Being a Medical Doctor– General and Clinical Psychology

Medicine and Surgery degree course

Humanitas University
2022-2023

Teaching staff
Prof. Giampaolo Perna and Dr. Daniela Caldirola
The journey of medical doctors’ professional identity formation

But……..
 The journey of medical doctors’ professional identity formation

The issue of negotiation

 Conflicts between personal values and beliefs and some medical interventions
or decisions

For example

Abortion
Contraception (e.g., IUD, intrauterine device)
The end of life

The use of embryonic stem cells for research aims

……
 The problem of the end of life

In Italy it is possible to suspend the therapies even if they are useful for the protection of
life.

Through the Law 219/2017, the patient capable of acting has the right to refuse any
assessment, part or entire treatment indicated by the doctor for his/her pathology, as
well as the right to revoke the consent given at any time, even if the revocation involves
the interruption of treatment.

This area includes, as indicated by the World Health Organization and the Italian scientific
societies, artificial nutrition and hydration, as it is the administration of nutrients based
on medical disposal and through medical devices. The renunciation of these, as well as of
other treatments, can have as a direct or indirect consequence the death of the person
who does not give her/his consent. If this refusal compromises the person's possibility of
survival, the doctor is required to discuss the consequences of the decision and the
possible alternatives to the patient and, if s/he agrees, to her/his family members,
promoting any supportive action, including by making use of assistance psychological
services
Years ago, some famous cases (Piergiorgio Welby-muscular dystrophy-,2006; Eluana
Englaro, 2009) fostered the debate about this topic..
 The problem of the end of life

The term "euthanasia" includes medical interventions that involve the direct
administration of a lethal drug to the patient who requests it and meets certain
requirements. At the moment, euthanasia is illegal in Italy.

Thanks to the sentence 242/2019 of the Constitutional Court, in Italy it is

instead possible to request medically assisted suicide, that is, indirect help
from a doctor to die.
The required conditions are four: the person who requests it must be fully
capable of understanding and willing, must have an irreversible pathology that
is the bearer of severe physical or mental suffering, and must survive thanks to
life-sustaining treatment

The recent cases of DJ Fabo (2017-2019) and

Federico Carboni (2020-2022)

“Remove the bars because now I'm free to fly

where I want”
The journey of medical doctors’ professional identity formation

An attempt to take into account multiple open issues related

medical doctors’ professional identity
The journey of medical doctors’ professional identity formation

The first one…

The journey of medical doctors’ professional identity formation
The journey of medical doctors’ professional identity formation

The last one…

The journey of medical doctors’ professional identity formation

To highlight the importance of

patient’s self-determination as one of
the key cornerstones of medical ethics

To more explicitly invoke the standards

of ethical and professional conduct of
physicians expected by their patients
and peers
The journey of medical doctors’ professional identity formation

This clause calls for mutual respect between

teachers and students, and among colleagues

This clause refers explicitly to the obligation to

teach and forward knowledge to the next
generation of physicians

This clause reflects both the issue of

the humanity of physicians and
the role physician self-care can play
in improving patient care.
 The journey of medical doctors’ professional identity formation

The issue of negotiation

In general, the norms established by the medical community

have to be flexible enough to ensure professional behavior while
allowing individuals to remain true to themselves

(Cruess et al, 2014; Cruess et al., 2015; Cruess et al., 2019; Afshar et al., 2021; Sarraf-Yazdi et al., 2021)
 The journey of medical doctors’ professional identity formation

In conclusion

“Identity formation is mainly social and relational in nature. Educators, and the broader
medical society, need to utilise and maximise the opportunities that exist in the various
relational settings students experience. Education in its most general sense is about
transforming the self into new ways of thinking and relating. Helping students form, and
successfully integrate their professional selves into their multiple identities,
is a fundamental of medical education” (Goldie J, 2012)

“Medical schools are not only where expert knowledge and judgment are communicated
from advanced practitioner to beginner; they are also the place where the profession puts
its defining values and exemplars on display, where future practitioners can begin to
both assume and critically examine their future identities” (Sullivan et al. 2007)
Who am I not? Who do I want to be ?

