Ep 198 Understanding and Improving Culture in Emergency Medicine: Key Insights

There is a culture problem in medicine. 70% of us are disengaged, more than 50% contribute nothing to our departments and more than 15% actively work against a healthy culture in our departments. What makes an Emergency Department run like a well-oiled machine with staff that find meaning in their work and who are grateful for serving the public? There are individual skills; there are team skills; there is the admin, and then there is the oh-so-important culture which permeates all of these and can make them great or can drive them into the ground. The culture of an ED can make it or break it. In this EM Cases podcast Anton chats with Dr. Peter Brindley and Dr. Leon Byker who have a deep interest in the Culture of Medicine to explore what culture in medicine is, why culture is so important, and then drive home 10 strategies to improving the culture in our departments emphasizing the importance of human connection, empathy, open communication, and a willingness to learn from mistakes in creating a positive and fulfilling work environment, so that we love our work, we love our department, we love taking care of our patients and our patients have better outcomes…

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Podcast production, sound design & editing by Anton Helman

Written Summary and blog post by Anton Helman October, 2024

Cite this podcast as: Helman, A. Byker, L. Brindley, P. Episode 198 Understanding and Improving Culture in Emergency Medicine: Key Insights. Emergency Medicine Cases. October, 2024. https://emergencymedicinecases.com/improving-culture-emergency-medicine. Accessed October 12, 2024

What is culture in medicine?

Culture in medicine integrates values, beliefs, behaviors, and interpersonal dynamics. Gert Hofstede’s framework outlines five key indices to evaluate cultural health in organizations: power distance, individualism vs. collectivism, assertiveness, uncertainty avoidance, and long vs. short-term orientation. Understanding where your department stands on these scales can illuminate pathways for cultural improvement.

Hofstede’s 5 Dimensions of Culture

1. Power differential – the degree of inequality that exists and is accepted between people with and without power
2. Individualism vs collectivism – the strength of the ties that people have to others within their community
   1. High IVD – high value placed on people’s time and need for privacy and freedom, an enjoyment of challenges, and expectation of individual rewards for hard work – in these communities should encourage debate and expression of people’s ideas and don’t mix work life with social life too much
   2. Low IVD – emphasis on building skills and becoming a master of something, people work for intrinsic rewards, maintaining harmony among group members is important, wisdom is important, avoid giving negative feedback in public
3. Uncertainty avoidance index – how well people can cope with anxiety
4. Long vs short-term orientation
5. Indulgence vs restraint

Why culture in medicine matters

The culture of an ED shapes every aspect of its operation, from teamwork to patient care. It is critical for fostering a supportive environment that allows medical professionals to thrive. Culture is often intensified in high-pressure situations typical of Emergency Medicine, making it imperative to assess and enhance cultural dynamics actively.

It can be a challenge to foster teamwork in a culture that often prioritizes individualism and status. The “status game” may be a prominent feature in an ED culture where unconscious competition for hierarchical position often has negative effects on culture.

