Geoff Mckay - Followership

The highest reward for a person's toil is not what they get for it, but what they become by it.
John Ruskin

Followership: If you have never heard the term before or never thought twice about it, you are not alone. It usually appears as a "non-word" when documents are spellchecked on the computer. Is it a new concept? Not really; just one that is often overlooked or forgotten.

And just why followership is overlooked and forgotten is an intriguing question. Without followers, would there be leaders? Who would they lead? Who would become leaders if they were not first followers?

Leadership is an interactive activity: leaders depend on followers and vice versa.
Team efforts are valued highly in today's workforce and such efforts require active followers. Followers set the levels of acceptance for leadership. And in many ways, it is more important for leaders to understand followers than for followers to understand leaders.

Followership can be defined as the willingness to cooperate in working towards the accomplishment of the group mission, to demonstrate a high degree of teamwork and to build cohesion among the group. Sounds pretty similar to leadership, doesn't it? Effective followership is an excellent building block to effective leadership. There are numerous sources to which one can turn to find helpful information on effective leadership, leadership practices and on becoming the best leader one can be. Fewer such sources exist on guiding one to be an effective follower, though there are some. Take a look at the following behaviors, which have been identified as those comprising effective followership:

• Volunteering to handle tasks or help accomplish goals
• Willingly accepting assignments
• Exhibiting loyalty to the group
• Voicing differences of opinions, but supporting the group's decisions
• Offering suggestions
• Maintaining a positive attitude, even in confusing or trying times
• Working effectively as a team member

As a follower, it is often easy to criticize the tactics, styles or ideas of a leader. This is especially true when one has been "beat out" for a leadership position and feels resentment, bitterness or jealousy. It is difficult to be an effective follower with such feelings lingering.

Sometimes it helps to critically evaluate our own views towards leadership, the organization and ourselves as followers in order to get a better understanding of the situation. Through this we can learn how to create change in ourselves, how to deal with difficulties and how to become productive and happy followers. We might also learn that being a leader is not as easy as it may sometimes appear! Take some time to ask yourself the following questions - and don't be alarmed if some of them are a bit difficult to answer:

• Am I truly pursuing the mission and goals of the group while balancing my self-interests?
• What ideas, purpose or values do I share with the leader? The group?
• Should I be taking more initiative?
• What particular pressures and challenges does the leader face?
• If I and/or the group provided more support to the leader, might it improve her/his behavior?
• The leader must have some redeeming skills, qualities and abilities that helped get her or him into this position of leadership. What are they? How can I help draw these out? How can I help change the environment so these skills and abilities can be demonstrated?

Although changing ourselves is usually not an easy task, most would agree it is easier than changing others. If you are experiencing frustrations or misunderstandings with your organization leader, take a step back and view the situation from the outside. Instead of asking how you can get the leader out of her or his position, ask how you can help her or him improve.

Even if you are perfectly satisfied with your leadership, it is necessary for you - just as it is for a leader - to evaluate your role as a follower/collaborator/group member to determine if you are performing in this role at the highest level possible.
Remember, effective leadership requires effective followership. Do your best to make your group the best it can be!

Geoff Mckay - Ethical Leadership

Minds are like parachutes - they only function when open.

Anonymous

CORPORATE CRIME...SCANDALS...ALLEGATIONS...MORAL DECAY OF SOCIETY
How often do we see words like these gracing the headlines? Probably a bit too often for the likes of most people. We continually hear about the "downfall of America" and how leaders (judges, pastors, presidents, to name a few) are often allegedly at the heart of many such problems. Does our society still have ethical standards? Morals? Values?

Based upon various polls conducted throughout the last decade, several researchers have concluded that Americans do not believe people in power ethically sound. One study concluded that 55% of the American public believes a majority of business executives are dishonest, and an even higher percentage feels white-collar crime occurs on a regular basis. Even studies of executives themselves show that a majority believe executives they know "bend the rules" to get ahead.

