Simulcast Journal Club July 2019

Introduction :  

Simulcast Journal Club is a monthly series that aims to encourage simulation educators to explore and learn from publications on Healthcare Simulation Education.  Each month we publish a case and link a paper with associated questions for discussion.  Inspired by the ALiEM MEdIC series, we moderate and summarise the discussion at the end of the month, including exploring the opinions of experts from the field. 

The journal club relies heavily on your participation and comments and while it can be confronting to post your opinions on an article online, we hope we can generate a sense of “online psychological safety” enough to empower you to post!  Your thoughts are highly valued and appreciated, however in depth or whatever your level of experience.  We look forward to hearing from you. 

Title :  “Pointing Fingers 

The Article : 

Bochatay, N., Bajwa, N., Blondon, K., Junod Perron, N., Cullati, S. and Nendaz, M. (2019). Exploring group boundaries and conflicts: a social identity theory perspective. Medical Education. 

Additional Reading & Podcast for those interested in a deep dive :  

Eppich, W. and Schmutz, J. (2019). From ‘them’ to ‘us’: bridging group boundaries through team inclusiveness. Medical Education.

The Case :  

“I think it’s important that we highlight this is a debrief, not a chance to point fingers.”.   

Nimali paused and took a deep breath.  Debriefing a traumatic event (particularly the sudden murder of a reviled colleague) had exposed frames that were more tribal than she’d anticipated.  Within this small group of people the frames were legion.  She glanced nervously across at Nitin, grateful that his calming, loving presence was within reach across the circle from her. 

“What else are we supposed to do, Nimali?” Jess snapped angrily.  “We know full well that one of us murdered him. And let’s face it, some people here have a clear motive.”.  Jess’ usually unflappable emergency nurse façade dropped for a moment.  “Everyone in PICU hated Snythe, especially you Brad.  Didn’t you once tell him that his primary source of hydration was the carbonated tears of bullied interns?”. 

Brad choked on his coffee and coughed frantically as he formed a counterpoint.  “I did hate Snythe.” He admitted. “But truth be told in a high stakes environment like children’s ICU, there’s lots of strong personalities I don’t always warm up to.  We have to be hard.  We see too many children die to be cuddly.   He was a cynic, but so am I in some ways…  I respected him.  He was a good intensivist, he was just a pretty nasty person.  I’d trust Snythe if my child was on inotropes, no questions.”. 

Catherine gave a wry half smile, “I’m glad you could see the good in him, his behaviour in ED left him few friends.  His brand of hierarchical bullshit didn’t go down well when we called him for help.”. 

Jacob frowned.  “I guess I didn’t know Snythe as much as an Intensivist, I knew him as an educator.  And in the last 12 months he’d grown into a much more open person.  The same vicious sarcasm he had on the ward would sometimes be disarmingly funny when we were teaching new grads together.  He’d even applied to be director of education a few weeks ago… He asked me for a reference.”. 

Jess glanced at Brad again.  “Didn’t you apply for that job?”. 

A heavy silence hung for a few seconds in the room when suddenly the lights blacked out and the room descended into darkness.   Nimali jumped as her phone began to ring frantically with missed call notifications.    

Her iPhone lit up in the darkness :  

Discussion :  

Last month in journal club, we explored teamwork behaviours through an ethnographic lens.  This month we want to extend that conversation by exploring other in depth theories regarding barriers to effective team formation.  In this month’s open access article, Bochatay et al explore the way we filter the messages we receive from other people by their hierarchical position and social group.  For those among you who are deep divers, we’ve also attached a podcast and additional editorial with similar themes. 

We look forward to the discussion! 

References : 

Bochatay, N., Bajwa, N., Blondon, K., Junod Perron, N., Cullati, S. and Nendaz, M. (2019). Exploring group boundaries and conflicts: a social identity theory perspective. Medical Education. 

Eppich, W. and Schmutz, J. (2019). From ‘them’ to ‘us’: bridging group boundaries through team inclusiveness. Medical Education.