Top 10 Strategies for Improving Culture in Emergency Departments

1. Reflect on Current Culture: Encourage staff to evaluate the power dynamics and individual vs. team orientation within the department. Self-assessment is the first step to recognizing areas for improvement.
2. Foster Effective Communication: Giving and taking rudeness is iatrogenic. Self awareness when we are grumpy and communicate poorly requires quick identification followed by an apology to prevent long term negative consequences. Both verbal and non-verbal communication skills need to be addressed. Encourage regular training and discussions around effective communication, especially in high-stress scenarios. In simulations, we practice structured communication techniques such as the SBAR (Situation, Background, Assessment, Recommendation) and the CUSS (Concerned, Uncomfortable, Safety issue, Stop) models. While these methods are crucial, they often feel disconnected from real-life scenarios.
3. Build Relationships: Take time to cultivate relationships among team members. Casual interactions, like sharing a coffee, can strengthen bonds that improve collaboration during emergencies. We need to move beyond performative niceness and be truly kind to each other. While we do not need to “like” or be personal friends with everyone we work with, we do need to be collegial for our ED culture to be healthy.
4. Embrace Feedback: Create a culture that welcomes both giving and receiving feedback. This promotes a safe environment where everyone can learn and grow. Feedback should not be confined to criticism; recognizing positive contributions is equally important. Sincere praise (rather than rehearsed positive feedback for all) is essential in promoting a positive culture.
5. Commit to Long-term Change: Recognize that while some changes can happen quickly, cultural transformation often requires sustained effort over years.
6. Self-Compassion, “Failing Up” and Being a “Failure Friend”: At the core of a healthier workplace culture is the concept of self-compassion—recognizing that everyone has imperfect days and learning from failures rather than being paralyzed by them. The notion of being a “failure friend” emphasizes the importance of supporting colleagues through tough times. This involves understanding what someone needs when they experience setbacks, whether it it space, a comforting conversation, or simply a cup of tea. Encourage open dialogue about failures within your team. Create a safe environment where colleagues can share their experiences without fear of judgment. This not only fosters camaraderie but also promotes collective learning.
7. Embracing Safety: Safety in medicine transcends just avoiding mistakes. It encompasses creating an environment where team members feel physically and emotionally secure. This involves open lines of communication where feedback can flow freely without the looming threat of blame. Implement structured feedback sessions that focus on systems and processes rather than individual shortcomings. Emphasize that the goal is to improve patient care, not to point fingers.
8. Changing the Emotional Contagion: Emotional contagion—the transfer of moods between individuals—can significantly impact workplace dynamics. A single negative interaction can ripple through a team, affecting morale and performance. Modeling positive behavior is not just beneficial; it is essential for fostering a supportive team culture. Acknowledging and managing emotions is crucial. Promote awareness of your own emotional state and its potential impact on the team. Use nonverbal cues to foster positivity and address negativity in a supportive manner. Simple gestures, like making eye contact or offering encouragement, can go a long way.
9. Dialing Down the Adrenaline: High-stress environments often thrive on adrenaline, but this can compromise decision-making and teamwork. Learning to manage stress is essential for maintaining cognitive bandwidth and clarity. Techniques such as deep breathing or square breathing can help regulate emotions in the moment. Pre-planning roles in resuscitations can also alleviate stress and create a more composed environment.
10. Taking One Day at a Time: Culture change is a marathon, not a sprint. Adopting a mindset of incremental improvement can make the process feel more manageable. Reflect on daily interactions and identify small areas for growth. Encourage reflection—whether it’s through journaling or team discussions—on what went well and what could be improved. Recognizing even 1% progress each day can contribute to a significant cultural shift over time.

Enhancing consultant communication in Emergency Medicine: Improving the culture of ‘push-back’ from consultants

Many Emergency Physicians encounter resistance or pushback when seeking consultant input. Transforming communication with consultants requires a concerted effort to build relationships, offer sincere feedback, and adopt a collaborative mindset. By focusing on the patient rather than a conflict and employing thoughtful communication strategies, Emergency Physicians can pave the way for more effective teamwork, ultimately improving outcomes and job satisfaction for everyone involved.

The Importance of Positive Feedback

One of the most impactful ways to improve relationships with consultants is through sincere positive feedback. When a consultant provides genuine help, taking a moment to express gratitude can go a long way. Thanking consultants for their support not only strengthens professional ties but also contributes to a positive culture within the hospital.

Understanding the Pushback

Resistance when reaching out to consultants stems from various factors:

• Burnout and workload: Consultants may be overworked, leading to frustration that gets passed on during interactions.
• Fear of litigation: A consultant’s reluctance to engage may come from concerns about liability and added responsibility.
• Communication styles: Poor communication can escalate tensions, creating an adversarial rather than collaborative atmosphere.

Understanding these factors can help us frame our interactions more effectively.

Transforming the Culture of Trainee Treatment in Emergency Medicine

The way we treat trainees can significantly shape the future of Emergency Medicine. Unfortunately, some hospitals perpetuate a culture where trainees feel overworked and undervalued. Many trainees report experiences that resemble outdated models of hierarchy and servitude. This culture is damaging not only to the individuals involved but also to the institution’s reputation and overall performance. When trainees are treated poorly, they are likely to internalize this behavior and replicate it in their future roles, leading to a cycle of negativity and discontent.

Transforming how we treat trainees in EM is not just a moral imperative; it’s essential for the health of our EDs and the quality of care we provide. By fostering an environment of empowerment, recognition, and mentorship, we can break the cycle of negativity and create a culture where both trainees and attending physicians thrive.