When leaders are perceived as unethical, it is easy for those around them to follow suit. Consider the business world, for example: often when the head honchos are viewed as unethical or immoral, workers respond in kind by being absent more frequently, stealing supplies from the office, performing poorly, or becoming apathetic or indifferent. If you don't think your ethics are on display as a leader, think again!

Despite the continual discussions of ethics, the subject is a challenging one to address. It is difficult to "teach" ethical behavior, but it is possible to introduce situations about which you might contemplate the most ethical responses. One person's ethical standards may differ from another's, however, because we all have varying views on what is "right" and "wrong." Take some time to consider the following situations and how you believe you should - and would - respond. Then, discuss these issues with others to find out if and how your views differ from each other.

• Some of your group members want to sponsor an extremely controversial event on campus (i.e., a lecture by a leader of the Ku Klux Klan). By simply allowing your group name to be associated with this event you risk losing credibility and being accused of racism (or sexism or ageism, depending on the situation). How do you handle this? Does this controversial person have the same freedom of speech as, say, Mother Theresa?
• You are the only student in a meeting with all of the influential, prominent faculty and staff members on campus. They are praising your ingenuity and creativity in a successful program you organized and are offering letters of recommendation, status and so on. The only problem is you didn't actually create the program - one of your first-year recruits did. What do you do? Because the new member created the program for the group you lead, can you take credit? Is it OK to take credit if the person will probably never find out?
• You are concerned with the morale of your group and decide to talk with each person individually to see if you can find out what the problem is. You assure each person all responses will be strictly confidential. Through the interviews, you discover several people mentioning that Jim, your group treasurer, has been stealing money from the group's account for his own personal use and threatening anyone who suggests they might report him. How do you handle the situation and maintain your promise of confidentiality? What if you decide to report the problem to the authorities and they refuse to take action unless they have the names of the group members who are suspicious?

In your leadership positions as well as in other aspects of your life, keep in mind some basic principles for ethical behavior:

1. Respect autonomy. Don't let your freedom of choice be neglected - as well as that of others.
2. Be fair. Treat people equally. Be impartial and objective.
3. Avoid harm. Take every possible measure to avoid physical, emotional and psychological harm or threats to one's self-esteem.
4. Be true. This means telling the truth as well as keeping your promises and maintaining loyalty.
5. Be beneficial. Do what you can to contribute to the general well-being of others, whether it is taking time out of your schedule to help them or simply treating them with kindness.

Geoff Mckay - Empowerment

The one who says it cannot be done should never interrupt the one who is doing it.

Anonymous

Anyone interested in the business field has probably run across an article or two on empowering employees. It seems leaders are truly realizing the benefits of training their subordinates how to handle situations and giving them the authority to do so.  It may seem like a commonsense approach to success, so why haven't businesses picked up on this earlier? Well, like so many things in the world, it is not always as cut and dry as it may seem.

Empowering others can take some creative work on the part of the leader. Some people like the idea of seeking approval for every minor step; that way if something goes wrong, they have someone to blame. Some people have not built up enough self-confidence to handle situations. Some leaders fear they will look unqualified, weak or indecisive if they seek input from other members. And sometimes leaders - for their own reasons - just don't feel comfortable relinquishing control to others no matter how much they trust them. If you are one of those leaders who cannot seem to let go - or you want to, but don't really know what this will entail - read on.

Following are the various roles a leader can take in empowering others to develop leadership abilities and even some self-confidence along the way.

DiscovererIt is important to note that there is no single "right way" to empower others. A leader's job consists of continually looking for new opportunities to accomplish the group mission. Are you always chairing the program committees? Do you lead the meetings as well as write up the minutes? Maybe it is time to recommend someone else for these duties. Not only does this empower others, it adds to your free time as well. As a discoverer, it is important to be a visionary and be flexible to change.

Illustrator 
As a leader, it is extremely important to remember - and remind others - about the goals, values and mission of the group. You can set a path towards accomplishing goals so that others may follow suit. As an empowering leader, you can inspire goal commitment - but in a way that doesn't equal demanding compliance. If you are committed to the group goals, let it be known in the way you approach opportunities or deal with obstacles.