Have a good journey!!!

Team working and negotiation
(2nd December 2022)

BMD – General and Clinical Psychology

2022 - 2023
You as a Person- You as a Medical Doctor- You as a Member of a Team
Personal identity Professional identity in Health Care-Team identity

Sharing
Desires Neutral Trust
Life Experiences Unbiased Conflict
Preferences Logical Balance
Needs Informed Similarity
Pre-judice Difference
Mental models
 Professional identity

Neutral
Unbiased
Logical
Informed Team identity
Personal identity

Sharing
Trust
Desires
You Conflict
Life Experiences
Balance
Preferences
Similarity
Needs
Difference
Pre-judice
Mental models
 Professional identity

Personal Team
identity You identity

 Balanced Decision Making and Judgement

 Correct management of your personal biases
 Focus on patients’ needs
 Taking advantage of the team working and mitigating barriers to it
 Is it useful in
clinical practice?

Yes, it is
A large body of research evidence suggests that:

 effective teamwork in healthcare is associated with reduced medical errors,

increased patient safety, as well as improved worker outcomes such as
reduced stress, increased intent to stay at work, and job satisfaction.

 the quality of teamwork in healthcare is related to reduced patient mortality in

hospitals, more streamlined and cost-effective patient care, reduced physician
visits and hospitalisation rates, lower staff absenteeism and turnover, more
effective use of resources and greater patient satisfaction

(West & Lyubovnikova, 2013; Bell et al., 2018; Salas et al., 2018)
is the collaborative effort of a group
to achieve a common goal in the most
effective and efficient way

(West & Lyubovnikova, 2013; Bell et al., 2018; Salas et al., 2018)
 A team is a group of interdependent*
individuals who work together
towards a common goal.

Everyone makes a commitment to reach

the goal

* Interdependence is the degree to which team members depend on one another for both individual
and team task completion. It is often high in health care. Task interdependence is not only determined
by the characteristics of the team task itself, but also by the extent of discretion that team members
exercise in establishing the level of interaction and cooperation required for effective performance. Team
members therefore have to decide to behave together interdependently - to work as a team.

(West & Lyubovnikova, 2013; Bell et al., 2018; Salas et al., 2018)
A team is a group of interdependent
individuals who work together
towards a common goal

Everyone makes a commitment to reach

the goal

Teams are a means of organizing work so

that individuals can accomplish more
than they can on their own

A team member does not need to be able

to do everything on his or her own:
a team allows access to a broader arrày
of perspectives, capabilities, and efforts

(West & Lyubovnikova, 2013; Bell et al., 2018; Salas et al., 2018)
Open communication is vital to effective teamwork:

 to clearly define the team's purpose so that there is a common

goal.

 to overcome obstacles, resolve conflict, and avoid confusion

 to increase group cohèsion

(West & Lyubovnikova, 2013; Bell et al., 2018; Salas et al., 2018)
 A negotiation is a strategic discussion that resolves an issue in a way that
both parties find acceptable

 By negotiating, all involved parties try to avoid arguing but agree to reach some
form of compromise
To sum up, team identity refers to the mutual
connection of individual team members to
work together and cooperate in accomplishing
goals. It is a sense of responsibility to prioritize
the demands of the “team first” before their
own.

(West & Lyubovnikova, 2013; Bell et al., 2018; Salas et al., 2018)
Sometimes theoretical constructs become reality in clinical practice………

The ideal

But often…..
It is not that easy to integrate a group of people and foster a
sense of belongingness into them!!. It is because everyone
thinks, acts, feels, and believes differently.
 The harsh reality?

