WEBVTT 00:00:25.000 --> 00:00:30.000 host from the drop-down menu. You can also use the chat function to comment on the presentation. 00:00:30.000 --> 00:00:38.000 Um, we encourage you to do so. It's best to direct these comments to everyone by making sure that option is selected in the drop-down of the chat before you submit. 00:00:38.000 --> 00:00:41.000 Just to make sure everyone can see your comments and questions. 00:00:41.000 --> 00:00:48.000 Uh, we will be monitoring the chat throughout the session, and there will be an audience poll as well, so please be on the lookout for that. 00:00:48.000 --> 00:00:56.000 When we open up for audience questions, you can also use the Q&A panel to submit questions. This option allows you to submit anonymously, should you wish to do so. 00:00:56.000 --> 00:01:05.000 And as always, the recording will be available on CAPSI's website, so you can view a recording if you miss any portion, or, um, you want to review the slides as well. 00:01:05.000 --> 00:01:22.000 You can also view all upcoming CAPSC events by checking out the events calendar. Lastly, we ask you to provide your feedback on the session in the very brief survey you will see pop up in your browser once we end, so with that, I'll go ahead on to today's session. I'm very excited to announce our presenters today. We're joined by Connie Dahlin, the co-director of the Palliative. 00:01:22.000 --> 00:01:28.000 APRN externship, an adjunct associate professor for the University of Maryland Baltimore School of Pharmacy. 00:01:28.000 --> 00:01:55.000 A palliative nurse practitioner for Salem Hospital and consultant to… Capsi. Terry Altilio is a palliative social work consultant with over 3 decades of direct practice experience in palliative care, most recently in the Division of Palliative Care at Mount Sinai Beth Israel Medical Center. 00:01:55.000 --> 00:02:03.000 Great. Welcome, everybody. We're excited to be able to start this conversation. It's a big conversation, and we know that, um. 00:02:03.000 --> 00:02:11.000 There are a lot of you online, so we're pleased that you were interested in this. Next slide. 00:02:11.000 --> 00:02:18.000 So, what we'd like to have happen at the end of this presentation is that you'll be able to describe the concept of toxicity. 00:02:18.000 --> 00:02:24.000 that you'll be able to identify elements that allow toxicity to manifest. 00:02:24.000 --> 00:02:30.000 that you will apply similar skills used with patients and families with our teams and colleagues. 00:02:30.000 --> 00:02:36.000 And that we will, um… have you be able to discuss strategies to address toxicity. 00:02:36.000 --> 00:02:42.000 Next slide. 00:02:42.000 --> 00:02:43.000 Yes. 00:02:43.000 --> 00:02:53.000 So I'll take it from there, Connie. So, the… thanks, Connie. So, I think that in any discussion, I think it's important to define our terms. So, I guess the question is, what do we mean by toxicity? 00:02:53.000 --> 00:02:57.000 And for this presentation, we're defining Texas C as an environment. 00:02:57.000 --> 00:03:04.000 or harmful behaviors are normalized. And it was funny, this morning, I was trying to think of examples of that, and so I asked my own team. 00:03:04.000 --> 00:03:07.000 And they were kind of jumping up with examples, kind of immediately. 00:03:07.000 --> 00:03:13.000 And some… some of the examples they threw out were team members intentionally not learning the rules of others. 00:03:13.000 --> 00:03:17.000 One-way communication, or talking down to other team members. 00:03:17.000 --> 00:03:21.000 working in silos with little interest in learning what other. 00:03:21.000 --> 00:03:26.000 team members did. And even in an environment where there was this sense of retaliation. 00:03:26.000 --> 00:03:31.000 Um, you know, clearly this can ultimately lead to a stress-filled kind of environment. 00:03:31.000 --> 00:03:35.000 Which can thereby leads to kind of lapses in patient care. 00:03:35.000 --> 00:03:44.000 errors and just generally poor care. Um, finally, I think, you know, as we all know, this isn't limited to individuals on the team, that it can involve, kind of. 00:03:44.000 --> 00:03:48.000 program leaders, um, and even up to the system level. 00:03:48.000 --> 00:03:53.000 Next slide. 00:03:53.000 --> 00:03:58.000 So, there are real implications to a toxic work environment. 00:03:58.000 --> 00:04:04.000 At the center is the individual team member whose well-being can certainly quickly deteriorate. 00:04:04.000 --> 00:04:09.000 But when enough individuals are affected, the team's well-being can erode. 00:04:09.000 --> 00:04:17.000 And the result is a loss of trust. high turnover, and we all know that replacing team members can be a very costly endeavor. 00:04:17.000 --> 00:04:22.000 And most importantly, that patient care begins to deteriorate. 00:04:22.000 --> 00:04:28.000 that there's lapses in judgment and even declining patient satisfaction. 00:04:28.000 --> 00:04:32.000 Next slide. 00:04:32.000 --> 00:04:42.000 So, why is this important today? The reality is that we're facing a tsunami of individuals with chronic, progressive, increasingly complex. 00:04:42.000 --> 00:04:50.000 and ultimately fatal disease. At the same time, I think all of our fields are suffering from severe workforce shortages. 00:04:50.000 --> 00:04:55.000 The result is we simply cannot afford, I think, to lose our current manpower. 00:04:55.000 --> 00:05:01.000 due to a toxic work environment. And more importantly, we need to not only recruit. 00:05:01.000 --> 00:05:06.000 new team members, but also kind of sustain them and not lose them in the future. 00:05:06.000 --> 00:05:11.000 Next slide. 00:05:11.000 --> 00:05:17.000 I think this is kind of an interesting topic, is why serious illness care teams are kind of especially vulnerable to toxicity. 00:05:17.000 --> 00:05:22.000 And I think the reality is that we're actually exquisitely. 00:05:22.000 --> 00:05:28.000 vulnerable to this. I think this is demanding work. I don't think anyone would deny that. 00:05:28.000 --> 00:05:39.000 Um, with clinical, moral, and spiritual pressures. But in addition to that, there's a chronic exposure to loss, grief, um, that the team is constantly dealing with. 00:05:39.000 --> 00:05:44.000 Um, finally, I think the most important part, what Terry emphasizes that this is a clash. 00:05:44.000 --> 00:05:48.000 cultures, that we have, kind of, trying to merge. 00:05:48.000 --> 00:05:52.000 kind of a wide array. of, uh, individuals with. 00:05:52.000 --> 00:05:58.000 very different kind of training. different perspectives, different priorities and responsibilities. 00:05:58.000 --> 00:06:01.000 So, the clinical people on the team, the physicians and nurse practitioners. 00:06:01.000 --> 00:06:05.000 have a different perspective and training as compared to the. 00:06:05.000 --> 00:06:13.000 social worker or counselor, or a pet. you know, chaplain and the like. So we have these cultures kind of merging together. 00:06:13.000 --> 00:06:21.000 And naturally, there's going to be that… the risk of kind of developing a toxic or kind of unproductive environment. 00:06:21.000 --> 00:06:31.000 Next slide. I think the other piece of this is that I think we all have to admit that there's power dynamics within the team. 00:06:31.000 --> 00:06:35.000 Um, and part of it comes from this class of… class of cultures. 00:06:35.000 --> 00:06:42.000 You know, certainly individuals can assume primacy. based on the culture of their organization. 00:06:42.000 --> 00:06:49.000 Um, you know, if the focus for the organization is on just medical treatment and kind of scientific approach to things, then. 00:06:49.000 --> 00:06:53.000 you know, the physician or the nurse practitioner may kind of have. 00:06:53.000 --> 00:06:57.000 kind of a sense of superiority to other people in the team. 00:06:57.000 --> 00:07:05.000 Um, but even… uh, you know, and so that is the risk. And also, I mean, even simple things like the shape of the room. 00:07:05.000 --> 00:07:11.000 Um, the structure of the room can kind of enhance or get in the way of productive. 00:07:11.000 --> 00:07:21.000 conversation. So with that, I think we'll move on to a poll. 00:07:21.000 --> 00:07:24.000 And the questions are, have you been part of a toxic team? 00:07:24.000 --> 00:07:47.000 Are you currently part of Itacha's team? Are you trying to mitigate a toxic team? 00:07:47.000 --> 00:07:51.000 Great. A few more seconds on the poll. 00:07:51.000 --> 00:08:15.000 Some of you might have all three. Some of you might just have one. 00:08:15.000 --> 00:08:17.000 been part of it, okay. 00:08:17.000 --> 00:08:20.000 Sort of equal. Almost, right? Yeah, yep. 00:08:20.000 --> 00:08:35.000 So, interesting. Well, that's really helpful. We hope that this will help you think of some other things, um, as we're talking, because we'll have a conversation, um, in the last 10 minutes of this, so think about, um, where you're at. 00:08:35.000 --> 00:08:47.000 Next slide. So, when we think about the ideal work environment, there are several pieces to it that, when we're thinking about more healthy teams. 00:08:47.000 --> 00:08:54.000 Um, what we're striving for, um, that we have an emotional tenor. This is the culture where. 