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Oct 10, 2019

Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Charles R. Thomas, Jr., Chair of the Department of Radiation Medicine at Oregon Health and Science University, who served as chair of the very important education session at the annual meeting this year. It's titled, Establishing a Mutually Respectful Workplace.

Also joining me today is Dr. Colin Weekes, a GI medical oncologist at Massachusetts General Hospital, who co-wrote an educational book article related to topics around interactions in the workplace that leave lasting effects. Dr. Weekes also presented his personal stories about being discriminated against by patients based on his race during the session.

The session also included stories about inappropriate comments made by a colleague about a person's ethnicity, gender, and sexual identity, and also some solutions to how to counter them.

Sometimes people make these comments, and they think they're perceived as jokes by the person saying them. But they are not, and they have long-lasting, negative consequences, and they can impact morale. With that being said-- Dr. Thomas, Dr. Weekes, welcome to the podcast.

Thank you for having me.

Yeah, this is great. Thank you.

Dr. Weekes, as education program chair, what were some of your hopes for the outcomes following the presentation? Do you think it led to meaningful discussion about how people treat each other at medical institutions?

Yeah, so I think for me the real goal of this session was to just, I think, initiate conversation and to provide a platform in which individuals of different backgrounds and perspectives in the workplace can have an open and honest conversation about how to address some of these issues-- and I think simultaneously provide tools, as Dr. Thomas said, to go beyond just a conversation, but implementation of problematic processes to try to address this topic.

Since the annual meeting, I have gotten feedback from members of my own institution about how much they enjoyed watching the session online and how impactful it was. And I've also received similar types of feedback from individuals from across the country.

So I think at the end of the day, it served a nice purpose to once again initiate this conversation and to be thoughtful about how we as practitioners in our work lives can help one another to make everyone's experience better.

So we're hearing a lot about microaggressions. But how do you define that? And how should someone handle these types of comments?

Basically, microaggressions represent verbal, behavioral, and/or environmental indignities that really can communicate hostile, derogatory, and really negative slights that insult a target person, or really a group. These type of messages can result in either individual or group marginalization and, in some respects, isolation. And at the end of the day, cumulative microaggressions can impact the quality of care given to patients.

And it really goes back to probably the first thing you asked at the beginning of this podcast-- why do this? Ultimately, we want optimal patient care to be delivered to our oncology patients. Suboptimal behavior, which includes microaggressions, can take away from delivering high quality care. So at the end of the day, it's about the patient.

Absolutely. Civility and respect in the workplace has made some inroads, but it seems like there's a long way to go. Your educational book article, Dr. Weekes, talks about uncivility. Can you explain what that is? And also, what is cultural humility, and how does one work towards that?

So uncivility is really the action of being discourteous or impolite, so treating others with malcontent. And this can be done in a lot of different ways. And it can be sort of a disrespectful gesture. It can be jokes, as we hear every now and then. And so there's lots of ways this can happen. And even sometimes, it also could be a form of incivility when you see someone being mistreated and you remain silent.

So I think that's the framework to think about civility and respect within the workplace. It's really, how would you like to be treated, and being respectful of others, regardless of what their station in the practice or the setting in which you're working is.

And I think the goal of that then, at the end of the day, is if we're treating others with respect for manners, I think, as Dr. Thomas said, the patient experience, the patient outcomes are all better, because people are interacting with each other from a positive standpoint.

I'd like to add to Dr. Weekes' comment. This may involve we practitioners having some intentionality, meaning being somewhat conscious that behavior is suboptimal. Let me give you a specific example. We have two new women faculty here in the Department of Radiation Medicine at OHSU, who started this academic year. One of the things that I personally have been conscious of, without anyone telling me, is to make a conscious effort not to interrupt them when they're talking.

At an early age, boys easily feel comfortable interrupting girls. Young men feel comfortable interrupting young women. And these kind of early behaviors can migrate into the adult workplace. Sometimes you need to be conscious that you don't always need to get a word in, but that some of the behaviors that are reinforced in our male-dominated society can be modified, such as what I just gave as an example. So there needs to be some intentionality in how we approach our relationships.