Pseudo team entities are common in clinical practice

Without the “real team” characteristics in place

a team exists in name only
(West & Lyubovnikova, 2013)
Let’s try to understand how to use the benefits of
and mitigate bàrriers to team working in clinical practice
Temporal stability

(West et al., 2012; West & Lyubovnikova, 2013; Bell et al., 2018)
 Temporal stability

Team task: Relatively complex tasks that require mutual decision making and organization of care for a
well-defined group of patients during a well-defined period

Team composition:

• Individuals who together have the appropriate knowledge, skills and abilities; multi-professional;
interdisciplìnary (e.g. psychiatrists, clinical psychologists, psychiatric nurses, social workers, occupational
therapists).
• It can be useful to include both “big-picture types” (they can see patterns quickly in complex
problems, but have a low tolerance for detailed work) and “fine-detail observers” (they tend to over-
think and prefer work that has practical aspects; they are conscientious and achievement-oriented)
• Limited number of team members. Bàrriers: If the team is too large, and there are multiple occupiers
of the same specialist role, team members may compete for power or withdraw their participation from
the team.
• Clear role allocation; shared responsibility

(West et al., 2012; West & Lyubovnikova, 2013; Bell et al., 2018)
 Temporal stability

Organisational support: Supportive context; a reward system which encourages team

members to work collaboratively and recognises their task interdependence.

(West et al., 2012; West & Lyubovnikova, 2013; Bell et al., 2018)
 Temporal stability

Team objectives: Shared, clear, challenging, agreed upon, measurable, and limited

Reflexivity: Team regularly takes time out to think what it is they are trying to achieve, how
well they are working, what they need to change, and then making adjustments accordingly

Leadership: Leadership clarity associated with members’ autonomy. Bàrriers: entrenched

hierarchies, conflicts “for power” amongst professionals, status incongruities, and boundary
dispùtes

(West et al., 2012; West & Lyubovnikova, 2013; Bell et al., 2018)
Temporal stability

Many people are not suitable

to be team leaders, even though they are experts
in a certain field and/or have high positions in
organizations' hierarchy.
True leadership is sacrifice and not a privilege!
 Team còmpetencies

* helping other team members perform their roles

(Lacerenza et al., 2018)
 Team competencies

Teams Need Psychological Safety to Prosper

Sooner or later, all teams run into conflict

To resolve conflict, teammates need to participate in open and honest communication. This can occur
only if they do not feel worried about being judged or ridicùled by others on the team, have “the
license to speak up,” and can engage in difficult conversations about a problem.

This is why psychological safety is a must in teamwork. Psychological safety is a trusting behaviour that
is defined as the team’s shared belief that it is safe to take interpersonal risks without fear of backlash

Generally, psychological safety can be developed and/or enhanced through effective team debriefs and
leadership communication. During a debrief, if members are taught to take a learning approach and to
diagnose areas in need of development, they will be more likely to feel comfortable speaking up. Other
team meetings work the same way.

Leaders also play an important role in fostering a psychologically safe environment. When leaders
admit their own faults, they make others feel they too can safely communicate errors they make.

(Lacerenza et al., 2018; Salas et al., 2018)

 Team-Centered Approach: How to Build and Sustain a Team.
The four components

Personal Personal
Discipline experience Discipline experience
of the of the 2
discipline discipline

Person
Context
3

Finding common
ground
• Goals of care
• Team communication
• Mutual support
• Promotion & Prevention
• Policies & Procedures

(Stewart et al., in “Patient-Centered Medicine.

Relationships 4
Transforming the Clinical Method”, CRC Press, 2014)
 The first component

 The first component encourages each team member to:

• be ready to share and to learn about others regarding each member
discipline’s formal scope of practice as described by their respective
licensing body (surface-level attributes)
• share and learn about all members’ personal experiences of their
discipline – for example, their unique professional history and ways of
thinking about health. They may learn what they like about their role
and what aspects they find challenging

The mutual process of learning about each other’s discipline promotes

mutual respect and enables a more trusting interprofessional practice

(Stewart et al., 2014; Bell et. al., 2018)

