E110: The Social Domain of Risks

Kirtly: We are humans. We are social beings, and we do stupid stuff. As many of us spend a lot of time in the workplace with other people, some of this risky social stuff happens there.

I'm Dr. Kirtly Jones from obstetrics and gynecology, and we are working on the 7 Domains of Risk. And today, we're talking about social risk. I've worked in a huge and complex system called a health sciences center, and I also trained in one. I have spent my academic and work life with a lot of other people, and as a young trainee and faculty member with big eyes and big ears, I saw stuff, bad behavior, bullying, harassment, inappropriate relationships, and more. The guidelines weren't written when I was young, but I knew when I saw stuff. Did I speak up? It was risky for me personally and professionally.

And as I grew in my career, I became responsible for writing and enforcing guidelines, policies, and procedures for when bad stuff happens in the workplace. It was one of the hardest parts of my job.

So with me to talk about the social domain of risk and risk in the workplace is my co-host, Katie Ward. And she has spent her career in the same huge medical complex as a clinician and as an educator. She's a specialist in women's health, a professor in the School of Nursing, and has a PhD in anthropology, the studies of humans often doing bad stuff.

Katie: Well, there is a reason that "Grey's Anatomy" has been on for 20 seasons. Hospital romances and supply closet hookups, that is bingeable TV. But I think it does imitate life, right? The hospital throws cool people together who are doing intense stuff in long hours with high stakes and real emotions. And I think it's hard not to be attracted to cool people doing cool stuff, even when you work there.

My own career has been a little less in the cool place and kind of more in academia, clinics where I work with a lot of other people, a lot of other women, really, and it's a little less high stress than "The Pitt."

But academia feels like . . . So if we're going to talk about our work experiences, for me, it feels like "Yertle the Turtle," the Dr. Seuss book where Yertle's the king of the pond and he builds his throne by stacking turtles on top of each other. And the higher he stacks them, the more powerful he feels, and the turtles underneath are getting crushed. And that's kind of how the academic hierarchy feels to me.

Now, the problem is that stacking turtles on top of each other is no basis for a system of business management. That's where I felt like I've been, is that I'm getting climbed on. Other people are climbing on me for the purposes of advancing their career. And quite frankly, I've climbed on other turtles to try and get higher in the stack where the weight is somewhat less on myself. And that didn't feel very good either.

I think either way you're taking some kind of a social risk. Either you're getting crushed or you're stepping on those underneath you.

And so that's my analogy for academia without calling out anybody specifically. Well, somebody did tell me once that in academia, the competition is so fierce because the stakes are so low.

Kirtly: The battles are so bitter because the stakes are so low. Well, I can't say that I felt that way, Katie, but maybe I could have been clueless because I have been protected, because I was.

But when I was a medical student on my surgical rotation, I was working with a chief turtle, a surgeon who was notorious for being tough. I remember being in the operating room, and he would call the resident in the case . . . They were all guys. He would call them "fat boy." "Do this, fat boy." And the resident wasn't fat by any means.

And this chief turtle, boss surgeon, would call me "kitten." I was the only woman on the team at the time. And it was my first awakening to what I thought was inappropriate behavior by a boss.

Was it creating a hostile work environment? I didn't know the phrase at the time. But I knew how it felt. And was calling me "kitten" sexual harassment? Did I prefer to be called "fat girl"? I did not want to be in the crosshairs of this powerful person.

So I tucked it away to think about it and to learn that I would never behave that way, and everyone in my future operating room would be treated with respect. And I did nothing to try to stop the behavior. These are complicated situations, risky behavior in the workplace.

Kirtly: Today in the Virtual Scope Studio, we're talking with Dr. Harriet Hopf. She is a professor and Executive Director of Faculty Development and Academic Affairs in the Department of Anesthesiology, Perioperative, and Pain Medicine, an adjunct professor in bioengineering, and she's co-director of the Utah Coaching and Advancement Network and past president of the Academic Senate at the University of Utah. So she's helped people deal with risky social stuff.

Thanks, Harriet, for joining us. Thanks a lot.

Katie: Yeah, welcome.