A Positive Approach to How We Treat Trainees: Empowerment and Choice

At institutions that prioritize a supportive culture, trainees often express that they enjoy their learning experience. This satisfaction stems from a few key practices:

1. Empowering Decision-Making: Allowing trainees to have a say in their schedules and patient interactions fosters a sense of agency.
2. Recognition and Appreciation: Acknowledging the hard work and contributions of trainees helps them feel valued. Simple gestures of gratitude can transform their experience from one of servitude to one of teamwork.
3. Mentorship and Support: Providing strong mentorship creates a safety net for trainees, allowing them to learn and grow without the fear of being overburdened or undervalued.

The Impact of Culture on Recruitment and Retention

A positive training environment attracts the best and brightest. Departments known for treating trainees well often become the preferred choice for trainees. This “virtuous cycle” creates an atmosphere where trainees are excited to join and contribute, leading to improved patient care and a better work environment for all staff.

The Journey Through a Medical Career

As trainees evolve into attending physicians, their perspectives shift. The concept of “learning, earning, and returning” encapsulates this transformation. Initially focused on external validation and career advancement, many eventually find fulfillment in giving back to their community and nurturing the next generation of medical professionals.

The idea of moving from the first mountain (career-building) to the second mountain (commitment to service) reflects a deeper understanding of one’s role in healthcare. This journey is often accompanied by challenges, such as burnout, underscoring the importance of supportive cultures throughout one’s career.

Improving the culture around death and dying

As emergency providers we frequently encounter families during their most vulnerable moments, often without prior knowledge of their cultural or personal beliefs regarding death. This lack of understanding can complicate end-of-life discussions, leading to moral distress. The challenge is exacerbated by the legal and institutional pressures that prioritize aggressive treatment over compassionate care.

Dying Certificate: Dr. Brindley’s concept of a “Dying Certificate” is one means of fostering clear communication about prognosis and facilitating end-of-life planning. This is not a certificate in the traditional sense, but a way to clearly articulate a patient’s status and prognosis. This candid communication can foster a more humane approach to care, steering away from mere data points (like oxygen saturation and lab values) toward a holistic understanding of the patient’s journey and family needs.

The “3 Ts” framework (Treatment, Time, Transplant) for evaluating the potential for successful intervention is a useful way to think about communicating with critically ill patients and their families. If there is no specific treatment that can improve the patient’s trajectory and time will not improve the patient’s trajectory and an organ transplant would not improve the patient’s trajectory, then this should be explained to the patient and their family to help guide end of life decisions.

Taking a minute of silence for the deceased: One strategy is the practice of taking a minute of silence after a patient’s death. This simple act can remind the team that they are dealing with individuals, not just a clinical case, and build strength of the team. This acknowledgment can help bridge the gap between medical efficiency and emotional engagement.

Changing the culture around death in healthcare requires concerted efforts at multiple levels:

• Education in Primary Care: Initiating conversations about mortality in primary care settings can normalize discussions about death. Practitioners should feel empowered to discuss patients’ end-of-life wishes long before a crisis arises.
• Enhanced Communication Skills: Training healthcare professionals in effective communication can mitigate misunderstandings and moral distress. Utilizing clear, empathetic language when discussing prognosis can provide families with the clarity they need to navigate difficult decisions.
• Incorporating Family Values: Emphasizing the importance of understanding a patient’s life story—what brought them joy, their relationships, and their values—can create a more compassionate approach to care. This includes involving families in decision-making processes and respecting their wishes. This is difficult to do in a busy ED with time constraints and usually occurs in the ICU over several days.
• Creating Supportive Environments: Departments should encourage environments that support family presence and participation in end-of-life care. Recognizing families as essential components of patient care can facilitate a more holistic approach.

While changes in communication and teamwork can be implemented swiftly, broader cultural shifts may take decades. However, each individual has the power to influence the culture positively, emphasizing the need for sustained commitment to improvement. By actively engaging in these discussions and strategies, EDs can evolve into environments where staff feel valued, patients receive better care, and overall morale improves.

Quote of the Month

“True joy is being used for a purpose…

Not a feverish, selfish clod of ailments and grievances,

Complaining the world does not devote itself to making me happy.

Life is a splendid torch which I hold for brief moment.

I want to make it burn brightly before handing it to future generations.”

-George Bernard Shaw

References

Drs. Helman, Brindley and Byker have no conflicts of interest to declare