kind of going along this topic a little bit, Difficult Situations. Basically, what we're gonna do is kind of, I'm gonna present some real world difficult scenarios, and we're gonna talk about kind of what potentially you would do in this situation. Okay, and it doesn't have to be just these, if anyone else has any comments or whatever, you're welcome to join in. All right, so we'll start off kind of with the first. So, you're in the endoscopy lab, and you're doing a polypectomy, and you ask your tech for a cold snare, and the tech hands you a snare, and you go to put it out, and you realize that it is not the snare you asked for, and you said, this is not what I asked for, can you hand me the cold snare? And the tech says, well, you know, this gray-haired senior physician uses this one, and it's way better. So, this is what we chose, or this is what I chose for you. Go ahead, what would you say in this situation? So, I volunteer, and I go first? No. No, no, no, no. Yes. Robin can go first. No, no, I can, I'll take this one. So, I mean, I would say, okay, thank you. I mean, I appreciate that you admire that physician, but I may give the tech some background knowledge about this type of polyp, and why I want to remove it, and cold snare, and maybe present some of the data. This way, it's more like educating the tech, and at the same time, it's showing them, building confidence in my decisions, because it's evidence-based, and so they'll have a better understanding, okay, this physician knows what he or she's talking about based on data, and was respectful, and educated me, and so we'll just hand them the proper snare. Sometimes, it's a little tricky as a female endoscopist. A lot of our techs are male, although where I'm at, there are some females. They default, are supposed to look to you as the leader when you are attending, and they're supposed to do what you say, but I do welcome dialogue, but what I have found to be very helpful in communication with techs and things like that is to be very concise, and clear, and specify what I want, but you do have to try to remove some of the emotions from it, because you're like, hey man, you gotta do what I say, because ultimately, I'm the one getting sued if something goes wrong, right? So what I have done in the past when things aren't exactly what I look for, or they bring in some senior guy's experience, and I'll just say, that's great. I think Dr. So-and-so's great with that, in his experience, it works for him. For me, though, it would be nice if you guys had one, and if you don't, you could explain it. I tend not to take too much time during the procedure itself to do the full explanation. If it's something that is particularly egregious, I will do sort of a side conversation later with the tech, or whoever it is, privately, because I find that that's a little bit more responsive, but I will say, in that particular moment, I'm more comfortable with doing this particular scenario. If you could find one for me, that would be great. Please, thank you, those things work sometimes, you know? So that's probably what I would have done in this particular scenario. I agree with that. I think being a female sometimes is a little difficult when it comes to this, just like Dr. Halsop, but what you wanna say is what you don't say, so you just have to take a minute. Yeah, you just have to take a minute, because obviously, especially if it's a difficult polyp, and you're asking for that particular chair for a reason, you have the right position, obviously we wanna do things quickly, so I will first compliment, I will do a similar thing. I will compliment, like, you know what, Dr. So-and-so is a fabulous endoscopist, and that's really gonna be a good idea, but for this particular way the polyp is late, and I'll just kind of very briefly explain my rationale in five seconds, and again, just be like, this is really what I need, and usually that's all that's needed. So this actually happened to me, really. It was like my first year out, and it happened to me, and basically I said, this snare works fine for this purpose, but I need to get the equipment that I'm asking for at the time that I get it. It was probably not, or the time I asked for it, it was probably not the right choice in that setting. Going back, looking back, it was fine. We have a fine relationship, but it was one of those things that I was just, I was taken aback that he would hand me something that I did not ask for because I knew that it was gonna be fine, but if I had asked for something different and didn't know about it, and I had used the equipment and it was different, it might have been a problem, right? So that I was actually a lot more blunt about it than all of these nice people up here. That's kind of what I was gonna say. These are fantastic PC responses. Not sure what I would do, but it really. Not GPT responses. Yeah, yeah. Not sure, I probably would be a little bit more blunt, but it also depends a lot on who you're dealing with. Is it a senior, like really senior tech who knows kind of what they're doing? You're like, oh, maybe this is actually better, and some have actually taken their advice, but usually the first time, this is probably a response, but what if this is someone who's done it to you now five or six times, and you're like, dude. When do you start throwing scalpels? I would, so I think what I've learned is when you're in the middle of a case and things get testy, that's not