Strategies to tackle unconscious bias in surgery

Mrs Scarlett McNally BSc MB BChir FRCS(Tr&Orth) MA MBA FAcadMEd

Consultant Orthopaedic Surgeon, Eastbourne D.G.H. Council member, Royal College of Surgeons of England I have no conflict of interest

£0 Unconscious bias

• Is normal • We all instantly form judgements • We must force ourselves to look beyond them • Don’t say the first thing that comes into your head Who has unconscious bias?

• You • Surgeons in training • Nurses • Other staff • Patients • Students Other effects of unconscious bias

Success their work and failure luck (if similar) Attribution bias Success is luck and failure their fault (if different) Confirmation bias We expect. We seek info to confirm. Comparison bias When comparing, we exaggerate the differences. Source bias We challenge less if one source. Benevolent bias We try to protect, by not exposing to challenge. Halo – horns bias One characteristic colours our judgement. Primacy, Recency and Impact bias First time / major embarrassment easier to recall. Status Quo bias Desire to not ‘rock the boat’ Bias Blind spot Can’t see defects in our own decision-making Stereotyping Apply group stereotypes to an INVIDIVUAL Why?

• How we behave as a result of Bias can be interpreted as Bullying • How we select… Unfairness? • How we de-motivate… Lack of diversity?

FACTS: • Bullying is how the victim feels • Equality is pretending there is no difference and judging against criteria • Diversity is listening to how an individual needs to be better • Behaviour can be changed How to avoid it? • Think of every action (thought / word / deed / body language): • Listen / Employ / Work with / Give feedback / mentor

• Have positive contact with people from other groups • Put yourself in their shoes • Avoid pejorative jokes. Challenge others • Avoid triggers / slow down • Fake it • Smile • Focus on the task • Be clear “The Iceberg of Practice” (Fish & Coles, 2008)

• People can’t see: • why you do something • what other alternatives you considered • what you meant • Behaviour change is possible • Re-setting the culture of what is normal is also possible Find out more: www.surgeons.org/respect • Australian surgery has/had bullying problem • 48% surgeons in training had witnessed it • They recommend: “Call it out”

• Most alleged perpetrators (Australian surgeons) didn’t realise how they were perceived.

Being accused of bullying…

• Can be devastating • “The second victim”

• Medical Women’s Federation: “the perpetrators of domestic violence need help too”

• Often a sub-optimal trainee • Often a stressful environment • Often a trigger Who is most at risk of being accused of bullying?

• Is a doctor who qualified when teaching by humiliation was normal • Is very dedicated to patient care • Is very irritated by cases of failure in patient care • Is personally very detailed • Is highly intelligent • Has had plaudits from many trainees • Is poor at coping with below-average trainees or staff • Expects too much of trainees at a junior level • May not have insight into the effects of their actions and behaviours There is a fantastic e-learning package on bullying, 50 minutes on BMJ learning LINK http://learning.bmj.com/learning/module-intro/tackling-bullying-in-medicine.html?moduleId=44 The operating theatre – reduce difficult behaviour

 Use the team briefing well o Introductions o Explain which ops tricky o Plan who should assist, scrub, etc. for the whole list  Get new staff/students to understand the possibilities & expectations: o Be clear – eg where to meet? o Send them the RCS guidance: “learning in operating theatres”  Try very hard not to make assumptions. Treat everyone as their role requires.  Be polite. Just try. TRAINERS SHOULD:

• Be equal in training opportunities • Avoid favouritism • Feedback: • About the TASK/action not the PERSON • Offer strategies to change • Prompt & constructive • Highlight positive • Avoid behaviour that belittles, humiliate, threaten or undermines • Avoid inappropriate behaviours: shouting/swearing/public outbursts about trainees • Make time UNACCEPTABLE BEHAVIOURS • Persistent attempts to belittle and undermine work / undervaluing efforts • Persistent and unjustified criticism and monitoring of work • Intimidating use of discipline or competence procedures • Destructive innuendo and sarcasm / persistent teasing / threats / inappropriate jokes • Withholding necessary information from individual • Freezing out, ignoring or excluding Work • Unreasonable refusal for applications for leave/training style • Setting impossible deadlines/ Undue pressure to produce work • Shifting goalposts / removal responsibilities without telling the individual • Persistent attempts to demoralise individual • Persistent attempts to humiliate individual in front of colleagues • Physical violence / Violence to property • Discrimination based on racial, gender, sexual orientation and disability • Unwelcome sexual advances SAS It is like a party invitation…