Kirtly: Let's talk about "if you see it, say it." People, faculty who experience what they perceive as bad stuff, hostile work, it's risky. Job promotion, retirement, you've got to go back to work. How do you balance the risk of speaking up when there's bad stuff?

Dr. Hopf: I think I need to add my own sort of perspective a little bit first, which is why I'm so interested in helping other people manage risk.

I'm six feet tall. I played three sports in college. I did not experience being called "kitten." It would have been kind of, I think, laughable for anyone to call me "kitten," right?

So I think I had a bit of a different experience of navigating the system. It was not a perfect experience, but what I saw was lots of other people being treated in ways that I didn't like. And so I think that helped inspire me to help other people manage risk.

I have never felt constrained from speaking up. One of the things I've tried to understand is this sort of risk of speaking up, and how do people interpret it and how do I get people not to feel like it will be the end of their career. But I also recognize that there are things about me that make it less risky, perhaps, to speak up. But I also think that speaking up may be less risky than we think it is, if that makes sense.

So I always like to say this caveat at the beginning of these conversations about how to manage risk and how to speak up in risk, which is that a goal of my entire career has been to fix our system so we have less need to report and less risk in reporting.

I am sad to say we aren't there yet, although I see some advances, but I also see places where we aren't as far ahead as I want to.

So I think what we're going to be talking about today are strategies, tactics, approaches to navigating the current system. And that's really valuable for mental well-being, for being successful. I do not want to suggest that learning how to navigate the system means it's okay for the system not to change.

So I just want to kind of get that out there to begin with as a basis here that everything else I'm going to talk about is recognizing our imperfect system, but not saying the imperfect system is our best way to be.

I will say I think there is value in taking risks. And you also have to be smart about taking risks, but there is value in taking risks in that we cannot change the system if people don't speak up. So I am a strong proponent for speaking up.

I also recognize that you have to assess the situation, and it's not always safe to speak up, right? You have to choose when to speak up and how to speak up. You need to find allies.

So let's sort of start big picture with what do you do in that moment when someone's calling you "kitten" when . . . I don't know who the turtles are. You are the bottom turtle.

Kirtly: I was the bottom turtle.

Dr. Hopf: When the surgeon says to you, and you're standing there with . . . This is my residency experience. I was a surgery resident at the time. There's a woman medical student next to me. It's in the pediatric surgery OR late at night. We're both standing scrubbed, but not anywhere near seeing the procedure. And the surgeon says, "Will one of you broads come up here and hold retractors?" And I think, "I can't let the med student have to respond to that." So I went up and held retractors. And that was sort of an opportunity to protect someone.

But let's get to speaking up. Here's what I say to people who come to me and say, "Hey, here's the thing, I don't want to speak up. I'm afraid of what will happen to me." What I say is, "This bad thing has happened to you. Not speaking up is also risky."

And I think that's the part of the equation that we often miss, is, "Oh, it's too risky to speak up." Well, think about the risk of not speaking up. It's risky for your health and mental well-being because we know that even just with instability, not responding to it, not having it responded to really interferes with mental health.

It's bad for your work. It's hard to work when you're just distracted by how upset you are. And it drives burnout.

We think about our incorrect choice. It's not, "Oh, I'm going to take a risk and speak up," or, "I'm going to be risk-free and not speak up." It's, "Which risk is better, speaking up or not speaking up?"

We always think about, "The first thing I want to do is support people." Like, "This sucks. I am so sorry. This is a horrible situation to be in. And I'm here to tell you that there's no way to make it not a horrible situation. You can speak up, you cannot speak up, it will still be a horrible situation."

But then what I think about is if no one speaks up, nothing ever changes.

Katie: Exactly.

Dr. Hopf: I also think about the value of speaking up early to stop that cycle of devolving instability, right? Let's think about surgeon calls you "kitten." Obviously, you don't say anything in that moment. You're a medical student or a resident, whatever you are. It's a horrible situation. You would like someone to stand up for you.

I'm a big believer in bystander training. Wouldn't it have been great if somebody in the room had said, "Hey, I'm not sure it's a good idea to call someone kitten"? Or one of my favorite things, "I'm sorry, I think I missed that. What did you say?" Which is a great way to stop people in their tracks, right? You're not in conflict with them. You're just like, "I'm sorry, what?" And that gives them a moment to go, "Oh, maybe that wasn't really appropriate," and they often stop, right?