00:08:54.000 --> 00:09:05.000 It's really this team is working so well together, it's okay to reach out, um, it's okay to think about what are the different needs of the teams, my own and the people on the team. 00:09:05.000 --> 00:09:14.000 Um, that we're all working with independence, but we're also given and empowered to work within that independence, and that we have. 00:09:14.000 --> 00:09:20.000 permission for our time and space, that our schedule isn't taken over by somebody else, and we have no control in it. 00:09:20.000 --> 00:09:25.000 Then there's the physical safety of where we work, and that is that we are, um. 00:09:25.000 --> 00:09:36.000 really in a place that we can trust that we will be protected from harm and injury and threats of violence. And by this, we mean more physical violence. 00:09:36.000 --> 00:09:41.000 But then, um, in terms of thinking about emotional safety, that people can express feelings, they can disagree. 00:09:41.000 --> 00:09:48.000 Uh, that people are able to talk about, um, things that they don't think are going well, that everything is not rah-rah, this is great. 00:09:48.000 --> 00:09:55.000 Um, that emotions aren't considered a sign of weakness, and that people are, um, and we'll get into a little bit with, um. 00:09:55.000 --> 00:10:01.000 psychological safety, but that there isn't the fear of psychological violence. 00:10:01.000 --> 00:10:09.000 Um, and then there's this balance, and this one, we haven't done so well in palliative care, partly, again, because of the hierarchy. 00:10:09.000 --> 00:10:15.000 But this part about, we know that people who are on the front line with direct care exposure all the time. 00:10:15.000 --> 00:10:24.000 are going to be at higher risk for some of the toxic pieces than team members who may get time away and have kind of more of a choice of. 00:10:24.000 --> 00:10:31.000 you know, being unservice, doing educational projects, doing whatever. And I think in palliative care, we haven't kind of had that conversation about. 00:10:31.000 --> 00:10:38.000 How do we have this balance where everybody gets some time away, and it's not counted against them? This is really difficult right now. 00:10:38.000 --> 00:10:47.000 Because everybody in stress seems to go back to productivity rates rather than good patient care. Um, so just kind of thinking about that balance. 00:10:47.000 --> 00:10:48.000 Next. Yep. 00:10:48.000 --> 00:10:53.000 You know, Connie, before we get off this slide, as you were talking about physical and emotional safety. 00:10:53.000 --> 00:11:00.000 The thought that also was wandering through my mind was the whole area and the whole study of microaggressions. 00:11:00.000 --> 00:11:03.000 And that… that we need to be thinking about. 00:11:03.000 --> 00:11:11.000 different populations, different staff members, in terms of micro, both emotional and knowledge microaggressions. 00:11:11.000 --> 00:11:16.000 Um, and… and that just weaves together with this idea of safety. 00:11:16.000 --> 00:11:25.000 And people bringing different cultures, um, different experiences to the team. So we'll talk more about that later, but as I was listening to those two sections. 00:11:25.000 --> 00:11:30.000 The literature on microaggressions invaded my brain, so I had to say that out loud. 00:11:30.000 --> 00:11:35.000 And that is why we have an interprofessional team in even presenting this, because. 00:11:35.000 --> 00:11:38.000 Know that we all bring different perspectives to this. 00:11:38.000 --> 00:11:44.000 Um, and I think, um, you know, the other part of thinking about this is that. 00:11:44.000 --> 00:11:57.000 Um, we'll talk a little bit more, but we are all human and palliative care teams, and so we may be susceptible to things just like on any other team. So, next slide. 00:11:57.000 --> 00:12:02.000 So, um, in terms of thinking about psychological safety. 00:12:02.000 --> 00:12:07.000 um, you know, this is this whole part about confidence to speak up without fear. 00:12:07.000 --> 00:12:10.000 Um, this is so important, because if we can't. 00:12:10.000 --> 00:12:17.000 talk on our teams about, um, things that are going well or things that are not going well, we can't improve and work together. 00:12:17.000 --> 00:12:20.000 And there's this sense that if we say everything is wonderful. 00:12:20.000 --> 00:12:30.000 that that's great, but that's not true, because, you know, the joy and the difficulty of this work is that we come to this from being different individuals as humans. 00:12:30.000 --> 00:12:36.000 But also, different professional cultures. And so, we've all been empowered or not. 00:12:36.000 --> 00:12:43.000 to work on a team, and so really thinking about, you know, people being able to say, you know, what's good and what's bad. 00:12:43.000 --> 00:12:49.000 Um, that people are trusting each other, um, and there's inclusion and respect. And I can say that. 00:12:49.000 --> 00:12:53.000 you know, I worked on a team at one point, and there was a group of people. 00:12:53.000 --> 00:13:04.000 that were doing things after work, but they didn't invite anybody else. And it's not that people may have not had time to do it all, but there wasn't an open invitation, and it was sort of like. 00:13:04.000 --> 00:13:16.000 wow, this is really interesting dynamic of… This is an activity, why wouldn't you just ask the whole team and just let people say no, but then people feel included, and it's not like a special group? 00:13:16.000 --> 00:13:26.000 And then, sort of thinking about this link to a better communication and outcomes, and think about this, we're working so close together in really emotional work, and you want to know. 00:13:26.000 --> 00:13:34.000 that somebody has your back and trusts you. So even if they don't agree with you that they will still support you. And I think about that with. 00:13:34.000 --> 00:13:47.000 You know, we go into patient rooms. Not all of us will click with somebody, and so we're A letting somebody else step in, but B, it's not a sign of weakness that we do that, and also, it might be that. 00:13:47.000 --> 00:13:53.000 When you think about pain management, that we sometimes… I speak for myself as a nurse. 00:13:53.000 --> 00:14:05.000 want to rush in and fix it and do the package, and yet the pain is not all about physical part, and I need to have my colleagues, and I need their perspective, because their therapy. 00:14:05.000 --> 00:14:16.000 of listening to the patient, being present, thinking about meaning, and that whole concept of total pain might be better than any that I do. And so, when I can walk out of the room and say, oh. 00:14:16.000 --> 00:14:23.000 This isn't really about me and what I can do, it's for the other team members. Let's bring them in, rather than, oh. 00:14:23.000 --> 00:14:32.000 Wow, I can't fix this. I must be wrong, and I'm gonna get in trouble. That's what we're trying to say of, like, how do we have an open atmosphere for that? 00:14:32.000 --> 00:14:37.000 Next slide. And Terry, tell me when it's time for you to come in. I think I'm still on the grids. 00:14:37.000 --> 00:14:38.000 Yes, you are. 00:14:38.000 --> 00:14:46.000 So, when we think about healthy team benefits and unhealthy team benefits, the reason why we're talking about toxicity so much is. 00:14:46.000 --> 00:15:03.000 the benefits for the team, it's, as Jay kind of mentioned, when we don't have it, we have bad patient care. When we do have it, it's really about good patient care and family care, and we are weaving and doing this dance with each other that just is coordinated, and we are so know each other's steps. 00:15:03.000 --> 00:15:11.000 that we can work together. That we're more productive as a team if we're not looking around and thinking, what am I doing wrong, and oh my goodness, I gotta be careful. 00:15:11.000 --> 00:15:19.000 Um, thinking about job satisfaction and enrichment. When we work on a team that works, it's exciting to go to work. I know things have changed since Zoom, but. 00:15:19.000 --> 00:15:26.000 I actually like going to work and being present, and seeing my team members, and hearing what they're thinking, and thinking, oh, I learned something from them. 00:15:26.000 --> 00:15:30.000 And then also thinking of creativity and problem solving. 00:15:30.000 --> 00:15:36.000 The consequence is if we don't have it, is that we're less effective clinically, our productivity might go down. 00:15:36.000 --> 00:15:45.000 We might see people that disengage, so there's absenteeism, there's staff turnover, which then stresses the team, because every time you change the dynamics, you've got to work on that. 00:15:45.000 --> 00:15:59.000 Um, some dysfunctional inter-team behaviors. Um, and then we kind of then lose our compassion for this work. We might no longer be empathetic, we might have moral distress about what we're doing, and flow into compassion fatigue and burnout. 00:15:59.000 --> 00:16:13.000 Next slide. And then when we're thinking what we've said about this, there's the individual level, there's the team level, there's the program level, there's the organizational level, there've been a system level, and we're only talking about the bottom two. 00:16:13.000 --> 00:16:27.000 But we have to think about what is it the effect on a program. And so, well-being with the team, um, helps other team members say, oh, I want to work with them. They're working really well together. I'll refer to them. 00:16:27.000 --> 00:16:38.000 Um, that we have a synergy of goals, with people realize we're… we're trying to help the care for all, not just the palliative care patients, and that's when we really move things forward. 