 The second component

 The second component stresses the understanding the whole person

of each team member:
• Each member will be encouraged to share relevant aspects of his or her life history,
personal context, and his or her perceived ability to respond to change and manage
conflict (deep-level attributes )
• It will be encouraged sharing one another's understanding of the team’s current
context, in terms of each member’s perceptions of the opportunities and constraints
of the team environment. It may assist in getting the team started and, ultimately,
sustain the team
• Social activities, sharing life events, and developing unique routine and rituals foster
relationships and team cohesion

Such sharing may enable each team member to relate to the others in ways that
promote effective team functioning

(Stewart et al., 2014; Bell et. al., 2018)

A few examples of social activities, sharing life events,
and developing unique routine and rituals that foster
relationships and team cohesion
 The third component

 The third component represents the shift, from the focus on the individual team member
sharing his or her history and experiences, to all team members co-creating the new team
environment, moving toward a shared language, culture, and perspective

Components 1 and 2 have provided some of the necessary building blocks of information
and experiences from the past.

* “Backstage communication”, “hallway consultation”; accessibility and physical proximity of

team members are essential.

(Stewart et al., 2014; Bell et. al., 2018)

 The fourth component

 The fourth component is enhancing the ongoing team relationships:

• Each professional needs to recognize that other disciplines have skills and
interests in that domain too. Bàrrier: team structures that place individuals
in less powerful positions (e.g., relationships medical doctors-nurses)

• Positive feedbacks, to reinforce appropriate behaviour.

• Constructive mutual feedbacks based on objective standards. Bàrriers: Criticism

based on personal and subjective issues; criticising personal traits; criticising
only pointing out what’s wrong without offering concrete advice on how to improve

(Stewart et al., 2014; Bell et. al., 2018)

 Constructive mutual feedbacks based on objective standards.
Barriers: Criticism….

Discovering the I-position

Speaking from the I-position is a non-judgemental way of

describing other people’s behaviour that’s causing you difficulty,
without blaming or judging the other person.
It consists of four parts:
• Your feelings;
• The other person’s behaviour;
• How the behaviour connects to your feelings;
• What you need to happen.

To speak from the I-position, you use I-statements

along the following lines:

✓ I feel ________________________(state your feeling)

✓ When you _____________________ (describe the actual
behaviour) Beginning a sentence with “I feel”
✓ Because ______________________ (say how the action is better than “You should”…
connects to your feeling)
✓ What I’d like is ____________ (recommend action to
address the behaviour)

(Kuhnke E., 2013)

 Constructive mutual feedbacks. Barriers: Criticism…. in daily life

Discovering the I-position

✓ I feel ________________________(state your feeling)

✓ When you _____________________ (describe the actual
behaviour)
✓ Because ______________________ (say how the action
connects to your feeling)
✓ What I’d like is ____________ (recommend action to
address the behaviour)

“You should stop yelling at me when I go out with my

friends without you!! I hate your stupid and pointless
comments!! What is your problem?!! Are you still
jealous??!!....I can’t stand it!!
“I feel stressed when you yell at me as I go out with
my friends because I want to be treated with respect
and regarded as trustworthy. What I’d like from you is
for you to explain to me calmly what your worries are
so we can find a solution together.

(Kuhnke E., 2013)

 Constructive mutual feedbacks based on objective standards.
Barriers: Criticism….

Discovering the I-position

✓ I feel ________________________(state your feeling)
✓ When you _____________________ (describe the actual
behaviour)
✓ Because ______________________ (say how the action
connects to your feeling)
✓ What I’d like is ____________ (recommend action to
address the behaviour)

For example

If you’re a team leader speaking to one of your team
members who’s not performing well, you may say:
“I feel anxious when you fail to meet your deadlines
because I’m afraid we’ll miss our targets, which will
threaten all our jobs. For now, what I’d like you to do
is to create a progress report that we can review at the
end of every week for each project you’re working on
so that we can monitor your progress and I can provide
additional support when you need me to.”
If your team leader or a team member is a yeller,
you may say:
“I feel offended when you shout at me because I want
to be treated with respect. What I’d like from you is
for you to speak to me calmly so I can take in your
message”

(Kuhnke E., 2013)