Encourager 
In most organizations, the days of the leader's way being the only way are long gone. To empower others to take responsibility, be supportive: offer reassurance, recognize successes, believe in your members and take a vested interest in their achievements. You don't need to look the other way when failures occur, but dwelling on them accomplishes little. Acknowledge them, make improvements or suggestions for the future, highlight the successes and move on!

Enabler
In some situations, enabling is viewed in a very negative light (i.e., substance abuse). In empowering leadership, however, enabling others can be very positive. In this sense, enabling involves offering a helping hand to boost chances of success. You might consider yourself to be a coach or team builder in this position, which would be accurate labels for the roles you are playing here.

Smoother 
Finally, an empowering leader needs to facilitate accomplishments to the extent possible. This means smoothing the way for others by providing them with necessary information to complete a task, networking with outside contacts to build positive relationships and serving as a resource. This is a critical step in the empowerment process; people need to know they have the support and resources they need to help them accomplish goals.

The benefits to empowerment are numerous, not only to those being empowered, but to the leaders and overall organization as well. Aside from building self-confidence and increasing free time as mentioned earlier, take a look at some of the other potential benefits:

To the followers:

• Increased motivation
• Higher degree of learning
• Improved tolerance of stress

To the leaders:

• Increased organizational commitment
• Less role ambiguity
• Increased satisfaction with roles and the organization

To the organization:

• More flexibility
• Better sense of community
• Requests/problems handled with increased speed
• Group coordination and development

Geoff Mckay - Active Listening

In our active world of communication one cannot afford to exclude the art of listening. As a leader, you must listen to your constituents in order to be effective. You need to listen and correctly understand all messages from group members.

Active Listening differs from hearing. Hearing is the act of perceiving audible sounds with the ear and is a passive act. Listening, on the other hand, is the active pursuit of understanding what the other person is saying and feeling. In active listening, the receiver tries to understand what the sender is feeling and what the message means. The listener puts his/her understanding into his/her own words and feeds it back to the speaker for verification. It is important to feed back only what the listener feels the speaker's message meant, nothing more, nothing less. This creates an atmosphere of acceptance and understanding in which the speaker can explore the problem and determine a solution. To listen actively and to understand is not a passive or simple activity.

The following are important characteristics of a "good listener".

Be There
Be present in heart, mind and spirit with the person. You need to hear what he/she has to say. If you don't have the time, or don't want to listen, wait until you do.

Accept
Accept the person as she/he is without judgment or reservation or putting the person in a mental box or category, even though she/he may be very different from you.

Trust
Trust the person's ability to handle his/her own feelings, work through them, and find solutions to his/her own problems. 

Listen
Don't plan what you are going to say. Don't think of how you can interrupt. Don't think of how to solve the problem, how to admonish, how to console or what the person "should" do. DON'T THINK TO STRUGGLE OR REACT...LISTEN!

Keep Out Of It
Keep yourself removed. Be objective. Don't intrude physically, verbally, mentally. Keep Quiet. Listen. It maybe hard to be passive.

Stay With the Other Person
Put yourself in the other's shoes. Don't become that person, but understand what he/she is feeling, saying and thinking. Stay separate enough to be objective, but involved enough to help.

Geoff Mckay - Informed consent

Definition:  Informed consent is the requirement that physicians share decision-making with patients. Informed consent is an extension of the principle of autonomy, introduced in FPC in the organs block.   Informed consent is how physicians operationalize respect for patient autonomy.

Clinical Applications: The phrase “informed consent” has a variety of meanings, depending on the context and speaker. Two broad categories of meaning are:

1) Mutual decision-making between the doctor and the patient. This is the broadest definition of informed consent.  It involves an open exchange of information, education on options and alternatives for care, and assisting the patient in making a decision that is consistent with his/her values.

2) Obtaining the patient’s consent for medical procedures or participation in research trials. This sense of informed consent focuses purely on legal requirements for disclosure rather that shared decision-making.  Often, it only involves a warning of the risks of proposed interventions and may simply refer to a legal procedure that protects physicians and medical centers from litigation (e.g., having a patient sign a waiver/consent form before surgical procedures).  However, simply having a patient sign a form is not informed consent.  The signature should only be seen as confirmation that a conversation between the physician and patient occurred.