So I sort of think about how we get to the bad level of discrimination and harassment and all kinds of bad things, but there's a lot of stuff that's starting at a lower level that if you're not good at managing that, it's impossible to manage the big things.

And if you don't manage being called whatever or doing some little things, then they tend to give permission for the bigger things. The perpetrator, let's say, the person who is behaving inappropriately, if they don't get pushed back on, then they can convince themselves there's nothing wrong with it.

Katie: No big deal. Yeah.

Dr. Hopf: It's no big deal, right? If you haven't learned how to speak up appropriately and you say to the surgeon, "Don't call me 'kitten,'" the surgeon's going to say, "Oh, you need to learn how to take a joke. You women are so sensitive."

Katie: "Smile more."

Dr. Hopf: Yeah, "Smile more." That doesn't work. So I think this idea of, "I'm sorry, what did you say?" . . .

I'll also say you need to find your right moment, right? A group at Mayo Clinic came up with this very nice GRIT mnemonic, which is Gather, Restate, Inquire, Talk It Out.

So the gather part is someone just called me "kitten." Sorry, Kirtly, I hope it's okay if I'm using your kitten example. It's really making me mad. But someone just called me "kitten." I'm going to take a deep breath. Am I safe in the moment to say something? How could I say it in the moment? What am I going to do next?

And then there's this idea of restate. That's where I love the "I'm sorry, could you repeat that? I'm not sure I understood."

And then inquire, sort of be curious, right?

Kirtly: Did you really call me "kitten"?

Dr. Hopf: Exactly. It's a difficult one, right? And I don't think I would do it in the operating room while I'm taking care of a patient. Or you might say something like, "My name's Kirtly. I know it's hard to remember, but mine's Kirtly," something like that. But you might later on try to go do that.

There are data that somebody in a room where there's more than one person other than you says something to you that's inappropriate and no one says anything, that is where the harm comes, right? Not standing up for someone.

What's even worse is if you then leave the room and that person, that bystander, comes up to you and says, "I'm so sorry. That was a horrible thing to have happen," because then you know that they recognized it was bad and did nothing, right?

So it's a complicated situation. You have to be careful. There's clearly risk. I will say I know there's a lot of belief that, "Oh my gosh, if I go to the Office of Equal Opportunity, somehow that's all going to devolve badly on me." They have worked really hard to be trauma-informed care. They maintain confidentiality unless you give permission, right? There are lots of things they can do short of starting an investigation, and they are a place for institutional support.

But institutions have all kinds of other kinds of support: ombuds offices, deans of students, faculty office, HR.

I also think you need to train yourself to know policy and know how to support people in the moment or if they come to you for help.

And then finally, think about the fears that keep you from speaking up may not reflect the reality of speaking up. And every time you choose not to speak up, your body learns that that was fear that was justified. So it makes it harder and harder to speak up.

When you actually speak up, most of the time you will learn that your fear was overestimated. If you learn to speak up well, hopefully it won't reverberate on you. I mean, yelling at someone is rarely a successful way of dealing with this.

And so one of these I would just advocate for is recognize . . . I find it's helpful to me to remember that not speaking up is also risky, right? That way you're weighing risks.

Kirtly: Yeah, there are people, I think particularly for women, and this is a women's health podcast, who were culturally taught not to speak up. So the business of not speaking up may go back to your interactions with your parents, particularly your dad, or often forceful people in your household. So not speaking up can be both a cultural . . . there are cultures where women don't speak up.

I'm going to go back to "The Pitt" for just a sec because everybody's watching it. There are so many examples of risky behavior, interactions that really aren't appropriate, and people from different cultural backgrounds and how they manage it or don't manage it.

Well, Harriet, you and I and Katie work in this huge workplace. Over 20,000 people work at the University of Utah Health Sciences. And there are coaches and there are policies and procedures and there are ways to help people negotiate boundaries.

But I think what you brought up is that there are online resources and books about how to speak up for people who work, let's say, the intense business of a restaurant, where in the front, in the back, in the kitchen, there can be bullies. Chefs can be bullies.

