Welcome to the I'm Pharmacy Podcast! On our first episode, host Samuel Chan tackles the the topic of interprofessional collaboration with Leslie Dan Faculty of Pharmacy Professor and Murray Koffler Chair in Management, Dr. Zubin Austin.
You can find a full transcript of the episode on our simplecast site!
Samuel (Host): Hello everyone. My name is Samuel, I’m a fresh grad from the U of T pharmacy and I will be your host today. The podcast is produced by Kendra, a fourth-year pharmacy student doing all the hard work behind the scenes, and the podcast is supervised by Certina, a faculty member at our faculty and project lead at ISMP Canada. So, the aim of the podcast is to spread information about topics of interest to PharmD students and recent grads. And for each episode we will be inviting a guest expert for the topic being discussed. So enough about us. Let’s begin today’s episode on interprofessional health collaboration. And for our special first episode, we have an equally special guest in Zubin Austin. He is a professor and the Murray Koffler Chair in Management at Leslie Dan and for the first years that have not met him yet, you will soon be meeting him in the second semester where he teaches the psychology part of the Social and Behavioural Health. And just a quick side plug, because I personally really enjoyed the classes, is don’t skip theclasses.
Zubin (Expert): Good advice, Sam.
Samuel (Host): (laughs) He did not bribe me to say that, by the way, just making that clear. His research focuses on professional and personal development of the health workforce with an interest in interprofessional collaboration amongst other things. With over 160 manuscripts, publications and 100 invited international keynote presentations, and also receiving numerous awards recognizing his work’s societal impact, he truly is an expert at his field. Honestly when I was looking at these numbers, it kind of like blew my mind and made me think “how long has he been working [laughs] in the faculty for?” But anyways, I hope that didn’t make him too mad. How are you today,Zubin?
Zubin (Expert): I was a lot better until I heard your introduction.
Samuel (Host): Okay, that’s not a good start. So let’s get this podcast started.
Zubin (Expert): It seems like a good start considering we’ll be talking about interprofessional conflict.
Samuel (Host): [laughs] That’s part of it I suppose. I hope we don’t have too much conflict at this
moment. But part of it is also about mending the conflict and being resilient to it.
Zubin (Expert): True that.
Samuel (Host): Okay. So, as an introvert this first question hits close to home, but really I think it is a question for everyone. And, so, I sometimes feel stressed thinking about joining new teams and meeting new people and making a good impression. I’m wondering if research has indicated how pharmacists can best build rapport with a new careteam.
Zubin (Expert): Rapport is a really interesting and important part of collaboration. Another word for rapport is actually trust. We have rapport, we have psychological connection, we have a sense of affiliation with people when we trust them. And so, the real question I think to ask is, “What can we do to build trust with other care team members?” Our studies in this area suggest thatpart of the issue that many pharmacists face is that we have a very different mental model of what trust means than, for example,familyphysicians.Forfamilyphysicians,trustisactuallyearned,whileformanypharmacists,
trust is actually conferred. What does that mean? If you are a pharmacist and you are introduced to somebody who is a physician, you are likely immediately going to trust them. You are going to believe that, oh, this person is a physician, they went to school, they got a degree, clearly somebody else thinks they are smart and competent and capable; therefore, I can trust them. You will freely give trust to physicians. In contrast, our studies of family physicians in particular show that physicians do not confer trust, trust instead needs to be earned. You may have the greatest title in the world, the most number of degrees, have won a lot of awards, but until you’ve done something directly to prove yourself, to prove your value, to a physician, they’re not going to immediately trust you. Now, for the people listening to this, they can’t see you, but as I’ve been speaking, Sam, you’ve been nodding going ‘yeah that makessense.’
Samuel (Host): Yeah.
Zubin (Expert): One of the issues unfortunately is if that if you are the kind of person who gives trust, and the person you are talking with requires you to earn trust, you’re going to get hurt feelings. You’re going to assume, “Well I’m giving my trust freely to this person, why aren’t they giving me their trust in return? Maybe that person is a bully. Maybe that person is a know-it-all. Maybe that person thinks they’re better than I am.” And as a result, simply because we have different mental representations, or different mental models of what trust means, we start our interprofessional collaboration from a very different spot. And as a result, it might be a little bit more tricky to build rapport than we actually think it should be.