 The fourth component

 The fourth component is enhancing the ongoing team relationships:

• Listening with an open mind. Bàrriers: Judgemental / distorted / resistive / interpretive/

past-behaviour-based listening

• Listening with the intention to understand. Bàrriers: Not maintaining eye contact,
not minimizing external distractions (computer, smartphone), not letting people make
their point, interrupting

• Respect of different styles and approaches (e.g., extrovert/introvert). Bàrrier: judging

and not respecting each team member's pace

(Stewart et al., 2014; Kuhnke E., 2013; Bell et. al., 2018)
 Other barriers to

 “Exaggerated Egos”: one (or more!) team members think that they
have nothing to learn from, or that they are better than, the other
members of the team
Assumptions, intolerance

 Defensiveness: team members can place barriers between themselves and other
team members to protect themselves from criticism and “personal attacks”

 Exaggerated competition, envy amongst team members

 Meetings themselves can be a source of stress if inadequate time and remuneration

become an issue; the location and timing of meetings can create tension on the
team, particularly when certain agenda items are viewed by some members as
mundane or not relevant to their role function

(Stewart et al., 2014; Kuhnke E., 2013; Bell et. al., 2018)
Communication Skills Course
aa 2019-2020
 Negotiating with emotions

Getting an agreement by acting on the

emotional atmosphere
 Page 1

 We can not feel emotions neither

more nor less than we can not
think.

 The challenge is learning to

stimulate favourable emotions in
those with whom we have to
negotiate and in ourselves
 What is an “emotion”?

• It is a signal
• It is a strong call for action

• Induce a unique and stereotyped pattern

of physiologic and behavioral changes
Humans and animals: emotionally different?
 Brain as a System
RATIONAL BRAIN
(Cerebral cortex)
Environment/Context

Body
EMOTIONAL BRAIN
(Amygdala & Lymbic system)

HOMEOSTATIC BRAIN
(Brainstem)
 Control of the muscles of the face
Unconscious control

Cingulate
Gyrus
EMOTION
Orbicularis
oculi

Zygomaticus
major muscle

REASON
Motor
cortex
Conscious and
unconscious control
 Emotions can be obstacles in a negotiation

 They can shift attention from substantial elements

 They can damage a relationship

 They can be used to manipulate you

 • Humiliation
• Excitement • Shame
• Satisfaction • Embarrassment
• Fun • Denial
• Enthusiasm • Envy
• Sweetness • Jealousy
• joviality • Disgust
• Ecstasy • Impatience
• Pride • Irritation
• Gratification • Anger
• Joy • Fury
• Relaxation • Intimidation
• Serenity • Concern
• Patience • Surprise
• Tranquility • Fear
• Calm • Panic
• Hope • Gooseflesh
• Wonder • Sadness
 Managing Emotions:
Three unsuccessful approaches

• Stop emotions? It is not possible!

• Ignore emotions? Emotions affect your body, your

thinking and your behavior!

• Manage emotions directly? Cyclopean enterprise!

(they are many and they change quickly)
 FOCUS ON THE CORE CONCERNS WHICH
GENERATE EMOTIONS…

…NOT ON EMOTIONS ITSELF

Core concerns: Human needs that are important to

almost everyone in any negotiation

Negotiations: every core concern should be adequately

met, neither excessively nor minimally

- Equity
- Honesty
- Consistency with the circumstances
 Core concerns The concern is The concern is
ignored when... satisfied when...
Appreciation Your thoughts, feelings or …are validated
actions are not validated

Affiliation You are treated like an …you are treated like a

antagonist and kept at a colleague
distance
Autonomy Your freedom to make a …is respected
decision is denied

Status Your position is …is fully recognized

underestimated compared
to that of others

Role Your current role and …they are considered

activities are not significant significant
 Feel appreciated: core elements

• Understanding of the point of view of others

• Finding the value (positive) in what others

think, feel or do

• Communicating appreciation through words or

actions
 Understanding another person’s
point of view:

• Listening skills

• Ability to ask good questions

• Put yourself in the “shoes of others”

• Understanding the emotional music of the verbal

message

• Listening to meta-messages (emphasized words, body

language)
 Communicate your appreciation
through words or actions!