Between these two extremes lie various interpretations of informed consent and the degree to which the doctor assists the patient and assists him/her in making an informed choice.

In order to meet the broadest definition of informed consent, the following are required:

Competence – the ability for the patient to understand and make decisions. Assessing patient competence in making autonomous decisions will be introduced during Brain, Mind, and Behavior.
Disclosure – the doctor shares information and advice that are necessary for the patient to make an informed decision about medical treatment. Physicians should share:
the nature of the proposed intervention(s)
expected benefits, risks, and likely consequences of proposed action (including emotional and social consequences)
alternatives to the proposed intervention along with the benefits, risks, and likely consequences (alternatives that other reasonable physicians would recommend)
recommendations, opinions, and advice. Physician recommendation and advice are often essential for patients to make sound decisions.
This is the key part of informed consent.  The amount of information shared should be sufficient for the patient to understand the decision.  Patients do not need to become medically savvy or gain medical knowledge like a physician.  The physician must explain the information in simple terms yet convey the benefits and risks of the intervention enough so that the patient can decide if the benefits outweigh the risks.  Physicians should elicit and answer all patient questions.
Understanding – the patient not only receives the information, but must also understand the implications of what the doctor has shared. It is important to remember that patients are often in emotional states that limit or impair understanding and rational decision-making so it is the doctor’s duty to facilitate this understanding.
Voluntariness – the patient makes the decision while free of coercion, persuasion, or manipulation
Consent – the patient agrees to participate in the discussed treatment plans and gives consent for necessary procedures
Examples of situations involving informed consent:

Broad definition: Translating statistics about risks and benefits into terms and concepts that are meaningful to a patient with breast cancer deciding between lumpectomy and mastectomy; discussing treatment options with a patient with prostate cancer; explaining the potential emotional consequences of a positive test for the BRCA1 gene mutation; discussing the risks and benefits of a renal biopsy including how the information from the biopsy will be used to benefit the patient and the potential risks and their likelihood and how they would be treated.

Narrow/legal definition:  Asking a patient to sign a consent form for a surgical procedure in the emergency room; and translating an emergency room informed consent form into a foreign language for non-native English speakers.

Geoff Mckay - Advance Directives

Definition: Advance directives are statements by competent patients that indicate who should act as a surrogate decision-maker or what interventions they would accept or refuse if they lost decision-making capacity. There are several forms of advance directives:

Oral statements to family members or friends
Oral statements to physicians
Written advance directives: living wills or health care proxies
When do physicians rely on advance directives?

Recall from the module on decision making capacity that illness may result in an individual’s loss of the ability to make decisions regarding medical care. Once a physician determines that a patient lacks decision-making capacity, it is important to decide 1) what standards should be used in making medical decisions for the patient and 2) who should act as a surrogate decision-maker for the patient. Several devices may be used to help decide on standards for making medical decisions for the patient; if available, advance directives are the primary means of determining standards for the patient’s medical care.

Why do physicians rely on advance directives?

Advance directives help to preserve a patient’s autonomy even when he/she is no longer capable of making informed decisions. Since the patient gives informed consent and expresses his/her preferences while still competent, advance directives provide a means of projecting autonomy into the future; they allowing the patient’s preferences and values to guide care even when he/she lacks decision-making capacity.  In addition, advance directives may provide guidance and help alleviate stress on family members who have to make decisions for the patient.

What are the different types of advance directives?