Samuel (Host): So, I think that’s a very interesting take on having to have found out that there are two different models of the psyche where we… one side is conferring the trust and one side is giving the trust. I’m wondering how long it takes to build trust and does that change if, per-se, you started off on a bad foot for example.
Zubin (Expert): Great question. And the short answer to that is we don’t really know how long it takes to earn trust. But we are pretty confident that trust is earned in a very situationally specific way. So, in some cases a pharmacist may simply not have an opportunity to earn trust if, for example, a physician doesn’t ask them to do anything. In other circumstances there might actually be a situation, an emergency, a crisis, a mistake that actually requires the pharmacist to very suddenly and in an unexpected way step up to the plate and in that one moment a whole pile of trust might be earned very quickly. There’s no magic formula, it all really depends on the situation and the context. But I think it’s most important to recognize that from the get-go you cannot generally expect that trust is going to be immediately conferred. You should expect you’re going to have to do something to earn that trust.
Samuel (Host): And as a pharmacist are there any things that you think students or fresh grads can do
when they’re on a new team to try to earn that trust?
Zubin (Expert): Great question. I think there’s a lot of things that pharmacists can do. The first thing that I would suggest is actually answer questions. This might seem like a strange thing, but when you examine conversational patterns between family physicians and pharmacists, you actually see that many pharmacists are hesitant to answer a question clearly and directly. Let me give you an example. If a physician asks, “Hey Sam, I’m glad you’re here, what’s better, drug X or drug Y?” Many pharmacists will have a tendency to answer that question, “What’s better, drug X or drug Y?” by saying “Thanks for asking that question, drug X does blah blah blah blah blah, drug Y does blah blah blah blah blah, drug Z doesblahblahblahblahblah.HaveyouheardofdrugA,it’snew,itdoesblahblahblahblahblah?”
When a physician asks the question “What’s better? Drug X or Drug Y?” What do you think they’re
expecting to hear?
Samuel (Host): The answer, which we didn’t actually answer it.
Zubin (Expert): X or Y. When we answer a clear question with a lot of blah blah blah blah blah, the signal we send to physicians, our potential collaborators, is that we actually don’t have confidence in the answer we’re giving. And so, if I don’t have confidence in the answer I’m giving, why should you have confidence in what I’m saying, and why should you trust me? So, actually learning to answer questions clearly and directly is a really important first step in establishing rapport.
Samuel (Host): So I hope every one of you listeners, including myself, would take this advice to heart. It sounds like something we can all definitely put into practice.
Are there any evidence that point towards, that, when there is conflict within an interprofessional team, would lead to any chan- or any adverse changes to a quality of care that a team can provide?
Zubin (Expert): There’s a lot of interesting research emerging right now about conflict in primary care. Both interprofessional conflict, that is conflict between people with different professional designations, as well as interprofessional conflict, that is conflict between people that have the same professional designations or are in the same field, for example between pharmacists and regulated pharmacy technicians. And across all of these different literatures, one of the common themes that emerges is that not only is conflict stressful and produces a difficult work environment, it also increases the incidence of error, it also reduces the quality of decision making, and ultimately compromises the quality of care that patients receive. In large part, this is because where you have conflict, communication shuts down and when communication shuts down, you don’t have access to the entire array of different perspectives, opinions, ideas from a group of different people and you end up having a lot of unidimensional, individual decision-making rather than taking full advantage of the diverse skills of a team
Samuel (Host): Do you think there are particular reasons why there is this break down, or conflict that would arise?
Zubin (Expert): That’s a difficult question, but it’s, and, of course every situation and every team will be different, but there are a couple of common themes across intra- and inter-professional conflict that might help to answer your question. The first is that each of us appears to have a specific conflict management style. And our conflict management styles sometimes are the root cause of a conflict. For example, many pharmacists are indirect communicators. As we mentioned in the previous question, we don’t like to say “drug X is better than drug Y.” We spend a lot of time talking in circles. And, as pharmacists we like to think that when we talk in circles, we are covering our butts. We are presenting a lot of information so to let somebody else make a decision and take responsibility rather than us having to do that for ourselves. That pattern of communication is sometimes referred to as ‘avoidance’. In contrast, when we look at the conflict management and communication style of many family physicians, we see that they are very direct communicators and they have a very clear sense of what is right and what is wrong. And in communication theory, that is called being a conflict forcer. The fact that many pharmacists and many physicians have these different, arguably opposing, communication styles, means that we may be more prone to conflict because we’re literally speaking a different language with one another.