• Unless you say what the rules are, you can’t penalise them for not adhering

• Start time • Expectations • Dress code • Leave policy “It’s another one of your tick-box forms, Scarlett” • Set clear rules • Induction • Write it down Performance management is bureaucratic

• Clear person specification • Regular review / appraisal • Clear goals / targets • Multi-source feedback • Team / group to talk things through including management • Everyone should have a friend / mentor • Set up a system • Make time • Collect evidence In 1990s we lived for work = some excuse Now, be the work persona for the 48 hours of work-time

In 1996: Emergency procedures: 41% at evenings, nights Many at weekends

Now, we have CEPOD lists Why?

• FAIR Supporting individuals – to be the best they can be • BUSINESS Less grumpiness / productivity • FUTURE Better workforce – more adaptable Royal College of Obs & Gynae – advice to trainees see Appendix in RCSEng bias

 Be assertive: Learn from mistakes. Explain what you want the perpetrator to do and why.  Talk it over: with someone you can trust.  Take no further action: If isolated event, perhaps. Underminer must realise their actions  Speak to the perpetrator: If the behaviour happens again: Some undermining isn't deliberate. Arrange a meeting in private and take along a trusted companion. Plan what you're going to say beforehand to explain how their actions made you feel. Stay calm and polite. Afterwards, make a written record.  Write it down: Make a note of each episode. Collect any documents that may back this up, especially emails. Evidence and reflection.  Speak to a senior colleague: Before pursuing a formal complaint, try talking to a senior colleague. Eg: Educational Supervisor, Clinical Supervisor, College Tutor, Clinical Director, Medical HR, Training Programme Director, Postgraduate Dean. +/- occhealth, the BMA or a Trainees' representative. Extra support can be found through counselling. What if the undermining persists? NUCLEAR OPTION = make a formal complaint in writing with evidence Very destructive and, like resigning, can be done only once. It effectively ends the relationship. The underminer will know this too and will be just as anxious to avoid it. So when am I bullied every day? People not realising they are behaving badly… So where are the rules?

Rule 163 Give cyclists as much room as you would when overtaking a car Rule 182 Do not overtake just before you turn left

23 24 Unconscious bias leads to:

A lack of diversity Perth, Australia Fellowship Jan 2000 – Jan 2001 [email protected] 27 EXERCISE on www.aomrc.org.uk

1. The Glass Ceiling Morrison, A. M., White, R. P., & Van Velsor, E. (1987)

2. The Glass Cliff Ryan, M. K. & Haslam, S. A. (2005)

3. The opt-out revolution Belkin, L. (2003) Identity Fit Model - traits

30 Trainees who perceived their own and Consultants’ personality traits as similar reported:

• higher fit perceptions (r=.54, p<.001). • This in turn predicted higher career ambition (r=.35, p<.001) • and lower burnout at work (r=-.37, p<.001). www.rcseng.ac.uk look in “careers” section JUST KNOW – there is a way

We need men and women to support the future… Mentoring: New RCS guide

www.rcseng.ac.uk Search “mentoring”

This is a simple guide about being a mentor or mentee, basic ground rules

https://www.rcseng.ac.uk/library-and- publications/college-publications/docs/gsp-mentoring/

Equality vs. Diversity

Equality Diversity Embracing difference; Being equal at the point of asking what else is needed; selection/ exam / how to get the individual to be the best that they can be. Eg if you are their supervisor Behaviour change

Is possible 39 Behaviour change strategies • I was lead author for this www.aomrc.org.uk • Exercise at 30 minutes 5x per week reduces risk • breast cancer 25% • Dementia 30% • Hip fracture 50% • Get started, then do more • Know what is stopping you • Make it a habit