the time to have the conversation, and so if it's a repeat thing that keeps happening, what I usually will, if I feel comfortable, like I have a couple techs that are senior, junior, just depends on the person a little bit, might go to them directly when we're not in a case and just talk to them. If I don't feel, I've had one that I just didn't really feel comfortable with, I actually did go to their supervisor and talk to them about it, but that was a little bit of an extreme situation, but those to me are the not in the middle of the case while the patient is on the table, talk about it offline. I was like the king of escalation when I was young, and you just have to get your ears boxed a few times, as they say, but thinking about how do you deescalate a situation, and sometimes you don't even appreciate that you're escalating, and so I really like Linda's, hey, let me have this, and then let's talk about it afterwards, and that way the patient isn't being affected, and I think that's really important to be like, actually, let's kind of take a deep breath and I'm gonna get my part done, and then we can take a time, or when there's a pause, we can do it, but not right now. Awesome. Oh, yeah, yeah. This has happened to me. I'm like, okay, if I get a complication, though, this is your fault. You know what I mean? I mean, because we have, you know, we all have those senior fellows, and the nurses and techs, they're very good, but they've had that experience with the senior attending, so, you know, so I, and then, you know, we're always trying to save money and not open another standard, that sort of thing, it's like, all right, I'm gonna use this, but fleeting something, you know, so you're kind of joking around and trying to escalate it a little bit that way, and then later, again, it depends on the situation, privately away from, you know, because there's not just you two in the room, it is, I think, always better, but relatively soon, not like two days later or later on the day, you know, because it does give you time to kind of just, I guess, de-escalate your own mind, you know, if you're really upset about it or not, that sort of thing, so. Awesome, all right, scenario number two. You overhear a staff member commenting about a patient's appearance in an inappropriate way. Like a physician or any staff member commenting about a patient? Does it matter? No, I'm just curious. I'm not sure. I need specifics, you know? Yeah. You overhear a staff member commenting inappropriately about a patient. So I'll, this happened to me, so, and I think being endoscopists, just important to remember, y'all are probably too young to remember this, you know, I had a staff, a nurse, as we put a patient asleep for a scope, start commenting about the patient as they were asleep. So it's a small amount of people in the room, and there was actually a physician, this was like 10 years ago at this point, that got sued because the, this happened, a similar situation happened, and they had their phone on record, and so they could hear the whole thing. And the whole room kind of started going in on this and everything, so I talk with my, like, if anything like that happens, or if I hear that, I very clearly will say, like, that's not what we're about, and we don't need to speak about that. And I will do that very bluntly. Because I think it's important to remember, patients are asleep, or you know, it doesn't matter if patients are asleep or not, to be honest, but that's not what we're about. And so I will be very blunt. That's one of the, I think sometimes as a female, you worry about being super blunt, because it can be taken many different ways, but when it comes to things like that, I put my foot down pretty quickly. That's me. Yeah, I agree, same thing. Straightforward, blunt, end it there. And then procedure, on that topic, procedural conversations, you think that the patient's asleep, but there was, again, a lawsuit because of an anesthesiologist that was very inappropriate. So be very careful about the conversation in the procedure, whether it's related to anything, just keep it just simple, very, very professional. But yeah, in this situation, be blunt. Yeah, Big Brother's watching. Yeah, Big Brother is watching everywhere. There's actually a lot of states where it's only one party needs to consent to the recording. You actually have no say. California's not one of them, but there are certain states that allow for just you being recorded without your consent in these situations. So Big Brother's always watching, like I tell my kids. So I will just end it, that's inappropriate, and you just change the subject. And then if this is something, you know, that needs to be addressed, you, again, take it outside the intraprocedural time, if you will. And just in kind of the flip side of that, although we don't have to go through it, it's probably very similar, but if a patient says something about a staff member, it's probably appropriate also to call them out on it. But, yeah. I mean, it's hard. I also go to the staff and say, how do you want me to handle that so that you're comfortable with the situation? And I've had the whole range that you can imagine of that, and I really do, I'm like, because I'm not good at those conversations. And so I'm like, tell me what's gonna make this work better. And sometimes that's not a reasonable solution. Like, I want you to call the hospital manager or something. But again, it's complicated, and