Katie: Notoriously.

Kirtly: Notoriously. And so there are online options and books to help you speak up if you're not in a place that has Harriet's office where she'll speak up for you.

Well, I want to move to intimate relationships in the workplace, just briefly.

Dr. Hopf: Can I add one more really bad source of harm? It is customers. There, having a manager who supports you is crucially important. I don't know if I like to think of my patients as customers, but in some way they are.

But the Association of American Medical Colleges a couple of years ago . . . They do an annual survey, and they added in some questions about whether you'd seen sexual harassment in the breadth of the meanings, so from microaggressions . . . It turns out it's pervasive, that people report that they have seen it or experienced it in the last 12 months. Fifty percent of women and 25% of men said that they had experienced or seen sexual harassment.

What are the sources of this sexual harassment? Other physicians, followed closely by nurses, followed closely by patients. I think that's not unlike working in a service industry where everybody can be mean to each other. And so, yeah, it's a problem.

Kirtly: I think at the University Hospital, I've been a patient, and I've been in clinics. When I think about who are the best, it's often the people cleaning my room.

Dr. Hopf: There's also an association between power, which we have more of than someone who's cleaning the room, and misbehavior. Becoming in charge of something basically drives bad behavior almost.

Kirtly: That's not the servant leader. That's not being a servant leader as far as I'm concerned.

Dr. Hopf: I often have great days in the operating room where everybody is working together and it's all a team. And then there are some days where I'm just like, "Are you kidding me?"

Kirtly: Well, I was going to talk about intimate relationships, but I just want to talk about relationships. And Katie, you had some interesting things to say about harassment or things that get overlooked in relationships in the workplace.

Katie: Yeah. The intimate relationships, the supply closet hookups, those get a lot of attention, and I hear they happen. That is not a reality I'm familiar with. But one thing that I can talk about that I think happens in lots of groups is just more the in-group/out-group dynamic.

And so you have these close-knit healthcare teams and they can be really tight-knit, and somebody doesn't quite fit in. Not because they're doing something wrong, but they just don't conform to the group's social norms and they just don't get to be part of the inner circle.

When that dynamic takes hold, then the in-group starts to influence who gets hired, and you sort of bring in more and more in-group-type people. And if you're not in that, then you maybe don't get supported. You get sidelined.

Harriet, I'd be curious your thoughts on this. It feels like that maybe happens more in workplaces that are entirely or mostly women. And maybe I'm wrong about that just because I work . . . maybe that's my experiences working largely around women, but it's a power dynamic.

I think it does matter, again, for our conversation about risk, because in healthcare, it can also be a patient safety issue. If someone on a clinical team feels like they're on the outside and they carry that extra layer of stress, and it has nothing to do with patients, but they might be less likely to ask for help when they need it because they perceive that they're already out. Being vulnerable and asking for help or asking for a consultation also feels risky.

Dr. Hopf: And Katie, I just want to suggest that . . . You called out that somehow women's groups sort of created cliques. I would suggest that our dominant narrative, our dominant culture, is so invisible to us that you haven't noticed that there's a clique that excludes women, right?

Katie: Yeah.

Dr. Hopf: I don't know that I would say there's a genderedness to it. I think it just shows up differently in how it might be experienced. And there's also some data on you expect women to behave better, right? And so you're more judgy of their behavior than you might be of a male colleague's in the same way.

It's really hard to know if that is what's going on or not, right? So I would just throw into that mix, that in-groups and out-groups, that's sort of how you build comfort.

Katie: Yeah. And it's also important. It's an important part of how we find safety too, right? I do need to find the group that's my people. I think that's part of our background as humans.

Dr. Hopf: I think building culture is crucial. And I think, Kirtly, you talked about servant leadership, transformational leadership, whatever kind of leadership. There is a top-down nature to building a culture where people are welcome. But I think there's also a bottom-up version of that.

And I think here, we're at an institution that's growing really fast, and that puts stresses on, "Oh, you build a culture where people feel welcome."

Oftentimes people have trained here and stay here, at least in medicine, and so that can be an in-group. They have a shared culture. Someone comes from another institution, now they have to learn our culture.