About Ben Symon

Ben is a Paediatric Emergency Physician at The Prince Charles Hospital in Brisbane and a Simulation Educator at Lady Cilento Children's Hospital. He currently teaches on a variety of paediatric simulation based courses on paediatric resuscitation, trauma and CRM principles. Ben has a growing interest in encouraging clinical educators to be more familiar with simulation research.

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3 thoughts on “Simulcast Journal Club July 2019

  • Susan Eller

    Hello Jesse and Ben,

    I am glad that one of the tenets of this site is to have online psychological safety.

    I first read the Bochatay et al. article, then Eppich & Schmutz’ commentary. I found the social identity theory discussion useful in giving a terminology to the in-group/out-group behaviors that I have observed in healthcare. I appreciated the four strategies outlined in the commentary, and am glad that Walter and Jan provided suggestions for transforming some of these potentially challenging conversations into productive learning opportunities.

    I decided to delve a little deeper by listening to the podcast. I was not sure at first that it would resonate with me – until I experience a huge “aha” moment. A few months ago, I heard a simulation colleague advocate that it would be good to refer to people in the third person, or by their titles, during debriefing – rather than call them by name. Their rationale was that it could neutralize negative emotions. I disagreed, and expressed my concern that calling someone “the nurse” could be perceived as very impersonal and hierarchical – especially if done by a physician debriefer. The speaker did not agree with me, and said that the nurses they worked with all liked this model. I still had my doubts, and internally wondered if those nurses were just too afraid to speak up against the hierarchy. When I heard Malcolm Gladwell quote Malcolm X in describing the difference between the house negro and the field negro – it struck that same nerve.

    When we look at social identity theory to understand the reasons for the in-group and out-group behavior, it gives us a way to discuss the behaviors and barriers that create the house nurse/woman/LGBTQ/etc. paradigm. (I hesitated to write that last sentence, as it did not seem “politically correct”. However, it also seemed correct to call out the fact that our culture/system can create such divisiveness). How wonderful that Walter, Jan, and others are exploring and explicating ways to break down those barriers and behaviors. I am profoundly grateful that in my own professional career – I found my kindred spirits across professions, gender, and other perceived boundaries, before encountering too many of the in-group architects.

    • Ben Symon Post author

      Hi Susan it’s so nice to have you back with us this month! I agree with you strongly with regards to the referring to colleagues by position reads as dehumanising rather than Emotionally neutral.

      I’m glad you enjoyed the additional deep dive reading and the podcast. To me they all very much hit at their heart about what it means to belong, how important that is to us as a driver of our behaviours, and it helps me be wary of this in myself but also hopefully reminds me to try and be more empathetic when I see it in others. I don’t always succeed I guess, I like belonging too.

  • Sonia Twigg

    I am rather fascinated by qualitative research papers – trying to take on the lens of a new theory like social identity theory is like reading a juicy new novel… so I was sucked in to this story – and could identify with the examples. Intersectionality was a useful concept to describe the complexity of how our membership of different groups (eg gender and role in the hospital) interact. It rang true to me that hierarchy is the most salient social category involved in physician conflicts. It seemed an ironic fact that during conflicts with out-groups, we emphasise the positive behaviours of our in-group colleagues and criticise out-group colleagues. It made sense that conflicts between groups have negative effects on group interactions and hardens the boundaries separating groups.

    Junior doctors are under enormous stress trying to fit in to their in-group, and become knowledgeable members of that specialty… and since many rotate every couple of months they are always working to fit into a new In-group. The actions of those higher in the hierarchy may have greater consequences than they realise. It is easy for conflicts to occur – and the junior doctor may not be in a position to use this “moment of tension” for a “productive conversation”.

    As a supervisor of junior doctors (and still in training myself), this article helped me reflect on my responsibility to help my colleagues feel welcome on my team and reminded me of some simple tools to minimise conflicts; being careful of the consequences of my actions, explicitly welcoming input, thanking team members, and modelling perspective taking – explaining how I might understand the sometimes annoying actions of an out-group member.

    And Eppich’s editorial gave me a moment of relief thinking about how to make productive use of conflict when it inevitably occurs. A conflict could turn into a great teaching moment if I can model an inclusive, productive and ethical approach.

    Lots of things there to look forward to on my next shift 😊