00:16:38.000 --> 00:16:50.000 that we're helping foster recruitment and retention of palliative care staff, because they see that it's a team… it doesn't mean that you will agree with everybody on your team, but you can respect each other and come to the table and work on. 00:16:50.000 --> 00:16:59.000 Um, you know, when you disagree, how do you do some things? And, you know, that's really hard right now, because that's not necessarily a value in the bigger landscape. 00:16:59.000 --> 00:17:10.000 And then thinking about expansion, if people… if we're doing really well, and things are… it means we're successful, and we're doing better patient care, well then, we're going to expand much more. 00:17:10.000 --> 00:17:17.000 And then the consequences is that, you know, people can see what's going on, so even if we think we're hiding our team mess. 00:17:17.000 --> 00:17:24.000 People pick up on it. So, we will lose respect, because they're like, why aren't they working well? Or we can hear them kind of backbiting or something. 00:17:24.000 --> 00:17:38.000 Um, which leads to a reduction in referrals. Which means that then we don't meet the program or health goals. And then we have this continual disruption because the staff isn't stable enough to kind of have new. 00:17:38.000 --> 00:17:47.000 people come and… because we're having so many people go. Um, so that's some of those pieces to think about. Next slide. 00:17:47.000 --> 00:17:56.000 So, one of the things to think about team toxicity is people say, well, what does it look like? Well, what it looks like is that you don't have. 00:17:56.000 --> 00:18:06.000 people sitting at the table as Jay talked about, that can't even sit at the table and be civil to each other, so people are disruptive, they're late, they're apathetic, they're sarcastic. 00:18:06.000 --> 00:18:13.000 They're hopeless, um, they're… a lot of illness, and then you have people who are this martyrdom. And so. 00:18:13.000 --> 00:18:23.000 Um, that's kind of interesting, because one of the things that I think about, um, when we're having teams, and especially when we're having members, and members watching us, visitors. 00:18:23.000 --> 00:18:31.000 If you don't want that behavior of what they're seeing to be reported in the newspaper, like as somebody making observations. 00:18:31.000 --> 00:18:45.000 You need to be thinking about how your team's working together. Um, and I've seen so many sarcastic teams, or sort of some of the black humor that might be okay with our team, but outsiders don't understand it. And so really having to be thoughtful about that. 00:18:45.000 --> 00:18:58.000 Um, chronic poor attendance at team meetings. I know teams struggle about starting on time and finishing on time, and I think having that rule, and you don't deviate, and people who are late need to know there's consequences to that, right? 00:18:58.000 --> 00:19:09.000 Um, people aren't following up with tasks. You have people who are staying beyond normal work hours, and that's really problematic because they're exhausted. You need to be able to come back the next day to do the work. 00:19:09.000 --> 00:19:13.000 Or, something's not right with the efficiency, or you're not feeling good about that. 00:19:13.000 --> 00:19:28.000 And so, when you can have teams that's working, that everybody's leaving at about the same time, and there's a sense of what will happen during the night of who's caring, then that's a challenge. Um, you know, constant differences or conflicts that people don't name. 00:19:28.000 --> 00:19:35.000 Um, and sort of say there's a dis… they're agreeing to disagree, but they're just kind of out there. Um, I've sort of said junior high behaviors, where people are. 00:19:35.000 --> 00:19:40.000 click like, gossiping, um, not sort of working for the common good. 00:19:40.000 --> 00:19:53.000 And then, um, people are constantly. working so hard that they can't do some of this other work that we all need, sort of, to keep going, um, as this work is just so emotional. 00:19:53.000 --> 00:19:55.000 So I think that slide is my last, and I'm going to turn it back to Taryn. 00:19:55.000 --> 00:20:01.000 Let's say we'll see what's next. Nope, this is yours. 00:20:01.000 --> 00:20:02.000 Yep. 00:20:02.000 --> 00:20:13.000 Okay, the quick assessment, um, so this is, um, something we've made up for the monograph, um, that we wrote for CAPSI, uh, in 2013. We're updating it currently. That one was called Maximizing Team. 00:20:13.000 --> 00:20:18.000 Team Health. We're now calling it Wellbeing, because that's where the language is. 00:20:18.000 --> 00:20:34.000 But really looking at your team, you know, is there open communication and trust to share personal feelings? Now, I'm not saying that it's every time you're meeting as a team, it's a therapy session, but there… you can say you have things going on at home, and, you know, it's a stressful time, or something like that, or sharing really good news. 00:20:34.000 --> 00:20:39.000 Um, that every team member knows the program mission and goals for the 20 months. 00:20:39.000 --> 00:20:47.000 I would say to you, the challenge with this sometimes is teams feel like, ugh, we don't want to be business-like, mission and vision, that's boring. 00:20:47.000 --> 00:21:03.000 If you don't do it in the beginning, you will have to do it, because you have to have everybody aligning. And you do not want your marketing team to be making up your little blurb that they put in your brochure as your mission and vision. So that should be very clear. So you also could match up what you're doing. 00:21:03.000 --> 00:21:10.000 Um, that people work well together to achieve goals in a timely manner, and part of that is negotiating what's a timely manner. 00:21:10.000 --> 00:21:14.000 Um, you know, how fast do you see consults? What's priority? What's not? 00:21:14.000 --> 00:21:23.000 Um, and how do you work through that? Um, that people are, um, accountable to each other to complete tasks, because then, you know, if somebody doesn't do something. 00:21:23.000 --> 00:21:27.000 And it's left undone. Sometimes somebody else has to pick it up, and that's not a lot of fun. 00:21:27.000 --> 00:21:33.000 Um, roles and responsibilities are well understood, and this is really important because as a team. 00:21:33.000 --> 00:21:38.000 You need to look at all of the overlapping things that happen within the professions. 00:21:38.000 --> 00:21:45.000 There's a lot of things that we share, and sometimes people get, oh, we're different, but there's a core set of things. 00:21:45.000 --> 00:21:51.000 that we all share, and then we go off into our professions about what our licensure is, scope of practice, and all that. 00:21:51.000 --> 00:22:05.000 Um, that you're having team patient meetings, but you're also having administrative means to talk about how the team is doing, what are the measurements, what are QI things you're being held to, what are clear outcomes, what's going to be the follow-through? Are you meeting quarterly? 00:22:05.000 --> 00:22:11.000 Who's in charge? Um, all of that. So, uh, thinking about self-care and team care activities. 00:22:11.000 --> 00:22:21.000 I will just say I'm careful about using self-care sometimes, because that's a responsibility that's only on the individual. I would say well-being activities, I think we saw during COVID. 00:22:21.000 --> 00:22:29.000 things that didn't work, like telling people that you appreciated them by giving them cookies or socks, didn't really go over well. 00:22:29.000 --> 00:22:40.000 So, thinking about how do you give time off, how do you have people flex if they've finished what they've needed to do, you know, how do you work hours, how do you have people work out the schedule, things like that. 00:22:40.000 --> 00:22:51.000 Um, individual performance expectations. These are clearly defined. So, they might be different for the different professions, but one of the things, if you're really a healthy team. 00:22:51.000 --> 00:23:03.000 And you even, you know, you'll have a program leader, but say that the program leader's a physician, and you're nursing, well, you have the program leader, do you have that part, but you have somebody from nursing also accountable for your nursing practice. 00:23:03.000 --> 00:23:13.000 Same thing for social work. So that we're recognizing that there are things for the team, but there's practice things that also have input, so that that's real clear about some of the roles and responsibilities. 00:23:13.000 --> 00:23:20.000 And then, we have ways to work stress, and some of that includes that if somebody has really 3 difficult patients. 00:23:20.000 --> 00:23:45.000 And they're having really 3 difficult deaths. The work we do is recognizing grief and loss in our patients, and we need to be recognizing it in ourselves, and sometimes that we're doing… Um, you know, our work, this is really difficult work. We might be caring for family members or other people, or we have other things going on, and so saying to the team, I'm doing the best I can, and I'm trying to balance what's going on. So this is just very rough. 