I came here 20 years ago from another institution, and I had to sort of sit back a little bit and learn the culture here and figure out what was important to me.

As we grow quickly, thinking about building culture is a really important thing. Thinking about socializing and being inclusive in socializing.

I will also say I have an example from my department. One of my colleagues, Amber Bledsoe, ran our quality assurance program for a number of years . . . now she's handed it off . . . where we look at bad outcomes or bad cases or bad stuff that happens to our patients in the operating room. And there's usually a systems problem, like someone gets the wrong medication or someone doesn't recognize something.

She built a process for the quality assurance where we sort of start out with support for the person, we go through what happened, and then we look at what's the system's problem that we could fix. What led to this being a problem? Not, "Oh, the person's a bad person," but "How could we learn from this in a way to protect future patients?"

And so I think you can have individuals who kind of step up and say, "Let's build a culture." You can have leaders who just make that a priority. And it's still hard because we're humans and we like people like us.

Kirtly: Yeah. Well, we've talked about the risky parts of things happening in the workplace, but the good parts, if occasionally risky, of making friends in the workplace, it's really critical to have friends in the workplace. We've talked a lot about how important friends are. We did a whole 7 Domains of Friendship. You listeners may want to pick that up because it's powerful.

How do you meet them after you get out of school except in the workplace? And the best part of coming to work can be a collegial environment that grows into friendship. But there are always issues of boundaries.

We were just talking about there's getting cliques, getting too close, and excluding others. The issue of getting together now . . . We used to have departments, and we had big rooms, and everybody would have once-a-week faculty meetings, and we all ate together. The family that eats together stays together, and we would eat together. Someone would give me the pickles out of their sandwich because they didn't like pickles, and we would chat about stuff.

And that doesn't happen as much anymore. That getting-togetherness in a department where you talk about swapping call, that for me . . . Now I'm an oldster, but that for me was critical.

Katie, you've thought a little bit about what happens when people aren't together anymore. We're all separate.

Katie: Honestly, I've been thinking about this for a long time. It's been really driven home since COVID that we're not in our offices, and we've actually kind of in the meantime redesigned our workspaces. It doesn't even feel like there are gathering spaces anymore. Nobody's there.

I recall a time when I went to work and I worked in my office, but at lunchtime, we all kind of meandered down to the lunchroom, and as you were saying, Kirtly, shared our salad leftovers, and I ate your pickles, and you got my dessert or whatever. And these weren't formal meetings, but that was sometimes where our best ideas came from.

Now I feel like post-COVID, we've learned to work from home, and I enjoy that, but I can go weeks . . . And even if I go in my building, the way my building's designed, I cannot see another human being the whole time. I go in, I ride the elevator, I sit in my office. And there might be other people working in my building, but nobody eats lunch in a common room anymore and we don't have that space.

In spite of that, I would say after 30 years, most of my friends are people that are either the people I work with or people I've met through the people I work with.

So there's this other little risk that I was thinking about that is when I do talk about the stresses in my life and the things going on, I am asking people to wear two hats. I'm asking them to wear the "you're my friend" hat, and we're talking about this thing, and it's connected to my work. There are boundaries around HIPAA that I can't talk about patients, but maybe less boundaries about leadership frustrations or something.

But I'm going to ask somebody who works with me to hold the friendship in one hand and the work relationships. And I think that gets tricky too. I know, Harriet, you're nodding.

Dr. Hopf: So I will say, first, the not-in-person thing, I think that is really a challenge. And I remember when I went the first time my professional society was back in person. I think it's very comfortable not to be in person, right? I am in my work office today. I just want you to know. But we get comfortable not being in person.

I was like, "Oh, I'm going to go to this meeting because I have to go because I have got a thing, but I don't really need to go. Why can't we just do it all virtual?" And then when I got to the meeting and I walk into the convention center and I'm running into all my friends from all the other institutions, I was like, "Oh, being in person is different."

I think it's easy when you're not in person to forget how great it is to be in person. So part of it is just figuring out a way to lure people in to be in person.

The other thing I think about is I started med school in 1982. I'm going back for my 40th reunion this year. Kirtly, you know this. It was a different world. It was slower paced, right? There was something intrinsically bonding about I got a team and every patient is seen on a team. Now there are lots of attendings who spend a lot of time . . . not working alone but not working in teams as much.