• …in a clear, direct, simple and honest way!

• Express your appreciation with a confident tone

• Sum up what you understood that is important to others

• Express how you would feel (angry) in a similar situation if

you were them
Don’t forget that appreciating does not
mean agreeing or giving in!
2. AFFILIATION
 The power of affilitation:

• Feeling "close” each other

• See each other as part of a family

• Honest connection and sincere concern for our

well-being
 Types of affiliations:

B) Personal connections • Meet people live, not by phone,

(personal aspects) computer or e-mail (at least at
the first meeting)
A) Structural connections
(common group) • Avoid barriers (e.g. desk)

• Discuss things that involve you

• Age
(e.g. family, economic concerns,
• Role and social positions
emotional reactions, ethical
• Family dilemmas, doubts about your
• Origins
career)
• Religious beliefs
• Common interests (music, • Keep in touch
sport…)
Protect yourself from being
manipulated by affiliation!

Evaluate a proposal with the reason…

…but also listen to your stomach!
3. AUTONOMY
 ACBD:

Don’t overpower the autonomy of others!

A  Always
C  Consult
B  Before
D  Deciding
 The ICN grouping system

It ensures the correct degree of decision-making

autonomy

I  Inform
(small decisions)

C  Consult
(significant decisions)

N  Negotiate
(very important decision)
4. STATUS
 Recognize the status!

Recognize the high position whenever

it is present

Status: our position compared to that of

others
 Types of status:

A) Social status
(It measures the global social level)

B) Particular status
(It is based on a specific experience,
ability or education)
 Look for the personal area of each person
that characterizes a particular status

• education • social skills

• computer technology • life experience
• business • emotional awareness
• technical skills • professional skills
• holistic vision • power
• culinary skills • athletic ability
• public relations • …
• morality
5. ROLE
 Choose an appropriate role!

…and select the activities relevant to it

3 points to choose an appropriate role:

1. It has a clear purpose

2. It is important for the person
3. It does not claim to be someone else
but represents the real person
 Conventional roles: examples

• University students • Manager

• Actor • Father
• Analyst • Politic
• Artist • Scientist
• Cook • Seller
• Customer • Student
• Fashion Designer • Writer
• Grand father • Truck driver
• …
 Temporary roles: examples

• Collaborator • Colleague
• Competitor • Guest
• Victim • Host
• Attacker • Evaluator
• Who is talking • Friend
• Who is listening • Enemy
• Problem-solver • …
 Choose the temporary role
that facilitates collaboration !

• Become aware of your temporary role

• Adopt a temporary role that favors collaboration

• Appreciate the temporary role of others

• Suggest a temporary role for others

…AND IF YOU FEEL NEGATIVE EMOTIONS?
 Negative emotions can lead to:

• “Tunnel vision” (reduction of clarity and creativity)

• Risk of behaving in such a way as to regret it

• Long-term consequences

• Evaluate your emotional temperature

• Create an emergency plan before the explosion of

emotions
 Express intense negative emotions
during negotiation: aims

1. Decreasing emotional activation

2. Educating others about the impact of their behavior on us

3. Influencing others

4. Improving relationships
 Some strategies to decrease
the “emotional temperature”
• Count back from 10

• Breathe deeply 3 times

• Pause and silence

• Take a break (have a bath or take a phone call)

• Visualize a relaxing place

• Change topic

• Adopt a relaxing posture

• Let that the provocations pass from “one ear to the other”
“The general who wins the
battle makes many
calculations in his temple
before the battle is fought.

The general who loses makes

but few calculations
beforehand.”

(Sun Tzu)

Communication Skills Course

aa 2019-2020
 Active Listening

A good negotiator encourages all the participants to speak.

A great negotiator encourages all the parties to listen.

Communication Skills Course

aa 2019-2020