1. Oral statements to family and friends: This is the most common form of advance directive and is frequently used to guide decisions for patients. The problem with such statements is that patients may make comments without intending them to direct future care, or they may state preferences without thinking about them carefully. Family or friends may also not recall the statements accurately or dispute the meaning. A few states, such as New York and Missouri, restrict the use of oral directives unless they are specific about the type of treatment or intervention to be implemented or refused. However, most states have accepted oral directives to family and friends as an acceptable basis for medical decisions.
Following are characteristics of reliable oral directives:

The patient’s decision was informed (i.e., the patient possessed and understood all relevant information when making the decision.)
The directive stated the patient’s specific treatment preferences in various clinical situations rather than general preferences.
The directive was repeated over time, in different situations, and to various individuals.
2. Oral statements to physician:  Discussions with the physician about prospective treatments are the second most common form of advance directives. The standards for determining whether the directive is trustworthy are the same as for statements to family and friends. Oral directives to physicians are much less problematic than either oral statements to friends and family or written advance directives. The physician can verify whether the directive was informed and is able to gain a more complete sense of the patient’s wishes in one-on-one conversation.

3. Written advance directives: There are two types of written directives – living wills and health care proxies. Both must be witnessed or notarized and are accepted by almost all states as legal documents. The courts consider written directives to be more reliable evidence of the patient’s wishes than oral statements, although only 5% of patients actually provide written directives.

Living Wills: The patient directs physicians to withhold or withdraw life-sustaining treatments in case the patient develops a terminal condition or falls into a permanent vegetative state. Usually patients may only refuse treatments that prolong dying; however, some states do not allow patients to decline artificial nutrition/hydration through living wills. In addition, states may differ on what is considered a “terminal condition”—conditions such as Alzheimer’s and dementia are generally not considered terminal. Since living wills specify particular treatments that can or cannot be applied, they allow for little flexibility in making treatment decisions and do not provide comprehensive guidance.

Health Care Proxies: The patient appoints, in writing, an agent to make medical decisions in the event that he/she loses decision-making capacity. This agent, called a health care proxy, will have decision-making priority over all other possible surrogates. The proxy has authority to make decisions in all situations in which the patient is incapable of making health decisions, not only in case of terminal illness. The proxy is required to try to be consistent with the patient’s known values or expressed decisions or to act in the best interests of the patient. There are some limitations related to conflict of interest on who can serve as a health care proxy. For instance, in most states, the treating physicians cannot be the health care proxy.  One of the most effective ways to structure advance directives is to appoint a health care proxy and to supplement this with a living will that specifies particular treatments that would or would not be acceptable under various circumstances.  This provides for more flexibility in determining treatments while still allowing for specific directives.

What are some of the problems with advance directives?

Advance directives may not be informed: It is very common for patients to express strong preferences about treatments that they do not fully understand, especially regarding life-sustaining or emergency interventions such as CPR or ventilators. Once a patient has lost decision-making capacity, it is no longer possible to correct any misunderstandings.

Interpretation may be difficult: Advance directives often do not address the exact situation at hand and may require interpretation. Directives often employ vague terminology (e.g., refusing “heroic” interventions) and may describe general preferences that provide little guidance in specific cases. In some cases, they specify treatment preferences for one situation, but the patient develops an entirely different condition.

Advance directives may conflict with the patient’s best interest: Patients make assumptions about the prognosis or life situation when they give advance directives. However, for a variety of reasons, the reality of the situation may be very different from when the patient originally stated his/her intentions. For instance, new medical therapies, changing family situations, development of additional medical conditions, and other factors may mean that prior advance directives are no longer relevant to the patient’s current medical condition.

Patients change their minds: This happens to all of us, all the time in life!  It is not surprising that individuals tend to change their minds regarding life-sustaining treatment
So how do advance directives affect regular interactions with patients?

Talk to your patients about advance directives! Despite some limitations, advance directives allow the patient to express his/her values and beliefs regarding medical care. They also encourage physicians, patients, and patients’ family members to discuss life-sustaining treatments before it is too late, which relieves a great deal of stress once decision-making is required. Studies show that most patients want to discuss advance directives with their physicians before medical crises, and most want the physician to bring up the subject.

Informing patients about advance directives is a legal requirement in some situations. The Federal Patient Self-Determination Act (1990) requires that all hospitals, nursing homes, and health maintenance organizations that accept Medicaid and Medicare inform patients about their right to provide advance directives at the time of admission or enrollment.