So I think there's lots of stuff in our current environment that is not COVID-related that make it harder to connect because you've got less free time. You've got less leisure thinking time, I want to say. There are just so many layers of all kinds of things that you have to do.

Work is a great place to meet people, but there are other places to meet people. I think one thing to think about friends outside . . . When you have friends in the workplace, there are all kinds, I think, of levels of things. I think gossip is really destructive. So as you're trying to build culture, remembering that venting, while it's good, may not be good within the circle of people who are working with the person, and yet that's the place you want to do it.

It's sort of interesting for me because there's HIPAA, and then there's coaching for me where you want to keep things confidential. So I'm getting really good at that.

My sister-in-law fell off her bike last fall, and I'm a wound-healing kind of person, and it wasn't super healing well. So she called me, and I gave her some advice on how to work on it. I did not tell my husband because I was providing medical care. So although it's not a formal relationship, I felt like I was covered by HIPAA.

And then they all got together or something, and she was like, "Oh, yeah, Leo, my knee is all better." And he goes, "Your what? What's going on with your knee?" And she's like, "Did Harriet not tell you?"

I think I would say that is an example of possibly taking it too far. So it's a balance of how do you vent?

I think about venting as I can complain about my boss. While I do that, I need to have understanding of the stresses on them. I need to think about the fact that they have good intent. They are not trying to harm me. There is some side effect that's harming me.

And I need to think about, "Is there something in this situation that is amenable to something that we could do together to make the world a better place? Can we just be bonded together in enjoying life anyway?"

And no matter how great a boss you have, there will be times you don't like it. So I know I'm sounding very Pollyanna, but I think that's a thing, being careful about gossiping.

I think it's time-honored maybe to gossip about your boss. Gossiping about coworkers . . . And when I call it gossiping, maybe that's a little pejorative. But talking out of turn about coworkers is also probably something to think about as a way of undermining relationships. Sort of not saying anything you wouldn't say to their face.

But that's a really hard thing when you balance it with we work in a really stressful place, I can't talk about it at home, and I want to talk about it with colleagues.

I think what I try to do is I try to think about how I could be constructive in the situation, and also think about humanizing the person I'm complaining about. They're a person. They have stressors I'm not aware of.

Kirtly: That is just so important, because negativity breeds negativity. And when you complain about people or gossip about people that are coworkers or even bosses, it ends up accelerating an issue beyond what needs to be.

So if you want to talk about a Pollyanna, I'm the queen of the Pollyannas. If it's going to hurt somebody, particularly in the workplace, I don't think it's worth it, personally. Not that I don't have needs to vent, but I just don't want to be saying something that I consider might be mean or negative in the workplace. It can be a behavior that needs to change, and I frame it as that, but I'm pretty careful.

In my career, some days I went to work for my patients and sometimes for my students, but often, my colleagues were the best part of my day. And though I've seen inappropriate behavior in my workplace and had to do the painful work of dealing with it, I've seen the very best that humans can be day after day, and that was most of the time.

So some of my best continuing friends come from friendships that started in the workplace. And we do need to know where the lines are drawn for risky or inappropriate behavior.

We are human beings. We do stupid stuff, but goodness reigns in the vast majority of times. I believe that goodness reigns, and it's just that we should know what to do when there are lines that are drawn and lines are crossed.

Harriet, thank you. Dr. Hopf. I'll call you Dr. Hopf, not Harriet, although this is The Katie and Kirtly Show.

Dr. Hopf: Harriet is good. I gave the example, but Harriet's great.

Kirtly: I want to thank you for helping us think about this, and GRIT. I've got GRIT between my teeth. I'm going to use that.

Kirtly: So thanks for joining us, and thanks for listeners who are listening to the Social Domain of Risk. If this is your first time listening to the "7 Domains of Women's Health," you can catch all of our podcasts on risk and all of our other podcasts in the women's health session at womens7.com, or at "7 Domains of Women's Health" wherever you get your podcasts. It's hopefully engaging and informative and sparks conversation, and it's not too risky. Thanks for joining us.