It is worth making time to talk and to plan

The Red Queen in Alice in Wonderland – always running to stay in the same place • We all have unconscious bias • Start by NOT saying the first thing that comes into your head • Start by saying hello and looking welcoming • Try to find common ground • Focus on the task not the individual • Have systems to reduce your stress Start… Thiedeman’s (2008) Seven Steps for defeating bias in the workplace

1. Become mindful of your biases 2. Put your biases through triage 3. Identify the secondary gains of your biases 4. Dissect your biases 5. Identify common kinship groups 6. Shove your biases aside 7. Fake it till you make it (what we say can become what we believe)

https://www.amazon.co.uk/Making-Diversity-Work-Defeating-Workplace/dp/0793177634 My favourite stuff! www.rcseng.ac.uk/study

46 Common attributes of the disruptive leader

• Dominant, arrogant, aggressive, egocentric, impersonal and autocratic – being outspoken and often intimidating to other team members (eg in theatre; in MDTs). • Inhibiting the learning and development of other team members and trainees by dismissing their questions or challenges. • Neglecting to share important information. • Promoting the existence of factions/ rivalries within the team. • Inhibiting constructive feedback or identification of patient risks • Treating other non-clinical staff (eg management or administrative colleagues) without due courtesy or respect. • Passive disruption such as: • persistent non-attendance at key meetings (eg MDTs; directorate meetings); • refusal to abide by decisions agreed by the team; • undermining colleagues by criticising them in public; • refusal to delegate; • failure to carry out proper patient handovers https://www.rcseng.ac.uk/library-and-publications/college-publications/docs/surgical-leadership-guide/ If you are appointing, administering or chairing a committee

• Invite applications • Be clear on the Person Specification • Have a fixed tenure (eg members must re-apply / fresh blood) • Have a welcome for new members • Allow people to improve Unconscious bias can lead to:

Bullying Behaviour that subverts, weakens or wears away Undermining confidence Behaviour that hurts or frightens someone, often Bullying forcing them to do something they do not want to do

Harassment Bad behaviour related to a protected characteristic

is retaliatory action against someone who has made Victimisation or supported a complaint

Bullying can be by subordinates. Some managers are bullied. Undermining and Bullying in the Surgical Workplace https://tinyurl.com/surgicalbully

They have made these slides freely available Are you a bully? > how your behaviour might impact on others: > Do you listen to the other members of your team or do you do all the talking? > Do members of your team come to you with ideas or suggestions? > Does your sense of humour involve jokes that could be racist, homophobic or sexist? > Do you feel that ‘you had it tough so they should too?’ > If you are senior, do you use your position to offer mentorship or do people go to others for this? > Do you always apologise to someone if you lose your temper? > Have you written derogatory comments about someone on WhatsApp, Facebook or Twitter? > Do your colleagues look you in the eye? > Do you ignore any of your colleagues? > Do you blame others for problems that occur? > Do people speak freely in your theatre / clinic or do you dictate how people behave? > Does banter form a big part of your interactions with others? > Have you ever fired off an angry email? > Do you prefer to email colleagues about difficult situations, rather than discuss things face-to-face? > Bullying can happen anywhere and anyone of us can be guilty. Think about your behaviour on a daily basis. It is so easy for our behaviour to change without us noticing.

52 Reflect – am I a bully?

> Reflect on your own practice. > Have you ever been rude to the referring GP or A&E doctor? > Has someone tested your patience in theatre today? > Were you short with the clinic staff because you were overbooked? > We often think about clinical cases when we go home, but how often do we think about how our actions affected others?

