 25:00

going to give you feedback and this is how the feedback's going to occur. You're actually modeling how from somebody else is showing you how they receive it with grace. That's incredible because that makes a huge impact on you, but that's also going to create such a nicer environment for you guys to learn in. It sounds like what you guys are experiencing as learners is this really encouraging environment, but it's not one that's shielding you from conflict or from feedback. You are living it and experiencing it in such a way that you're actually learning how to work with it. That's huge.

>> So, I'm gonna ask you a question. What do you think would happen in the United States if we taught conflict resolution just like we taught ACLS? What if we actually had structured formuladriven curricula looking at conflict resolution? How do you think that would change not only medical education but how would it change medicine? I think if it were implemented in a way similar to way that South does it like interactive and very safe environment kind of way. I think that would be really useful just coming from a hospital setting and seeing all the implementations of all the things that were meant to be good. I always have hesitations about big sweeping things, but I I really do think it would be a great thing if it were done the way that South does it. I think a lot of it has to do with just your ability to reflect on your own actions. And I don't know if we can necessarily teach people how to resolve conflict because it's so individualized for every single scenario. But if we're able to teach people how to analyze their own behaviors and be able to reflect on them, then that can change how they interact with conflict in the future. And also just the very basic just exposing just putting conflict in there on the same stage as all the content that you're learning just automatically says this is important this is just as important as all the material that you're learning to you becoming a doctor and just putting it out there as something with value I feel like also starts to drive it home. >> That's awesome. No, I love how you guys are talking about that it's very much a part of your curriculum. It's not hidden in the curriculum, but it's not a kind of here's your lecture on conflict resolution. It's not that at all. It's something that's very embedded in what you're doing and it's embedded in every part of that curriculum from first year professional identity all the way up through your clinical education and even in doing your clinical diagnosis classes. It's embedded. It's not something that's taught separately. And I think that's really cool because again, it's giving you lots of practice in the different ways you're going to encounter it. But it's also, you said something really awesome, Rachel, and I want to go back to this is this idea of it makes you more self-reflective as a human being and then as a professional. >> It's given you the tools to actually be very meta about your behavior and how you interact with people. And the true blessing of learning how to manage conflict well is not that it makes us just better doctors, but it makes us better people. I've always said one of the greatest things I got from my conflict resolution of education is actually made me a better wife and mom because it actually gave me the skills to do those things where I had never had those things modeled for me before. And I think that makes a big difference in terms of how you guys are getting this.

It's really very beautiful. Let's say you've got somebody who's in college and you're mentoring them and it's like, "Hey guys, I think I want to go to medical school and I'm very excited about this. Tell me one thing I can start doing now that's going to make me a more peaceful, more engaged medical student and ultimately physician." >> I'm going to go ahead and assume that they're seeing patients in some way, shape, or form >> and that you got to shadow. You've got to have experience in some sort of way.

Honestly, this is more just a health care professional piece of advice. It's just that you're going to be going into a high stress setting more than likely. And in your training, you will absolutely see some high stress settings. And sometimes when in high stress, people say things that maybe they mean in the moment, but are just not what you would expect a professional person to say. and going into it with the understanding that it is high stress and that people are going to say and do some things that are just not quite aligning with what you'd expect. And already internalizing that and recognizing it when it happens and allowing yourself to take a second away from that person or whatever, regulate your own emotions and not respond with the same high caliber or whatever. I haven't been in the hospital at South yet. And I imagine that everyone is very kind and stuff, but like I've yet to see anybody who doesn't have their breaking point and who doesn't eventually snap or yell at somebody or something along those lines. And just acknowledging that it's going to happen and that you were in charge of your reaction and you were in charge of your emotions to go ahead and regulate, go ahead and have those tools on board. and coming back to it from a professional response is like the best way and processing it if you have a therapist processing it later like out loud with your partner with your therapist or anything like that so that resentment doesn't build up because that's something that I saw a lot too was a lot of resentment towards each other and then people can't work together and you definitely don't want that.

>> That is amazing. What a beautiful thing to tell somebody to help them before they embark on that journey. I love that so much. Rachel, what would you share?

Advice for Future Medical Students and Closing Remarks 31:00

Now that I'm in my third year and I guess I don't have as much autonomy over my time. I'm kind of given a schedule and told where to be. Sometimes missing out on important life events or things like that. just understanding that medicine like your medical education is temporary and just trying to find and build relationships with people at your medical school who will help support you. I remember it was a huge transition going from weedout classes at Auburn in an auditorium to medical school where the faculty actually care about you and want to see you succeed. So really just choosing a school that fits your values and has support systems in place to be able to support you because I mean the time is going to pass anyways but you are setting yourself up to miss out on a lot and yeah you're trading it for a much greater goal but kind of understanding the sacrifices that you're going to make going into it and then identifying people in your life to kind of help you navigate the situations.

Yeah, you definitely need people who are going through the same thing for sure or at least something similar because I've tried to confide in people going through grad school and stuff and like don't get me wrong, they're having a hard time but they don't get it. I think that's such powerful advice and what a great thing to build your Dr. Risa Lewis who's an ER doc has a book called Micros. She's a friend of the podcast, but one of the things she talks about in her book is having her personal board of directors, which is your people that you can call and I have them in my phone and they are a bunch of physicians and physician adjacent people, but they are the people that I can text or call and go, "Hey, this happened." Or, "Hey, can we talk about so building that skill set now as a medical student is going to serve you very well when you're in residency and practice. I am so thankful that you guys are going to be my colleagues someday.

You guys are going to bring so much to your patients and to the community and it's really awesome and I'm so grateful that you guys are getting this kind of education now and that you have the awareness to see the value of it, but also too that you've taken the time to share this with our listeners. And I would also encourage you, Caroline, because you were talking about this and I really loved this. You were talking about emotional regulation and being able to respond and not react. There is an episode of this podcast which is called Spark, which is a system that I use when I teach conflict resolution. So, we will put that episode in the show notes, but I have a bracelet that actually has the acronym on it that reminds me of what I need to do in that situation. So, if you guys want them, I'll mail you some. So, you can keep that around. Student Dr. Hawkins, student Dr. Carter, thank you so much for being here. It's been a pleasure.

>> Thank you so much for having us. I'm so glad we got to see you at the conference. >> Me, too. This was great. For all of our wonderful peaceful warriors who have joined us today on the scalpel and sword, thank you so much. And until next time, be at peace. Every episode [music] is an invitation to speak, to negotiate, to choose. I'm [music] Dr. Lee Chararma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful [music] warriors. May your choices be sharp and your voice be even sharper. [music] This podcast is a reflection of lived experience [music] and research in conflict resolution. The scalpel and sword is not intended as [music] medical or legal guidance. For personal matters, please consult a qualified professional.