00:23:45.000 --> 00:23:53.000 not very… it hasn't been scientifically approved, but we were kind of trying to look at some of the behaviors that you will notice pretty quickly. 00:23:53.000 --> 00:24:00.000 Um, and if you're excellent, we want to hear about that, because we want to know what you're doing. If you're doing poorly. 00:24:00.000 --> 00:24:06.000 We have some thoughts for you, and that's where Terry's gonna go next in terms of thinking about strategies. 00:24:06.000 --> 00:24:11.000 I think that's the next slide, right, Chelsea? So, palliative care lens. 00:24:11.000 --> 00:24:22.000 Oh, this is so… this is, uh… This is just important to think about. How is it… that we offer in role model grace and compassion in working with patients and families. 00:24:22.000 --> 00:24:30.000 Yet do not often do this with team members. And perhaps we do, you know? Perhaps we do. But it's an interesting lens to think about. 00:24:30.000 --> 00:24:34.000 When we look at our teams and look at each other. 00:24:34.000 --> 00:24:43.000 Um, and, um, want to understand and discover, perhaps, what is going on with them, what is going on with us. 00:24:43.000 --> 00:24:47.000 Um, that creates behaviors that are troubling, that are troubling in team. 00:24:47.000 --> 00:24:52.000 This is… the next thing is… it took me a really long time to come to. 00:24:52.000 --> 00:24:58.000 Um, the idea that there are things happening in your team or with colleagues. 00:24:58.000 --> 00:25:04.000 that are potentially harmful, unintended consequences that may do harm. 00:25:04.000 --> 00:25:09.000 To remain silent about that. is not acceptable. 00:25:09.000 --> 00:25:17.000 If you are working as a team. Integrity requires that we think about. 00:25:17.000 --> 00:25:27.000 how we can raise those issues, raise those concerns in a way that is helpful to the person, helpful to the team, and so on and so forth. 00:25:27.000 --> 00:25:31.000 And that not doing that, this is what took me a really long time to realize. 00:25:31.000 --> 00:25:36.000 Not finding a way to do that is a form of abandonment of colleagues. 00:25:36.000 --> 00:25:47.000 And that puts a responsibility on us. Um, and maybe there is a profound responsibility when you choose to work in a team that does the work that we do as team. 00:25:47.000 --> 00:25:54.000 Um, so, um, it's really interesting to think about it that way, and that implies, really. 00:25:54.000 --> 00:26:00.000 Um, that we need to find a way to create a way, and we'll talk a little bit about that in the next slides. 00:26:00.000 --> 00:26:04.000 to create a way to figure out how can I handle this? 00:26:04.000 --> 00:26:16.000 How can I approach this in a way that may be helpful to the other, um, and be consistent with my values and my ethics, and the role and the hope that we have to create teams. 00:26:16.000 --> 00:26:22.000 Um, that are not only effective and efficient. but also compassionate and caring of each other. 00:26:22.000 --> 00:26:28.000 So, um, one of the other aspects, of course, is always protecting our well-being and setting boundaries. 00:26:28.000 --> 00:26:34.000 I was never good at that. I will take full responsibility for that. I was never good at boundaries. 00:26:34.000 --> 00:26:41.000 Um, but the other part about setting boundaries I do believe has to do with the responsibilities that you have in your life. 00:26:41.000 --> 00:26:47.000 how not setting boundaries impacts you as an individual, and also how people work together. 00:26:47.000 --> 00:26:56.000 I was thinking, Connie, when you were going through that list, I have heard of teams that say, nobody leaves until everybody can leave. 00:26:56.000 --> 00:27:01.000 I think that's very interesting. I don't know how it works, but I think it's very interesting when you think about. 00:27:01.000 --> 00:27:06.000 workload and boundaries, and those of us who add none, and maybe needed help. 00:27:06.000 --> 00:27:10.000 setting them, and so on and so forth, is an interesting perspective. 00:27:10.000 --> 00:27:19.000 Silence can perpetuate harm. I speak about… I speak to this as a social worker, because you all know that we are minorities in the healthcare systems. 00:27:19.000 --> 00:27:24.000 Minorities do not mean that you accept being minoritized. 00:27:24.000 --> 00:27:29.000 It's a different concept. So you can be a minority without being minoritized. 00:27:29.000 --> 00:27:35.000 So, social workers, because of our place in the healthcare system, um, have a particular. 00:27:35.000 --> 00:27:46.000 challenge sometimes to find voice. The other piece of that is… has… According to our ethics, according to our caring for other. 00:27:46.000 --> 00:27:51.000 colleagues that are doing this work, we need to try to figure out a way to find voice. 00:27:51.000 --> 00:28:01.000 Next slide. So this is, um, this is what we do so much as palliative care clinicians. 00:28:01.000 --> 00:28:10.000 Which has to do not only with self-reflection, I mean, the self-reflection process comes from the idea that we are people of discovery and curiosity. 00:28:10.000 --> 00:28:17.000 about human beings, so we meet a patient and a family, and we wonder what is their culture? What do they bring to this experience? 00:28:17.000 --> 00:28:23.000 In terms of their history, trauma, lack of trauma, where are they in the world? Systems, systems thinking. 00:28:23.000 --> 00:28:31.000 Um, and this same kind of thinking is interesting to apply to what goes on in teams. 00:28:31.000 --> 00:28:36.000 How do we interpret what happens in teams? And those of us, all of us. 00:28:36.000 --> 00:28:41.000 come from families, we come from cultures, and our families and our cultures have. 00:28:41.000 --> 00:28:45.000 taught us certain values about being in a group. 00:28:45.000 --> 00:28:48.000 I remember you can be seen, but not heard. 00:28:48.000 --> 00:28:55.000 That was, like, my generation. You can be seen, but not heard. There are other families, other cultures, where the group. 00:28:55.000 --> 00:29:02.000 Happiness is a main… is the main priority, and is the main goal, so you don't disrupt. 00:29:02.000 --> 00:29:11.000 You don't express anger, you don't express disagreement. Because coherence in the family is most important. All those values, in addition to our professional values. 00:29:11.000 --> 00:29:17.000 We bring to team. So it becomes important when we're thinking about toxicity. 00:29:17.000 --> 00:29:29.000 to also then look at the self. And to think about, what do I bring here that makes this so uncomfortable for me? Would it be uncomfortable, and is it uncomfortable for others? 00:29:29.000 --> 00:29:39.000 How do they interpret it? That's the kind of authentic communication that we often have in palliative care with each other. Next slide, please. 00:29:39.000 --> 00:29:46.000 Ah, yes. Steps for addressing toxicity. This is step two. Find a safe person to discuss the situation with. 00:29:46.000 --> 00:29:50.000 And coherent… coherent with this, there is a social work. 00:29:50.000 --> 00:29:57.000 a social worker whose name is Joy DeGrew Leary. Joy DeGrewue Leary is, uh, did an enormous amount of work. 00:29:57.000 --> 00:30:03.000 on trauma, the legacy of trauma related to slavery. 00:30:03.000 --> 00:30:09.000 Um, and, um, and what that means in terms of current generations, what the generations bring. 00:30:09.000 --> 00:30:16.000 Um, to… to… from… from the history of slavery to their current lives and the current way they live their lives. 00:30:16.000 --> 00:30:30.000 So, Joy DeGru. Leary, taught us, Vicki and Lef and myself, this idea of that when you are in a difficult situation, when you're in a situation where you may want to discuss equity issues, issues related to racism. 00:30:30.000 --> 00:30:37.000 issues related to systemic. bias, so on and so forth, that you need to find what she called the green room. 00:30:37.000 --> 00:30:42.000 And the green room. is a… is a… is built. 00:30:42.000 --> 00:30:54.000 and relies on. this process on two folks who were named Mr. And Mrs. Green, Victor and Alma Green, who wrote a book. 00:30:54.000 --> 00:31:00.000 We'll roll a book for 30 years, from the 1930s to the 1960s, and that book was called The Green Book. 00:31:00.000 --> 00:31:06.000 And the Green Book was designed to help. African American families who were traveling in the South. 00:31:06.000 --> 00:31:25.000 to know where it was safe to go. To know the whole hotels they could safely stay in, where they could go and eat and be respected and be engaged and be invited in. So she takes this Green Book metaphor and says, when you're doing this kind of work, when you're doing this kind of exploration. 00:31:25.000 --> 00:31:34.000 sort of building insight, or trying to understand what's happening around you and in the system that you're working in. You need to know where the green room is. 00:31:34.000 --> 00:31:37.000 Where there are people where you can safely sit. 00:31:37.000 --> 00:31:44.000 And discuss what you are seeing, and also know that those people are going to ask you questions also. 00:31:44.000 --> 00:31:52.000 That invites you to think about your part in what you are seeing, in your team, and so on and so forth. So it's a wonderful metaphor, it's called the green room. 00:31:52.000 --> 00:31:57.000 Next slide, please. 