53 How to be assertive without being a bully > Surgery can be a highly demanding environment, prioritise patient safety. > Being assertive can sometimes be challenging without coming across as aggressive or intimidating. > EG: Not every trainee will develop at the required rate, but concerns need addressing. 1. Set a goal at the start of the theatre list > If time pressure, give clear instructions/expectation at the start of the day. E.g. "Case 4 needs to start by 3pm so if we’re running behind then I’ll take over at 2pm." So trainee doesn’t feel undermined if the case is taken from them. > Divide the case up eg trainer does resection, trainee does anastomosis. Don’t just assume. 2. Suggest someone takes a break > If progress is slow, or if a trainee or assistant is making mistakes that could compromise the patient, suggest they go and take a break. Any further feedback should then be discussed after the case has finished. 3. Have a feedback session following the theatre list or clinic > Comment on both good and bad aspects of the day, away from the environment. > Suggest an action plan for improvement rather than just offering criticism. > Apologise if you displayed hostile behaviour, no matter how critical the situation was at the time. 4. Keep goals level-specific rather than personal > Stick to the targets identified at the initial educational meeting in a placement > Give feedback based on the these goals, rather than how a specific trainee compares to others > Sub-optimal performance should be recorded on ISCP as good performance would be – but be open about this and do this with the trainee. Use this as an opportunity to record a baseline from which they can improve. Resilience “Very few highly resilient individuals are strong in and by themselves. You need support.” - Dr Steven Southwick, Yale School of Medicine “For resilience, there’s not one prescription that works. Find what works for you.” - Dr Dennis Charney, Dean, ICAHN School of Medicine

> Drs Southwick & Charney’s Expert tips for Resilience: 1. Develop a core set of beliefs that nothing can shake. (eg you will not tell lies, not bully staff, not cover up patient safety issues etc. State your beliefs openly & often when challenged). 2. Try to find meaning in whatever stressful or traumatic thing has happened. 3. Try to maintain a positive outlook. 4. Take cues from someone who is especially resilient. (eg informal or formal peer supporters as above) 5. Don’t run from things that scare you: Face them. 6. Be quick to reach out for support when things go haywire. 7. Learn new things as often as you can. 8. Find an exercise regimen you’ll stick to. 9. Don’t beat yourself up or dwell on the past. 10. Recognise what makes you uniquely strong – and own it. (e.g. see item 1 about your core beliefs and values) 55 > Speak up. If you see someone being bullied, harassed or undermined then speak to the perpetrator and challenge their behaviour. If you do not feel comfortable doing this on your own, then ask a colleague to accompany you, or speak to their line manager. DON’T leave it – challenge it before it becomes a recurring problem. > Report it. If speaking to the bully has not changed their behaviour and it becomes and on-going problem then report it to their line manager. In extreme circumstances you might wish to speak to the GMC.

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Future surgeons:

- Be nice - Get medical students and Foundation Drs: scrubbed to join RCS AFFILIATES!!! £15/year to join Women in Surgery FREE - Define the tasks - Knowledge is power - OR… What motivates (or de-motivates…)?

• 76% motivated by personal contact / senior • 34% “clinical placement actively discouraged them from surgery” Written expectations for EVERY future doctor i.e. all medical students • To feel confident in considering surgical diagnoses • To be able to manage conditions • To refer appropriately • To manage complications • To be able to talk to patients Curriculum Contents = 3 sections: Knowledge (syllabus) + Skills + attitudes/ ways of learning

61 www.rcseng.ac.uk/study www.rcseng.ac.uk/career

Please use this!

ANYONE who works in theatre – to help students and new staff SET the RULES: so ALL operating theatre staff help students / trainees

www.rcseng.ac.uk/study

Get them to scrub in! www.rcseng.ac.uk/learning-in-operating-theatres Doctors Assistants – we did six-month trial • Band 3 (£18,000pa) • Previously HealthCare Assistants • Two-week induction • Take blood • Update patient lists • i.v. drips • Draft Discharge summaries • Help Foundation/other doctors • Find protocols • Make phone calls • Shortlisted for HSJ Award 2017!! • http://www.bit.do/dr-assistants Job Descrip Literature

65 Unconscious bias - can lead to bullying - can reduce opportunity / fairness - reduces diversity 1. Individuals / tips: 1. Be a Role model www.rcseng.ac.uk/career 2. Be clear. LOVE RULES. www.rcseng.ac.uk/study 3. “Fake it till you make it” 4. Separate the task from the individual. Listen. www.surgeons.org/respect 5. Identify triggers. Plan ahead. 6. Have some words: “I don’t think you can say that” https://tinyurl.com/surgicalbully 2. Structures / Changing what is normal / training 3. Students: BE NICE! Have FUN! Get them scrubbed https://tinyurl.com/surgicalbias 4. ? Mentor http://www.bit.do/dr-assistants 5. ? Change institutions [email protected] 6. ? Change patients’ perceptions 7. ? Change other healthcare workers’ perceptions