Who should consider forming advance directives?

Physicians should definitely discuss advance directives with terminally ill patients as well as those with a serious chronic illness. Some physicians choose to discuss advance directives with perfectly healthy individuals. It is important to realize that advance directives are not acceptable in some cultures; physicians should respect these beliefs.

Geoff Mckay - Truth Telling

Definition:  Truth-telling, or veracity, can be defined as the avoidance of lying, deception, misrepresentation, and non-disclosure in interactions with patients or relevant to patient care.

Seems simple – why is it a big deal?

Being honest with patients about their diagnoses is a relatively new addition to the ethics of health care. Until recently, doctors often avoided telling patients the full extent of serious diagnoses, particularly when there were limited treatment options. In addition, in some cultures, it is customary to hide a serious diagnosis from the patient for fear that he or she will lose hope or become demoralized by the information.

Truth-telling also involves being forthright about medical errors. Many ethicists argue that the primary physician and observing members of a medical team all have an obligation to report errors not only to oversight committees but directly to the affected patient. This is not always easy to do - particularly when the mistakes harm patients and their families, when it is not obvious that telling the patient will improve the situation, and when the stakes for admitting errors are high. However, physicians have an obligation to report errors and to support colleagues who do so. Only then is it possible to recognize errors when they occur and to develop systems for avoiding the problems in the future.

Why is it so essential to avoid misrepresentation and nondisclosure of information?

Prima facie wrong: lying is viewed as an inherent wrong—something that we naturally consider unethical.

Barrier to Patient Autonomy and Informed Consent: it is inappropriate for a doctor to lie because it precludes the patient from making an informed decision and providing informed consent, thereby trampling over the patient’s autonomy.  If the doctor provides improper or insufficient information, the patient will not possess adequate information to make the most personally meaningful decision.            

Destroys patients trust: If the doctor lies to the patient and the patient later finds out about the betrayal, the patient will be less likely to trust the physician in the future.  This destroys the foundation of an effective patient-physician relationship, in which the patient trusts the doctor to provide appropriate information regarding diagnosis, prognosis, and treatment.  Accordingly, if one patient tells another patient about his/her experiences with mistrust, then this may lead to a slippery slope in which other patients may subsequently mistrust their physicians, leading to countless shaky patient-physician relationships.

Most patients want to know: According to one survey, 94% of patients said they “would want to know everything” about their medical condition, “even if unfavorable.”  Even more patients wanted to know about a diagnosis of cancer.  Therefore, it is inaccurate for doctors to think that their patients want to be spared the bad news.

Lying is impractical: One lie will naturally lead to another, creating a web of deceit.  Furthermore, other members of the healthcare team may notify the patient at some point during the course of illness, leading to the patient’s resentment at not having received the information directly from the physician in the first place.

What happens if a family member declares that the patient should not receive any information about the diagnosis, perhaps due to cultural reasons?

Although a family member may wish to uphold the cultural values of protecting the patient from bad news, the doctor must ensure that these wishes also reflect those of the patient.  Therefore, the doctor must explicitly ask the patient how he/she wishes to receive the information, if at all.  It is important to confirm the family member’s request with the patient in order to uphold patient autonomy—after all, there may be some cases in which the patient still chooses to receive the information, regardless of the family member’s request.

Are there any exceptions to truth-telling?

One exception involves the patient who directly tells the physician that he/she does not want to receive any information regarding his/her diagnosis.  In this case, it is ethical to withhold information because the patient does not wish to receive it, thereby upholding patient autonomy, or free will to decide.  One must never assume that the patient prefers nondisclosure, but rather one must ascertain these wishes through direct conversation with the patient.  This can be achieved by asking the patient how he/she wishes to receive the information before the test results even arrive, thereby allowing both the patient and physician to plan the logistics of breaking possible bad news ahead of time.

Another exception involves a mentally unstable patient who may put himself/herself in harms way after receiving the bad news.  In this example, a doctor may be justified in delaying the disclosure of information until after the patient’s mental health improves and/or the patient possesses appropriate psychiatric backup.