00:31:57.000 --> 00:32:02.000 Strategies for dealing with toxic… maintain professionalism and boundaries. 00:32:02.000 --> 00:32:16.000 Um, that, that, um… That means that sometimes when you're in the green room, you can emote to the highest level possible, but you don't do that in the hall, and you're very measured in terms of what you do or do not say. 00:32:16.000 --> 00:32:24.000 Uh, in terms of… in relationship to a team member who is maybe bugging the hell out of you and really making you think. 00:32:24.000 --> 00:32:29.000 that they are doing harm, not only to the team, but also to patients and families. 00:32:29.000 --> 00:32:37.000 Sometimes we minimize unnecessary contact. That's protective of self, that's protective of self. 00:32:37.000 --> 00:32:41.000 Um, and this is a… this is a nice thought, right? Anchor to purchase. 00:32:41.000 --> 00:32:50.000 and seek allies. That relates to the green room, but it also relates to why many of us got into this work. 00:32:50.000 --> 00:33:00.000 It relates to how can I continue. to stay in this work, to do what I love to do, and not allow this specific team member. 00:33:00.000 --> 00:33:04.000 to tamper with that, or to damage that? How do I create that for myself? 00:33:04.000 --> 00:33:15.000 Next slide, please. Offer feedback. Oh, yes, for strategies for dealing with toxic leaders. I had to learn how to do this. 00:33:15.000 --> 00:33:26.000 Uh, I always thought, for a while there, after 20 years, I thought that, you know, you're talking about unhealthy language with the rest of the world, but you don't have the courage to go into your. 00:33:26.000 --> 00:33:30.000 Um, to your chairman of the department leader's office. 00:33:30.000 --> 00:33:36.000 And suggests that perhaps he needs to stop using language like failing morphine and failing. 00:33:36.000 --> 00:33:42.000 The georegesic patch, so if you don't have that kind of courage, how do you build that kind of courage? 00:33:42.000 --> 00:33:58.000 So, sometimes that means you… build that courage by discussing it in the… Green Room, discussing it with somebody who knows you well and can help you to frame the kind of feedback that you would like to give to another human being. 00:33:58.000 --> 00:34:04.000 to help them, especially if you think that they are doing unintended harm, either to patients and families. 00:34:04.000 --> 00:34:17.000 Or to… The team. Document interactions. This is really… this… this is… this really gets to… a point at which toxicity becomes. 00:34:17.000 --> 00:34:23.000 to a level where you may actually have to do something about it outside of the team. 00:34:23.000 --> 00:34:30.000 Outside of the team. So you start to document things, document your efforts to make things better, document the response. 00:34:30.000 --> 00:34:37.000 Consult mentors, we've repeated that. Stay professional, which sometimes is easier said than done. 00:34:37.000 --> 00:34:43.000 Um, protect your… protect your energy, that's a boundary. That's another aspect of boundary setting, right? 00:34:43.000 --> 00:34:52.000 How much energy do I have for this? Is it… is it all my job, right? Is it all on my plate, or what did… to be on the plate of others. 00:34:52.000 --> 00:34:59.000 Um, on this team to try to negotiate an outcome here that not only protects the integrity of the team. 00:34:59.000 --> 00:35:08.000 protects patients and families, and perhaps. makes a difference in the life… in the life of the person who is perceived to be toxic. 00:35:08.000 --> 00:35:23.000 And then after weighing the pros and cons. There's this whole idea of consulting HR, which I can't speak to with any expertise, because it never was something that I considered. I think there are risks and benefits to consulting HR. 00:35:23.000 --> 00:35:32.000 Um, and before you would do that, you would really want to make sure that you know what those risks and benefits are, and what the responsibility is going to be. 00:35:32.000 --> 00:35:38.000 on you as an individual, if you bring something to the human resources folks. 00:35:38.000 --> 00:35:44.000 Now, where's the next slide? Let's see where we are. 00:35:44.000 --> 00:35:51.000 Decision making. Review culture, review the culture of the team, review your own culture. 00:35:51.000 --> 00:35:56.000 Review what you bring, what your culture tells you about negotiating difficult people. 00:35:56.000 --> 00:36:02.000 difficult family situations and difficult team members. What is possible to change? 00:36:02.000 --> 00:36:07.000 And what cannot be changed. That's always a very important exercise, I think. 00:36:07.000 --> 00:36:13.000 Because sometimes we spin our wheels trying to change something that is immutable, that it is not going to be changed. 00:36:13.000 --> 00:36:19.000 how you figure that out is, um… It's a process of discovery, as we were talking about. 00:36:19.000 --> 00:36:26.000 Revisit early signs. Where did this start? Where did I get so distressed about this certain team member? 00:36:26.000 --> 00:36:33.000 Um, where did I think that they were doing harm, and so on and so forth. How far back does that go, and what started that? Where did it start? 00:36:33.000 --> 00:36:39.000 Review the individual self. That's about looking at ourselves. It's about counter-transference. 00:36:39.000 --> 00:36:42.000 Palliative care folks talk about countertransference. What is it that you bring? 00:36:42.000 --> 00:36:47.000 to the situation that makes this person, this situation. 00:36:47.000 --> 00:36:52.000 toxic for you, but it might not be toxic for the person sitting next to you. 00:36:52.000 --> 00:36:54.000 How do we figure that out? How do we explore that? 00:36:54.000 --> 00:37:02.000 Review our responsibilities, what is the… that's another boundary issue, isn't it? What is my job? What is the job of the leader? 00:37:02.000 --> 00:37:07.000 Which often, as a physician. What is the job of the leader? 00:37:07.000 --> 00:37:15.000 And what can we expect from our leaders? Um, and how do we… how do we have those conversations where we feel that we have been heard? 00:37:15.000 --> 00:37:20.000 Psychological safety, that we have been heard. We might not like the outcome. 00:37:20.000 --> 00:37:25.000 But we have been heard. A decision to stay. 00:37:25.000 --> 00:37:33.000 can empower one to feel less trapped and taken control. It's… everybody… people… unique people. 00:37:33.000 --> 00:37:42.000 are in unique circumstances. And some folks think that they… it gets to the point where they feel like they have to leave a certain setting or a certain situation. 00:37:42.000 --> 00:37:48.000 And the reality is, when they look at it and sit down and weigh their responsibilities. 00:37:48.000 --> 00:37:52.000 And so on and so forth. They know that they can't leave. 00:37:52.000 --> 00:37:55.000 They don't have the privilege of being able to leave. 00:37:55.000 --> 00:38:00.000 And then, at least that is some kind of an assessment process. 00:38:00.000 --> 00:38:07.000 And if it's a choice to stay. That's some semblance of moving from feeling out of control. 00:38:07.000 --> 00:38:11.000 to have some semblance of control. I am staying. 00:38:11.000 --> 00:38:18.000 Even though this probably is not going to change because of A, B, C, and D. I've been here a long time. 00:38:18.000 --> 00:38:21.000 I love all the other aspects of this job that I do. 00:38:21.000 --> 00:38:26.000 I've built my professional life here. I have to keep a roof over my head. 00:38:26.000 --> 00:38:29.000 I have to keep food on the table for my kids. 00:38:29.000 --> 00:38:34.000 Those are the kinds of things that one weighs before one makes a decision. 00:38:34.000 --> 00:38:37.000 to leave. I don't know, where's the next slide? 00:38:37.000 --> 00:38:49.000 And Terry would say here that we decided not to talk about the whole leaving part, because that's a whole other webinar, and we are very aware of that. Um, but we felt like we wanted to focus on the toxic. 00:38:49.000 --> 00:38:56.000 team part and not focus on the leaving. Maybe we'll be doing something about that later on, but we were just very intentional. 00:38:56.000 --> 00:39:01.000 Yeah. I'm not sure where we are, let's see. 00:39:01.000 --> 00:39:03.000 Oh, takeaways, Jay! 00:39:03.000 --> 00:39:07.000 Okay, I'll take it away. So, thank you very much, Connie and Terry. 00:39:07.000 --> 00:39:13.000 very insightful comments. I learned a lot myself, but, um, so I'm here to kind of close things up. 00:39:13.000 --> 00:39:21.000 Um, so the takeaway, I think. Palliative care, I think we have to be humble. We're not… any more immune to toxicity than any other team. 00:39:21.000 --> 00:39:27.000 Um, certainly, I think it's clear, just based on this discussion, that toxicity undermines teamwork. 00:39:27.000 --> 00:39:32.000 Um, and patient care can definitely be adversely affected with that. 00:39:32.000 --> 00:39:36.000 I think one of the takeaway points that I took is that. 00:39:36.000 --> 00:39:41.000 You know, it's important to set up an environment where a person is psychologically safe. 00:39:41.000 --> 00:39:47.000 Either through, kind of, open communication, or using a green room, or having individuals who you can turn to. 00:39:47.000 --> 00:39:53.000 And I think taking a thoughtful approach to how to address the situation. 