it happens with staff, and it happens with patients as well. All right, very good. So you being the younger attending, maybe, or the female attending, or maybe you're just a nice person, routinely get new, new, old patients transferring within your practice to you because you listen better. Procedures are almost always completed already. Maybe you don't get paid for that. Yeah, right. I mean, I can start with that one. So in the closed system where we're set up there, because we're not as RVU-driven or based to a certain extent, I do tend to get in my clinic and in also my procedural patients a high number of females or very talkative males, or people who just need more time and TLC and hand-holding. It's sort of inevitable to a certain extent. Some patients are, my nursing staff calls them high needs. So what we do as a group, and I am very appreciative to my leadership for this, is you are not allowed to do that kind of transfer more than once. So that's something that you, that we have established a good working relationship with your chief, like you're not allowed to jump doctors. And if you do jump, you don't get to go back. So I've had that happen where they try to come back and they're like, so-and-so's not listening to me. I'm like, sorry, you blew it with me. We're done, you know? So if it exceeds that to a certain point within the Kaiser system, we'll move them to a different Kaiser location so they can still receive the access to care that they need, but not necessarily within our group. So you get to jump ship once. And I know some private practice models, the ones that are more equitable, tend to say, hey, you don't get to, this is it, or you get one. Just sometimes styles are different and things like that. But I'm very particular about my schedule and how many clinic patients are on it and things like that. So that's how we address it. I believe this kind of thing has to be a leadership group dynamic situation. Yeah, so this, my institution bought a local hospital like 45 minutes down the road, and we were experiencing this a lot. Just procedures were done, send the patients on. And at one point, just tried to educate the providers and talk to them about how to refer appropriately and that type of thing. That didn't work, so ultimately we have a rule now where we don't allow for switching at all, actually. So we don't even allow the one. So this, I think you have to have buy-in from your leadership about at some point. I would say it took three years to get that buy-in. So it didn't happen, it didn't happen immediately. We went through first attempting to educate, of course we're gonna take care of the patients regardless, but we went through attempting to educate the referrals. And that didn't have success, and then we had to move to a leadership thing about it. Right, so you get a, it's kind of about a peg consult. Your colleague said no yesterday. Now the hospitalist or the surgeon or whomever comes to you and says, you're my favorite. You'll get it done. You'll get it done. What do you do? So I mean, I'll definitely acknowledge my colleague's efforts and obviously seeing the patients and evaluating and see, ask, or I'll say something like, I'm sure there's a reason why he or she felt that it's not an appropriate or not appropriate to do this procedure. But just give me some time to review and you do your own assessment. And if you decide to do it, and if it's in the best interest of the patient, then just do it. If not, then you just say no. I think you can also have that conversation with your colleague and just see if, I think it's important to have good rapport with them. I think this similarly comes when patients talk about your colleague within your practice, like, oh, he or she wasn't able to remove this polyp, so that's why I'm here. So things like that, you try to also talk to your patients and explain that, well, it's not the situation, we really, this is the reason why we're doing it. And you should be on the same team with your colleagues, have a good relationship with them, but obviously take good care of the patient. Yeah, I agree with what he's saying there. You can always kind of, sometimes I'll tell them, my risk tolerance is higher because I went to way more extra school. So, because as an interventionalist, I do end up getting called the second time around for some higher risk procedure, and it's not fair to put that extra risk on them. They're great in other ways. So that's definitely one of those things. It's in group practice, it's a team model. Yeah. I don't place pegs. Because I'm an IBD doctor. We'll do it for you. Yes, so I'm gonna defer to, no, I mean, but I think the important pearls from this are, obviously making sure the patient's okay. And, but I would talk to my colleague first, actually, and just figure out like what the situation was. And then if you feel so inclined, evaluate the patient yourself, because you've got to make that decision. Because whenever you choose to do anything, whether it's a peg, whether it's a balloon dilating and an IC anastomosis, whatever it is, you have to be willing to accept the risk of that. And so at the end of the day, it still has to be appropriate for the patient. So even if you have your surgeon calling, the surgeon that you know, calling you asking you to do something, if it's not indicated, and if there was a extenuating circumstance that your colleague was able to point out to you, like there's obviously