Samuel (Host): So, do you think being more assertive is one solution to this conflict?
Zubin (Expert): It’s one solution but it’s absolutely not the only solution because it suggests that somehow we, as pharmacists are the problem. We’re half the problem.
Samuel (Host): Fair enough, it’s a two-way street.
Zubin (Expert): Exactly. And so what it means is that everybody in a team, whether it’s an inter- professional or intra-professional team, needs to develop a more diverse array of communication skills so that if you are a forcer and you happen to be speaking with an avoider, be a little bit more patient. Recognize that it takes them a little bit longer to say something. If you’re an avoider speaking with a forcer, be more direct, even if it’s not comfortable for you. There is a not a right way to communicate, and there is not a perfect way to interact with other people. Communication is a two-way street and both parties need to learn to adapt to one another as the best possible way to prevent the conflict, that may eventually compromise quality of patient care.
Samuel (Host): I think that’s very interesting and it actually sounds like the personality is where these conflicts arise in. I mean I feel like personality, when you make friends and those, it comes in to play and this scenario is no different as well.
Zubin (Expert): Yeah. Personality is certainly part of it, and it’s a difficult thing to actually morph your personality. And I would very rarely suggest that you should try to do that. You should not necessarily try to be somebody you’re not. What you may have more success in doing is learning a broader repertoire of communication skills. Your communication skills are independent of your personality. Your personality may be the first filter through which your communication skills develop. But even if you are an indirect communicator, who is introverted, who does not like to directly answer questions, that’s your personality. You can learn, you can practice, you can rehearse, and you can develop a different communication style even if it doesn’t come naturally to you, because of yourpersonality.
Samuel (Host): That you very much for answering that question. As you noted, earlier, one way to build rapport is to show the value, is to, and to build trust, is to show the value that the pharmacists have. And I think as pharmacists one way we can do is to show value through our care plans. And as a new pharmacist or student going into rotations, is there a good way to do this from a more junior perspective, and to prevent any interprofessional conflicts fromoccurring?
Zubin (Expert): Another great question, Sam, thank you. I sometimes worry that in school we may present a very unrealistic picture of what goes on in the real world. We may give you the notion that care plans are 10,000-word essays that have to have every ‘I’ dotted, and ‘T’ crossed, and every reference made in order to be effective. The kind of care plans that students develop in school or in academic contexts, while it’s useful for learning, may not necessarily be the best way to communicate with prescribers and other healthcare professionals. You used the word assertive; I would prefer to use the word ‘concise’. Primary care, in particular, is extraordinarily busy. People have barely enough time to breath and eat lunch, and if you are asking them to read a 5-page care plan, you are asking for something unrealistic. The best way I think pharmacists can communicate their value is to be accurate precise, and concise in all their communication. Whether that is in writing, or in documentation. What it might mean is using a standard procedure for documentation. For example, in some practices they like to use SOAP [Subjective, Objective, Assessment, Plan] notes, in other practice they use the SBAR [Situation, Background, Assessment, Recommendation] method. Whatever method is the norm,the
pharmacist needs to learn to use that and be as concise and clear as possible. The word assertive to me, implies something to do with power, or extroversion. And that’s not at all the case. It’s more important to be concise, precise, and accurate. And you can do that most effectively by using a standard communication template.
Samuel (Host): Would you think that students can still use what they learn and develop their care plans internally, and then producing that care plan, and then just concisely communicating it?
Zubin (Expert): Absolutely. There’s a reason why in pharmacy school we make you do such elaborate care plans. And that’s because it’s a good discipline to ensure you are not missing important details, and it provides you with what psychologists called a ‘scaffold’ to help you to actually build up your argument as clearly as possible. What’s important though, in the real world, is to recognize that what you need in order to think through a problem is not what a prescriber needs when you’re trying to answer a question.
Samuel (Host): Alright. Thank you very much for answering all of these questions in such a great
manner. And for coming on to today’s show, Zubin. And thank you for all the listeners for tuning in.
Zubin (Expert): Thank you.