That's a really important change. So let's talk about patients for a moment. One of the things noted during the presentation is that the University of Michigan has rewritten its patients' rights and responsibility document to specifically call out harassment by patients. Do you think more institutions will follow?

My answer is yes. Michigan is a leader in that realm with Dr. Jagsi and others. At OHSU we're actually piloting an app that people can have on their iPhone that gives contact and other information if and when this occurs at the bedside, and so forth.

And the big picture is, the goal is to allow certain virtues to enter the workplace while other behaviors exit the workplace. Let me give you an example. On one hand, we want more gender equity moving into the workplace, and we want unconscious bias to move out of the workplace. We want a psychological safety to move into the workplace and increase that, and, of course, exiting the workplace environment would be things like harassment.

And so again, bringing in certain pluses such as microaffirmations into the workplace culture, and then microaggressions hopefully being minimized and leaving the culture. And so some of these tools, both in Michigan and other institutions, will hopefully allow health care providers to be able to adjust-- at times, on the fly-- when dealing with certain issues with patients and other care providers.

Absolutely. Let's talk about the use of interventions to address issues when implicit bias and blatant discrimination occurs during visits with patients. How should physicians handle these situations? And at what point do you bring this to the attention of leadership?

I think this is a challenging issue to address. So I think in many ways the person who is feeling discriminated against-- I think there's certain degrees on which this stuff occurs. And so if it's something that I feel like I can manage in a room with just education of the patient and helping them to understand what the individual roles of the people are in the room, that's something that I try to do in my own practice.

One of the things that I do in my own practice when I meet a patient for the first time is I introduce myself, what my role is in the practice that I'm in. And then before I start to do the traditional medical interview, I ask the patient what are their goals for this particular visit. And so then I think, to some regards in that situation, the playing field is set.

People know what each other's roles are, and I have a sense of what the patient wants to get from the visit. And many times, family members, if they're with them-- they will also discuss things that they want to know about. And then we start the visit. So I think, in many ways, that's a way to deal with that up front.

I think if it becomes a repetitive thing, despite the fact of you re-educating the person that you're dealing with, then I think there's time in which you might go to the leadership and say these things are ongoing. How can you help me address these things?

I think the other thing that leadership can do-- and I think this is what Dr. Thomas is also relating to-- is forming institutional policies about how do we address these issues. And I know in my own practice in my GI oncology group that I'm in, we actually had a conversation around how we as a practice are going to address these situations. And are we willing to have patients continue their care with our group if they are mistreating our colleagues, and to what degree we think that's appropriate.

And so I think the other component of this-- and hopefully this session in and of itself gave the framework for us as colleagues to begin to, I think, have some uncomfortable conversations around these issues. And then also to understand the points of views of our colleagues.

I think, to some degree, some of this stems from-- ignorance may be a harsh term-- but in terms of you don't understand each other and where other people are coming from in a given situation. And that's an important component of this conversation as well. And so I think the more that we as practitioners and colleagues discuss these issues, the easier it is to deal with these situations when they arise.

In addition, senior leadership can use their agency, their authority, to explicitly-- not implicitly-- explicitly acknowledge what's happened or what's actually happening. Dr. William Tap from Sloan Kettering was actually on the ASTRO panel-- a Caucasian male. And the reason I bring that up-- some of the inherent authority that some folks have by virtue of our society allows one to really make a stand and make an impact in recalibrating the situation.

Dr. Tap articulated this during the session. And really I want to echo that really senior leadership-- more often than not, males-- more often than not, majority males-- can make a big difference by calling out some of the inconsistencies and really helping the team recalibrate.

What are some of the more specific tools? If this is a habitual problem, as Dr. Weekes talks about, one can develop a shared vision for multiple stakeholders-- initially, perhaps a small retreat, which can evolve into a written document that can actually breathe and evolve over time while being a professional facilitator to get major stakeholders in the same room.