gonna be reasons why that's, you just have to kind of do your own assessment there. There's a balance trying to do, you have to do the best for the patient, but also you have to be very collegial within your group. And also you have to, establish yourself as a referring physician for the person that called you. So trying to balance the multiple things is important. And so these are like the three main pillars with the top being taking care of the patient. At the end of the day. We have a question. Oh, a couple of questions. Yeah. I have a comment. Like, are you at liability if you decide to do it? Because let's say the general gastroenterologist was not comfortable. It's not like there's a contraindication to the peg. And then as an interventionalist, you proceeded and did the peg, but there was maybe small risk and complication happened. Are you liable because someone else said no, and then you proceeded? Depends on what's written in the patient record. If my colleague went ahead and said, there's an absolute, there's a contraindication to this for whatever reason. In the chart, it's gonna make me think a lot harder about proceeding with it. Then if they pulled me aside said, hey, I'm not gonna do it. Then if they pulled me aside said, hey, I know you're coming on service the next day. Can you take a look at this? And so it depends on what's actually formally written in the legal record. And I agree with that. And the scenario first about talking to your colleague is probably first and foremost to understand. But no doubt as an interventionalist, we get asked to do stuff that, you know, the surgeons might ask you to do something that they're not willing to do or vice versa, or your colleague said they couldn't do. But the same scenario happens with radiology saying a recommended MRCP for this procedure and anesthesia saying, we don't think this patient should be sedated. So I think it gets to the concept of how much you document and how much you talk to your patient. So these are, I mean, common scenarios about that we all see, I think on a routine basis. He glossed over that, but talking to your patient, extremely, extremely important. They need to understand why someone else said no and you're saying yes. To that point, I don't place pegs. So I probably would say no, but I would frame it to the patient in that this is not my area of expertise, not that it shouldn't be. I mean, it depends on the situation, but and if I ever documented that, I would write this. And whenever I am doing consults on the weekend for advanced procedures that I don't do, make it very clear to the patients that going to have to talk to my colleague about this and run your case by them. And try to explain it. You don't have to explain the patient down to the nitty gritty. I do IBD and I don't like, but you know, like obviously there's things that are standard in our specialty and things that are not standard and say your case falls under the not standard and needs some extra discussion and that's how I kind of leave it. And if I'm going to document it, that's how I document it. This is where you're not concise and brief. So what if the opposite is true where your colleague before you agreed to do the peg, but it's going to be when you come on service and you don't agree with the peg, then what do you do? Take this. So I came on as a first year attending and there was a patient with hemophilia that had some rectal bleeding and the bleeding had stopped, there was no clear, the hemoglobin was fine and I could not believe that on a Monday morning that this case was posted for me, I called my mentor in Boston and I was like, and he said, for the first two or three years, do whatever they ask you, then you can tell them to do it. Then you can tell them whatever you want to do. So there is some context when you're first getting started. You want to be appeased, but at the same time you have to do what's right for the patient, for you and for your team. But I think having good communication is important, but that scenario certainly happens and you show up, it's not uncommon, I'm sure we all have this where Monday morning there's a case posted for you and that may or may not have gotten signed out to you that you're going to be doing it and you don't agree. Yes. Just following up on that, how do you address the apology rounds with the patient? Because I feel like when we, if you decline to do a procedure that they were initially promised, I feel like patients often feel like then something is being withheld from them. So how do you tread lightly in saying, well, I actually don't think it's the right thing to do when your colleague did and without making your colleague look bad? It's really tough. It's tough. It's really tough. It is, it's really tough. I mean, I think you have to, because especially because you're coming on and you don't have any rapport with the patient. And so some of this is like going to the bedside and having a detailed conversation about it. And some of this is, if the patient still is not on board with that, then circling back and saying, well, this is my perspective on this. I'm happy to talk to this other physician again. I don't know if we can facilitate this through them, but this is not something that I'm comfortable with and that's why I'm talking about it. This is going to be a long conversation and I think what I go to a lot of times is talking to them about safety and that, again, kind of to what Lisa