00:39:53.000 --> 00:39:57.000 both kind of understanding what your personal reaction to it is. 00:39:57.000 --> 00:40:03.000 Um, getting other people's perspective. And I think Terry, in our discussion last year, brought up this idea of kind of being. 00:40:03.000 --> 00:40:16.000 Curious, but not judgmental. kind of in your evaluation. And then, I think finally, to use, you know, we… we… pride ourselves often in being open and kind of good communicators with. 00:40:16.000 --> 00:40:26.000 Um, patients and families. having an open mindset, and that we should try to use that similar philosophy with kind of grace and compassion. 00:40:26.000 --> 00:40:30.000 kind of our other team members. So I think we'll close it up there. 00:40:30.000 --> 00:40:32.000 Open up for a discussion. 00:40:32.000 --> 00:40:42.000 And, um, yes, and we've given you some references, um, and I think everybody will be getting at the slides. Um, there were two questions that I just wanted to address, um, that I saw already. 00:40:42.000 --> 00:41:00.000 One, and I didn't jump in when Tara was talking, you know, there's a couple of things about, you know, regarding allies. Do you need to seek team allies outside of work, or… Um, within work. I think where you work, it's always good to know if there is a person who can be. 00:41:00.000 --> 00:41:07.000 non-judgmental, that you can trust to be confidential, who knows the environment that you can talk to. That's. 00:41:07.000 --> 00:41:10.000 Always good if you have a person who can be saying. 00:41:10.000 --> 00:41:17.000 You know, my sense of the team is this, this is what I see, and they can reflect back, because they really know. 00:41:17.000 --> 00:41:23.000 the dynamics. There might be times when that's not possible, and it's really important as you are. 00:41:23.000 --> 00:41:27.000 Working with teams that I have suggested to many of my. 00:41:27.000 --> 00:41:40.000 um, newer colleagues. Um, that you find somebody outside of your organization who is kind of like your, in your position, so it's like peer mentoring, that you can be incredibly honest with. 00:41:40.000 --> 00:41:49.000 to say, this is what happened, this is what I did, and you have the trust of that person, and I've had this before. 00:41:49.000 --> 00:42:00.000 Um, that sometimes that person, it was a sheesh, would say, you know, Khan, I can't think of anything else you did. You were right on, I can't think of anything you did. But there were times also when she said, you know. 00:42:00.000 --> 00:42:15.000 And she did this in the best possible way that we love about, um, communication, of saying, I wonder if you could have done this. I worry you might have upset people when you did whatever. And so. 00:42:15.000 --> 00:42:27.000 could say to me in a very loving way, I think you missed something, and go back and try that. So, you know, you want to have allies and people that you can be talking to, and then thinking about. 00:42:27.000 --> 00:42:34.000 Um, within, you know, your organization, I always have also sought people that I knew. 00:42:34.000 --> 00:42:44.000 I could talk to about what was going on and could trust that. And I want to go back to when Terry was talking about HR. Remember that HR. 00:42:44.000 --> 00:42:53.000 who they are working for. They are working for the organization. So that's why you have to think about that. But I'm going to say something also about employee assistance programs. 00:42:53.000 --> 00:43:01.000 You also have to be thoughtful about going with them, as well. Um, and I will share with you, I had an experience where, um, I went to talk to them. 00:43:01.000 --> 00:43:10.000 And I will never forget, because the person looked at me and said, are you sure that that's what really happened, and that's your interpretation? 00:43:10.000 --> 00:43:16.000 And it would… it blew me away. It was like, okay, I have no trust in this person, because. 00:43:16.000 --> 00:43:27.000 They're actually now questioning my… my, uh, sensibility of a situation where I wasn't. 00:43:27.000 --> 00:43:33.000 I was naming potential things, but all of a sudden, my integrity was being questioned. 00:43:33.000 --> 00:43:39.000 So, you know, you have to think about working with some of these people as to what is it going to be. 00:43:39.000 --> 00:43:50.000 What is it for? Is it… And where are your allies in that sense of the word? The people that you can trust and be vulnerable with? Because you want to be careful when you're talking about this, because. 00:43:50.000 --> 00:43:57.000 Before you're doing certain things, and before you know where the team is, you don't want to say things that appear on your evaluation. 00:43:57.000 --> 00:44:04.000 And when you have a team that's toxic, you can't trust when you're trying to do some of this stuff in the beginning that it won't be interpreted another way. 00:44:04.000 --> 00:44:08.000 I think the one thing I might add to what you said, kind of. 00:44:08.000 --> 00:44:11.000 We're talking about allies, sometimes I find it helpful to. 00:44:11.000 --> 00:44:16.000 Right? In my career final, but someone who's. a little bit older and a little bit more experienced. 00:44:16.000 --> 00:44:20.000 in that role, rather than someone who's just on my level as a peer. 00:44:20.000 --> 00:44:25.000 Just because they sometimes have a better perspective and can talk me down off the ceiling. 00:44:25.000 --> 00:44:41.000 Yeah. No, I think that's true, and you know, people who can… And also, knowing that, you know, remember our… patience goes way… waxes and wanes, right? Like, if we're in the middle and a lot of stuff is going on, our tolerance may just. 00:44:41.000 --> 00:44:48.000 be low, versus we come back from vacation, and we're like, okay, you know, I want to still be in that vacation mode. 00:44:48.000 --> 00:45:02.000 And so I think, you know, recognizing how you want to come in and come out with that. I think the challenge also is you know when you're in a toxic team, if people are dancing around somebody, right? That they're working around them, because. 00:45:02.000 --> 00:45:19.000 It's… they're not effective, or they're… your communication styles are so bad, and… and so, you know, paying attention to what's happening with that. Somebody asked the question is, what if the toxicity occurs in a team that was once three members and is now 2? 00:45:19.000 --> 00:45:30.000 Um, that's a really interesting question, um, because what you're saying is you might have had, with 3 people, a little bit of a buffer, and now you are directly with that person. 00:45:30.000 --> 00:45:36.000 Um, and I think that's a tough one, right? I'll weigh in, but I'm gonna… I want to hear what Terry and Jay have to say. 00:45:36.000 --> 00:45:46.000 Um, you know, I think it depends on… Um, there can be a lot of things that happens of, like, who started when on the team, and do you have somebody who's. 00:45:46.000 --> 00:46:08.000 looked up to as maybe an informal team member, because they might have started it, and then somebody else came in, and so there's a little bit, maybe, of jealousy in that sense. 00:46:08.000 --> 00:46:09.000 Mm-hmm. Mm-hmm. 00:46:09.000 --> 00:46:17.000 Um, is there something about talking about what the… goals for the program are that you're coming at this, because sometimes, even if we… We don't agree with people. We can find commonality in patient care, so we can continue to work together and not be best friends, but we can figure out, this is this whole idea of respect, that I can. 00:46:17.000 --> 00:46:21.000 Not jive with somebody's personality or whatever, but I respect what they're doing. 00:46:21.000 --> 00:46:26.000 Um, so that's just my thoughts, but Terry and Jay, I'm gonna let you jump into that one. 00:46:26.000 --> 00:46:33.000 I mean, the thoughts are going through my mind is… is like… when something goes from 3 to 2. 00:46:33.000 --> 00:46:39.000 That's a loss, right? That's a major loss for both… for both, for the two who are left. 00:46:39.000 --> 00:46:59.000 Um, and it strikes me that whatever was. It gets diluted when there's three. It's like… you know, it's like a family. It's sort of interesting to think about a triangle versus a duo… duet. So I think the beginning for that is actually. 00:46:59.000 --> 00:47:05.000 to have a conversation about the meaning of what it means to go from 3 to 2 people. 00:47:05.000 --> 00:47:13.000 Um, and what that means in terms of change of responsibility, change of how you count on each other, so that instead of. 00:47:13.000 --> 00:47:26.000 do… instead of looking at it in the person, and who knows, I don't know who the… who the second person is that you're talking about, so maybe they're horrific, I don't know. Um, but it just feels to me like an opportunity. 00:47:26.000 --> 00:47:33.000 to take the structural issue. And say, we have gone from 3 people to 2 people. 00:47:33.000 --> 00:47:39.000 How are we going to manage this? This is like being a couple, you know, and we didn't choose each other. Maybe there's a place for humor. 00:47:39.000 --> 00:47:44.000 I don't know. We didn't choose each other. And here we are, we're now a couple. 