And really to value psychological safety-- I mentioned that earlier. That really refers to the willingness to take interpersonal risk, especially on the part of senior physicians, senior members of the department, who are aware of these-- admitting errors, asking questions, and/or seeking help are some of the aspects, some of the interpersonal risk involved in really imparting a cultural psychological safety.

That's great. It sounds like there's a lot of relationship-building that happens that can help mitigate some of these situations. I imagine, though, when you're in a situation that becomes heated and you want leadership to play a role in the changing morale, what are some tips on how to communicate with leadership in a calm way, even in the heat of the moment?

Depending on the situation, quite frankly, one can always respectfully walk away. And from time to time, I've had to do that. I'm in my early 60s, where I've had to physically say, you know what? I need to take a walk. I'll walk to the parking lot, or I'll walk outside and look at Mount Hood and recalibrate. So that's OK. People will respect you for that. That's OK.

Really emphasize if there are going to be phases of cultural change, we need to somewhat begin with a code of contact-- conduct-- excuse me-- code of conduct. Eventually, curiosity is going to follow that. And that's going to lead to a shared sense of entitlement, or I really want to say a shared sense of-- excuse me-- ownership. And that's going to lead to really adaptation in a positive way in the workforce, learning and continuous improvement.

Initially, there needs to be an initial conversation, and then there'll be iterative cultural changes. At the zenith of anger or something like that, one can always take a walk around the block and then recalibrate after the temperature settles down.

That's good advice. So we talked a little bit about how colleagues treat each other, how patients treat physicians, and how to communicate with leadership in a respectful way to make long-lasting change. And it seems like these things can have long-lasting positive or negative effects, but all in all, affecting professional relationships.

So how can institutions change the atmosphere to enable people of all genders, ethnicities, races, religions, and sexual identities feel included?

I mean, I think the one thing that Dr. Thomas has sort of reiterated throughout this entire conversation is the role of leadership. And I think this is a situation where it starts with the leadership, and the leadership demonstrating in their own actions-- personal actions-- their support for all members of the team, and not be involved in some of these conversations, jokes, microaggressions that occur.

And then when they witness it, however innocent or benign they may be, is to address it. And it doesn't necessarily require to have a large conversation. It's just, hey, maybe that's not the best way to speak or approach the situation. And a lot of times, little things along the way go a long way to promoting an environment.

And then I think, as Dr. Thomas has also said, is that there has to be an institutional approach to this in which there is a framework that's defined by the institution in terms of what is the code of conduct within our individual institutions, and also outline what are the steps that would occur if different degrees of egregious actions occurred?

And so I think that those two things-- that's really the critical foundation is the leadership exemplifying what they want the environment to be, and then the institution providing the framework in which we are supposed to conduct ourselves at work.

And I think as we are having more open conversations about these issues, I also think then we will begin to-- when we see things that we don't think are appropriate, instead of maybe not saying anything or walking away, you may say to your colleague, hey, maybe you can think about this a different way. And I think a lot of times, these individual conversations go a long way in the appropriate framework.

I agree. Most institutions already have mandatory onboarding online courses that one needs to take as far as how to show respect in the workplace. In addition, not just at the department level, but really at the institutional level, there can be implicit bias training. That is available. It would be nice if that could occur before there's a major issue that bubbles to the top.

And remember, at the end of the day, the more we're conscious of dealing with some of the issues of developing a mutually respectful environment in the workplace, at the end of the day, patient care can be benefited. And that's ultimately what we want, is a superior environment for optimal patient care to evolve and take place.

Absolutely. Well, it's been a pleasure speaking with both of you today. I just wanted to thank you for joining us on the podcast.

Thank you very much.

Yes, thank you.

And to our listeners, please read the educational book article, Establishing a Mutually Respectful Environment in the Workplace-- a Toolbox for Performance Excellence. And visit the meeting and slide section on to watch the powerful presentation about challenges and solutions to improve doctor-patient relationships and relationships with colleagues.

And also, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple podcast.