is saying, like this might be not appropriate for me to do for you, doesn't mean I can't help facilitate, if another opinion or talk to the person who suggested it, but I will approach it from a safety thing. And that's, I think, so I'm, again, I'm not an advanced endoscopist, so I'm not going to be doing the crazy thing. So when I see a polyp that I know I can't take off, that's, so that's, I'm bringing up this, I'm bringing up a situation. You're doing a, I see a five and a half centimeter, you know, lateral spreading polyp in the cecum. I'm probably not going to take that off. I'm going to reserve that conversation you have with the patient in recovery. Patient, a lot of times, is going to be a little upset because they have to go through another procedure. So how I've kind of coined that conversation is you have a growth that we did not expect that is more rare, you're only 45, and it needs more than a standard technique to take it off. And there are my partners that undergo very specialized training to serve you in a better way, and you're going to have a better outcome, versus if I attempted today to do this for you, I worry you wouldn't have as good of outcome. And you're just very honest about that. And it's not saying that I'm not, I feel like I'm a very adequate gastroenterologist, but my specialty is not doing certain things. And so I think it's just being honest about safety and then being honest about your own limits, and patients usually respond to that pretty well. And the flip side is when your patient ends up coming on the interventional side, and the patient, for example, is upset, I start off by saying, first of all, you're very lucky that Dr. So-and-so was able to detect this polyp. He or she did a fantastic job. You're here now because I have extra training, and we're in a different section in the hospital. We do our EMRs on kind of the inpatient side, so where there's surgical backup, and we have the equipment and training. So I compliment the physician who referred the patient so that the patient's at ease, and then I explain why we're doing it here. So that's like a continuous. I also compliment the patient. Thank goodness you drank all that PrEP to do that. You don't want cancer, do you? And usually they're, oh yeah. Right, awesome, okay. So your co-leader or co-chief fellow or kind of whatever you're in your, doesn't seem to pull his or her own weight, and you end up doing most of the work, but then not getting the credit for it. I think this is really hard. This is really hard. I think you have to at some, I mean, you can do this one of two ways. You can just never work with, try not to work. If it's a particular finite project or something, you can obviously just choose to not work with that person again, but oftentimes it's going to be a colleague that you're probably going to work with again or a colleague from a different institution that you have worked with on a collaboration and you want to keep that door open. And so if it's something that you think that's not super finite and you just never want to work with them again, you unfortunately have to have a very uncomfortable conversation. And it might not change the credit for the work in that incidence, but talk about if we work together again in the future as we move forward, these are my expectations of working with you. Similar to a mentor-mentee relationship, you have to have expectations set and then you can hopefully move forward from there. And if they're not okay with that, if they're like, well, I'm always going to be the one that's taking credit. I want my name on it always. That might be someone that you actually don't want to work with in the future, but it's a hard conversation to have and it's very awkward, but you have to do it. I've had an experience like this before, unfortunately. And for me, I hate confrontation. I actively avoid confrontation, but it was a scenario where I was going to have to continue to work with this person. And so I decided to try to approach it. And what I did after talking to several people about what should I do about this, I approached them and I kind of reframed what had happened and then said to them, why do you think it happened that way? And kind of forced them to acknowledge what had happened and explain their role in it. And that facilitated a conversation that I think we're on the same page now. Yeah, I agree. Yeah, same. Awesome, all right. You're gonna have people in your group that take credit for stuff either that they did or didn't do or seem to get more credit than they should for whatever reason. It's gonna happen. There's always an individual in a group that seems to be that way and that the supervisors don't just see for what it is. I've had it at every level. Maybe that's me sometimes, I don't know. But I don't think so. But I've seen it many times and it's very difficult to work in that scenario where there's always some person who's not kind of pulling their weight and they seem to get credit for stuff that they may or may not have done. Well, actually we're gonna end on that because most of my scenarios are very similar to all the things we've talked about. So fantastic. That's, y'all had great answers. There are lots of challenging things that'll come up for you guys that many around you have experienced. So don't be afraid to reach out and kind of talk about situations with other colleagues for sure.

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