00:47:44.000 --> 00:47:51.000 How can… how do you think we can make this work in the best way possible? That's a structural change that I think needs attention. 00:47:51.000 --> 00:48:02.000 that takes it out of the persons, if you will, and looks at the structure, and what does that mean? Do you have the same number of consults that you had when there were three of you? 00:48:02.000 --> 00:48:04.000 What kind of pressure is that putting on you? 00:48:04.000 --> 00:48:07.000 on each of you as individuals. How are you going to negotiate that? 00:48:07.000 --> 00:48:11.000 Um, those are some of the thoughts that, just take it from me. 00:48:11.000 --> 00:48:21.000 out of the individual persons, if you will. to a structural change that would feel major in my life if it went from 3 to 2. 00:48:21.000 --> 00:48:28.000 Think about your families, right? Go from 3 to 2 people, it's like, oh my god, you're the person I lived with when the kid lives home? 00:48:28.000 --> 00:48:41.000 And you… right? And you've been parents to a kid, and it's like they leave home, and all of a sudden, you look at this person, it's like, oh my god, you're the person I chose? So if you think about it that way, and I'm not… I don't mean to diminish it by using humor. 00:48:41.000 --> 00:48:42.000 But it is significant when a change like that happens. 00:48:42.000 --> 00:48:45.000 Yep. 00:48:45.000 --> 00:48:55.000 I don't know how you dilute. the impact of that, so that you make adjustments, so you can help each other, rather than knocking each other off, if you will. 00:48:55.000 --> 00:49:07.000 Yeah. Che, I'm gonna move to one, because, um, there's a question about a physician, so I'm going to leave it… I'm going to give it to you. It says, what is, um, what is also difficult is when the physician on the team is the toxic member. 00:49:07.000 --> 00:49:14.000 Due to the hierarchy of the organization, it sometimes seems easier to look the other way because the physician can bill. 00:49:14.000 --> 00:49:16.000 Putting you in the hot seat there. 00:49:16.000 --> 00:49:17.000 I can't imagine… I can't imagine a physician ever being a problem on the team. 00:49:17.000 --> 00:49:22.000 Steve? Yep. 00:49:22.000 --> 00:49:31.000 So, um… you know, I don't think I can speak to, kind of, the billing aspect of it, but I think it's brought up earlier, kind of this. 00:49:31.000 --> 00:49:51.000 idea of this kind of clash of cultures on teams, and that, um… in each individual on the team is kind of looking at things from a different perspective, has different pressures, so… I mean, I think the principle all along that I've listened to in this conference is the idea of kind of open communication, so I think that's critical, but. 00:49:51.000 --> 00:50:00.000 I do think that it's important. in defense of the physician, at times is sometimes, you know, they may be under pressures that you may not. 00:50:00.000 --> 00:50:10.000 be aware of. Um… you know, one of the things, you know, they're the ones who have to make decisions, for example, on medications that may or may not. 00:50:10.000 --> 00:50:15.000 be… cause harm to the patient. Um, they're under pressures in other ways. 00:50:15.000 --> 00:50:23.000 Um, to manage and to work with colleagues. So, that is not defending, obviously, toxic behavior or mature behavior, but certainly, I think. 00:50:23.000 --> 00:50:28.000 Just like anything else, I mean, even… From my perspective, I think the more I learn. 00:50:28.000 --> 00:50:39.000 the lens that other people on my team are working through, the better I'm able to work with them, so… I think the solution's mostly about, kind of, understanding, kind of, what is actually driving this. 00:50:39.000 --> 00:50:44.000 what's causing the stressors that he's behaving in that way? There might be something that you're unaware of. 00:50:44.000 --> 00:50:45.000 I'm not sure if that's a good answer. 00:50:45.000 --> 00:51:03.000 Well, I think, Jay, what you're speaking to also is sometimes when you have those behaviors, and you're not able to talk it in team meetings, because you only have an hour, and you're trying to do other things, this is not the time that somebody… it has to be time set aside. And that may be that you have a retreat, and you have a retreat facilitated by an outside person. 00:51:03.000 --> 00:51:08.000 And you want that outside person to be interviewing team members, because they're an objective person. 00:51:08.000 --> 00:51:09.000 Yeah, I mean, even… I mean, when I think about it as a palliative care physician, I interact with other physicians. 00:51:09.000 --> 00:51:14.000 to bring things. 00:51:14.000 --> 00:51:21.000 And sometimes another position might come across as… harsh or kind of, you know, difficult to communicate with. 00:51:21.000 --> 00:51:29.000 But when I step back, it's like, when I understand, kind of, the kind of pressures he's under, what he's trying to accomplish, it kind of makes it more. 00:51:29.000 --> 00:51:30.000 Yeah. Yeah. 00:51:30.000 --> 00:51:36.000 You know, I think the whole issue of billing is so interesting because it's not one that we regularly talk about. 00:51:36.000 --> 00:51:46.000 I mean, social workers in inpatient settings generally do not bill, um, and while some people, you know, would make the case, yes, yes, you should find a path to billing. 00:51:46.000 --> 00:51:48.000 I think it's a privileged physician in some ways. 00:51:48.000 --> 00:51:52.000 Not to have to bill. And it took me a really long time. 00:51:52.000 --> 00:51:58.000 To understand, Jay, part of what you're talking about, that there are roles and teams. 00:51:58.000 --> 00:52:02.000 And jobs and teams that I will never have to do. 00:52:02.000 --> 00:52:03.000 Yeah. Well… 00:52:03.000 --> 00:52:11.000 I'll never touch a body. You know, I just want to finish my thought, right? I will never… have to… that's why the roles, that's why the roles aren't equal. 00:52:11.000 --> 00:52:19.000 They're not equal because… The responsibilities are profound, in my brain, profoundly different. The prescribing decisions that you all make. 00:52:19.000 --> 00:52:26.000 Right? The idea, I had a doctor tell me once, you will never understand what it feels like. 00:52:26.000 --> 00:52:31.000 We were talking about resuscitation. When docs feel like a resuscitation is inappropriate. 00:52:31.000 --> 00:52:39.000 And she said to me, you will never understand what it feels like to do something that you think is morally, ethically, and medically wrong. 00:52:39.000 --> 00:52:46.000 And she was right. And over the years, it helped me to understand that there is a difference in role. 00:52:46.000 --> 00:52:50.000 That's why our ethics, you know, our ethics don't always merge in the same way. 00:52:50.000 --> 00:52:51.000 Yeah. 00:52:51.000 --> 00:52:56.000 Um, and… and billing is a part of that difference in role. Billing sustains the team. 00:52:56.000 --> 00:53:01.000 Does that give a physician the right to be rude and a bully or whatever? No. 00:53:01.000 --> 00:53:05.000 But it is interesting to think about the difference and how that gets acted out. 00:53:05.000 --> 00:53:06.000 Yeah. And I think it also raises the point that. 00:53:06.000 --> 00:53:09.000 If you will. 00:53:09.000 --> 00:53:15.000 We need to be aware, just not only on an individual, kind of what our roles are, but kind of what is happening. 00:53:15.000 --> 00:53:18.000 Uh, like, it's important to understand the financing of a team. 00:53:18.000 --> 00:53:23.000 how that works, because that might give you insight into why the program director is stressed. 00:53:23.000 --> 00:53:24.000 About bringing on another social worker to the team, or another team. 00:53:24.000 --> 00:53:39.000 Yeah. Yeah, and somebody just said that people are intimidated by the… by physicians on teams, and, you know, I was that way in the beginning, a long time ago. Um, but it took a while to not be intimidated and to… 00:53:39.000 --> 00:53:40.000 to think that somehow I didn't have a voice. Yeah. 00:53:40.000 --> 00:53:48.000 But that… that comes a little bit to culture as well, though, because when I first married my wife, I'll tell this story, because it was our 25th anniversary. 00:53:48.000 --> 00:53:53.000 is that she would say something, and I would keep poking questions to it, and she would get upset, like I was challenging her. 00:53:53.000 --> 00:54:01.000 But the reality is, is when we're on rounds, for example, they keep trying to break down your argument for a diagnosis. 00:54:01.000 --> 00:54:07.000 And when they can't, then they finally accept it. So that's just a cultural difference on teams. 00:54:07.000 --> 00:54:08.000 But I think, you know, what we're sort of talking about… so that's the whole part about. 00:54:08.000 --> 00:54:11.000 Yeah. 00:54:11.000 --> 00:54:27.000 you know, and Terry's mentioned it, that we come from different cultures. We are empowered in different ways, and, you know, full disclosure, Jay and I teach together, and it's an interprofessional cohort, but we find sometimes different clinical aspects are some of the newer ones. 00:54:27.000 --> 00:54:38.000 will say, well, I can't speak to that, it's not my scope of practice. And we're saying, wait, wait, wait, leadership isn't about scope of practice, but people have been so acculturated in their academic preparation. 00:54:38.000 --> 00:55:00.000 to not step into that, that when physicians are saying they don't want to step into it, it's that nobody's empowered them to do it. Nobody has taught them the skills, and if you want to look up leadership skills, um, just for you, for fun, if you look up leadership skills for physicians, there's a lot. When you look up some of the other interprofessional stuff, there's about nurse management leadership, and then for social work and chaplaincy and pharmacy, I'm sorry, there's just not a lot there. 00:55:00.000 --> 00:55:05.000 So, you know, kind of thinking about that part, but I think when you're thinking about. 00:55:05.000 --> 00:55:15.000 somebody who's asking this question about upstream, you know, acculturation. It's really thinking about where are people coming from? And as a team, when you're coalescing together. 00:55:15.000 --> 00:55:23.000 How do you start off so that you can avoid toxicity is having team meetings that are talking about your team process. 00:55:23.000 --> 00:55:30.000 Having, you know, rules about acceptable behavior and not acceptable behavior. 00:55:30.000 --> 00:55:54.000 And I don't mean to be hardline, but, like, just a norm part, right? Because sometimes you have teams that are… so quick that it's hard for them to bring on learners, because that means they have to take time to actually educate. It's not bad or good, you just need to know that, versus teams that love to do education, and they are really good with having people with no experience, right? So there's some… there's some dynamics about some of that culture. 00:55:54.000 --> 00:56:12.000 I think the other part is thinking about. When you're on a team, and I spoke a little bit to this, you know, you're wanting to invite people to do activities together so they meet new people, and, you know, sometimes people will say, well, I don't want to do that off hours. Well, some of that means. 00:56:12.000 --> 00:56:18.000 Then you have lunch together. Then you do something… you know, we used to make. 00:56:18.000 --> 00:56:23.000 cakes, we each would take turns, whoever would… these, what we called these trash birthday cakes that were not. 00:56:23.000 --> 00:56:38.000 beautiful, crafted things, but they were kind of silly. And… and it was kind of a fun thing that we did, that we got to know humor about each other, and what was important by how people baked, and who just said, look, I'm going to buy the store-bought cake, and I'm just gonna throw stuff on it. 00:56:38.000 --> 00:56:46.000 So, you know, thinking about, um. How do you have your team come together? But if you're noticing people are not getting along. 00:56:46.000 --> 00:56:50.000 What do we do with patients in the room when things are difficult? 00:56:50.000 --> 00:57:01.000 We name it, right? The elephant in the room, and if we have two people that are not getting along, at some point, somebody's gonna need to say, wow, I noticed the two of you don't get along. 00:57:01.000 --> 00:57:09.000 you might not be best friends, but how do we help you work in respect to each other, right? Because that's a different skill set than liking each other. 00:57:09.000 --> 00:57:14.000 But Jay or Terry, how do you want to respond to that? That was one of the questions. 00:57:14.000 --> 00:57:15.000 I lost the question, Connie. 00:57:15.000 --> 00:57:22.000 The question is, like, when you have toxic team members that don't get along, how do you kind of call it out, or how do you kind of help. 00:57:22.000 --> 00:57:27.000 the two people resolve when you're around these two people that are just toxic together. 00:57:27.000 --> 00:57:36.000 Ah, ah, ah, yes, yes, yes. Um, so you… so we're not talking about leadership, we're talking about peer conversations, right? 00:57:36.000 --> 00:57:37.000 You know, I think it's sort of interesting to imagine that you might use your own discomfort. 00:57:37.000 --> 00:57:41.000 Yep. 00:57:41.000 --> 00:57:46.000 to bring that conversation up, and to say, I get so uncomfortable. 00:57:46.000 --> 00:57:49.000 When I hear what goes on between the two of you. 00:57:49.000 --> 00:58:03.000 Can we sit down and talk about that? Because it makes me so uncomfortable. I can't stand my discomfort. I need to do something about that. Because helplessness is a problem, right? Helplessness is a problem. And if you're all working toward some kind of a goal. 00:58:03.000 --> 00:58:08.000 Um, and I think that some people don't understand the impact that they have on others. 00:58:08.000 --> 00:58:10.000 You know, it's a way of saying, I see you. 00:58:10.000 --> 00:58:17.000 You know, we're always talking about whether people can… Can you be what you can't see? That whole idea. 00:58:17.000 --> 00:58:30.000 Um, and to say to people. I see you, and I hear you, and it has an effect on me, and we need to sit down and talk about this. I don't know what to do about it, I don't have that power, but I do know that… that… 00:58:30.000 --> 00:58:36.000 a next step for me is to say I need to talk with the both of you, because it makes me so uncomfortable. 00:58:36.000 --> 00:58:39.000 Um, to see what goes on between the two of you. 00:58:39.000 --> 00:58:44.000 Um, I think that's just the beginning. But I think it's an important beginning because it's about. 00:58:44.000 --> 00:58:50.000 It's about, um… it's about… not… it's not… those folks are not invisible. 00:58:50.000 --> 00:58:57.000 They have an effect on other people, um, and they need to be invited to think about that. 00:58:57.000 --> 00:58:58.000 to think about that. 00:58:58.000 --> 00:59:09.000 Yeah, and I think sometimes in palliative care, we're so tied up with doing patients and families, and that takes our energy, right? That we're, like, terrified of doing the work with the team, because that's going to take our energy. And yet. 00:59:09.000 --> 00:59:19.000 I would suggest that, like, I've always thought about that, you know, I have my work family. I'm not saying that they're, you know, that close, but it's… I'm with them for 40 hours a week. 00:59:19.000 --> 00:59:37.000 That kind of is a familiar sport. And then I'm with my other family, and so, like, I want to be able to go into… out of those environments and kind of… be able to breathe and not be like, oh my god, what missile's gonna be thrown over me? You know, especially if you're the person at the desk in the middle and the barbs are going. 00:59:37.000 --> 00:59:38.000 Yeah. 00:59:38.000 --> 00:59:42.000 That can be really crazy. I'm aware that we are at the top of the hour. Your questions have been fabulous, um. 00:59:42.000 --> 00:59:47.000 Okay. 00:59:47.000 --> 00:59:51.000 Kelsey, I don't know if there's anything else we should be doing. We are grateful that all of you joined us. 00:59:51.000 --> 00:59:57.000 Um, we are thinking that we probably need to do this seminar again, and we, you know, also were talking about. 00:59:57.000 --> 01:00:11.000 You know, when people are in environments and they make a decision to go, that's a whole different, um… course of action and demands, you know, a whole hour. But, um, any last-minute comments, Terry or Jay, as we let people go? 01:00:11.000 --> 01:00:23.000 I just wanted to say another quote that somebody left me with, because it's so nice to… this quote so applies to palliative care. She taught me, it's the same doctor who taught me the other quote that I said. 01:00:23.000 --> 01:00:30.000 And she taught me that when you're in palliative care, Terry, she said, sometimes you're the orchestra conductor. 01:00:30.000 --> 01:00:34.000 Sometimes you're the soloist, and sometimes you're part of the orchestra. 01:00:34.000 --> 01:00:38.000 And I think it's brilliant, because it speaks to us. 01:00:38.000 --> 01:00:43.000 Having different roles, different relationships with families, different relationships with patients. 01:00:43.000 --> 01:00:48.000 And being okay with that. That we don't have to be the center of everything. 01:00:48.000 --> 01:00:57.000 Um, and we don't have to be the most important influencer on the team, so on and so forth. So I just love that quote, and I… it's running through my mind, and I want to share it with you all. 01:00:57.000 --> 01:01:01.000 And Jay, anything else that you would leave us with? 01:01:01.000 --> 01:01:05.000 I think… I think I learned as much as I think we gave a… gave away. 01:01:05.000 --> 01:01:09.000 Great. All right, uh, Chelsea, do you want to… close this out. 01:01:09.000 --> 01:01:18.000 Yes, Connie, thank you so much. Thank you, Terry, uh, Connie and Jay, uh, for presenting today. Thank you all so much for being part of the session. 01:01:18.000 --> 01:01:29.000 Uh, I just want to remind everyone the slides and the recording will be available on our website on the on-demand webinars page, so… Um, you can access the slides there, and if you missed any portions of the session, you can rewatch. 01:01:29.000 --> 01:01:43.000 those as well. Um, we'd love to hear your feedback, so if you have any feedback, I see lots of, uh, thank yous in the chat, and, uh, lots of requests for more of this, uh, content. So, thank you for that, and let us know, um, any suggestions for future CAPC topics you'd like to see, but. 01:01:43.000 --> 01:01:49.000 Thanks, everyone, so much, and have a great rest of your day.