The Daily Practice of Leadership with Dr. Jessica Bunin - Part 1

Hello, my peaceful warriors, and welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst. And I'm going to ask you a question. If you're in medicine and you're listening to this podcast, have you ever had formal leadership training? And if you haven't, did you realize at some point during your education or journey how valuable that would be? And in leadership, being able to handle conflict communication, being able to talk to the people with whom we work becomes such a vital skill. And I can't think of anybody better for us to have this conversation with today than retired Colonel Jessica Bunnin. Dr. Bunnin is the co-founder and chief architect of All Levels Leadership. She's a certified executive coach and an ICF-associated certified coach. She is passionate about leadership education and coaching, which are passions she's developed over her 23-year Army career, which includes deployments to Iraq and Afghanistan. She is a graduate of the United States Military Academy at West Point, and she did her medical education at Tulane. She is a critical care physician and professor of medicine and health professions education at the Uniformed Services University. She's been involved in academic medicine as a program director for critical care, Assistant Dean of Faculty Development, and an Associate Dean for Diversity, Equity, and Inclusion, and an Associate Dean for Community and Educational Culture. And I am thrilled to have her on the podcast. Jess, welcome.

Thanks, Lee. It's wonderful to be here.

I love, like, your background. I mean, you went to West Point, you've been deployed, you have had so many life experiences that I feel like Just molded your concept of leadership. But was there an aha moment as you were going through this process that you realized how vital it was to have this kind of education and training as a leader?

Yeah, I actually think that came later for me. I think the most distinct time that I remember thinking, I'm so glad I had some leadership training along the way, but I wish I had more, was when I was an associate program director for an internal medicine residency. My residency program was half military and half civilian, and there were a lot of folks running around who always had different concerns and problems and remediation needs and life needs at any given time. And I felt ill-equipped to handle them despite having had the amount of leadership training that I had at that point. And that really made me dive into learning more, reading more, attending any course I could possibly attend that would give me more education in academic leaderships. Specifically so that I could understand and help folks as best as possible. But that's the time I distinctly remember learning, wow, I'm glad I know how to run a meeting. Wow, I'm glad I know how to have difficult conversations in real time. What I didn't know was how to handle remediation most effectively and to handle a lot of the program-level conflict effectively. And so, I think a lot of the learning happened me there, but I was so grateful to have had a leadership background. Wow.

There's so much I want to talk about, and I think it's also really interesting that was a flashpoint for you where you really saw how much you needed that, because I have heard that from other guests on the podcast, people who didn't necessarily have the kind of military leadership career that you had, but who had been in private practice or had been in a big group setting. And knew they needed some of those skills, but didn't actively seek them out until they were in academic medicine and specifically dealing with residents. So I think that's so interesting that that was where you really saw that, because I think that's a common experience for a lot of leaders in medicine when they get to a residency program director level. They're really having to interact in so many different ways. And one of the other things you said that I thought was really cool is. is that you had a half-and-half program. You had half military and half civilian. Did you get to see in real time sort of the differences in the worldview and the differences in the way people approach tasks? Because I can really see that being so different between those 2 populations.

Yeah, it's such a great question. I actually think there's less of a difference than you would think. I think there's so much hierarchy in medicine anyway that actually overlaps a lot with the military. And so folks were wearing scrubs most of the time. And if they're wearing scrubs, you honestly didn't know who was military and who was civilian. There was a lot of overlap with folks that struggled in either direction or folks that excelled in either direction. So I'm not sure that you would have been able to pick folks out necessarily from one way or the other. I do think that there's a steeper learning curve for folks who have never been engaged with the military at all to now be working in a hospital that is a military hospital. So there's some learning that needs to happen there that might make it a little harder upfront. But overall, I think the quality of the residents is the same. I think the education we give them is the same. I do think that the civilian residents in our program probably got a little bit more leadership education than they might have gotten otherwise. The overall perspective, the overall commitment to medicine, the overall willingness to be at work early in the morning and there for long days. I think that's the same in medicine everywhere, whether you're military or civilian.

Yeah, that's an incredible insight that just by nature of the work, by nature of the culture, but also by nature of the hierarchy that's inbuilt into what we do, that it was less of a dramatic difference between those populations.

Correct.

Some of it is sort of inbuilt already. You talked about doing, you know, as one of the things that really drew you to building this more formal education in leadership was remediation within the program.

What was that experience like? Yeah, I felt personally like I had just never learned that. Before I learned about the faculty development program at the Uniformed Services University, I wasn't aware that faculty development was a field or an available service. And so I didn't know how to approach a learner that was struggling. I didn't know what the rules and regulations were. I didn't understand the difference between remediation and probation. I didn't know how best to create a system for someone who needed more support without it being a formalized program and without it feeling to that person like they were under a microscope. And it was really important to me to learn that and to learn how to build the structure of people around someone so that they felt supported by a mentor, by a coach, by a program director, but more importantly, having these supports around you that were not involved in grading you at all and were just committed to making you better and stronger and to get through the program that you're trying to get through. And so, I think that was one of the big learning points for me is what is the difference between an advisor and an evaluator? And a mentor and a coach? And when are those all most effective? And I think that was a big part of my leadership education, was learning when we can most effectively use each of those roles.

That is so cool. And I love how you, number one, talk about this as a structure, that you're building this as a scaffolding, a support around the learner. This is not something that's a one-size-fits-all. You're having to really design this for the individual. But one of the other things that I bet made this really successful was the fact that there was a clear delineation from this in the grading process.

Yes.

That you must do these things to pass. You must do these things to make your milestones. No, we want you to be a more successful, happier human. And kind of trusting the process to say that as they became a more successful, happier human, they were naturally probably going to meet those milestones. Wasn't one of those things that we have to see you do this. We trust this process we're creating that you are gonna do it. And I felt the learners were way more receptive to it when you presented it that way.

Yeah. Oh, I think there's a huge element of creating a truly psychologically safe environment where learners can admit when they're struggling, when they don't know, when what you're telling them isn't making sense. And that doesn't exist everywhere. It takes a lot of effort to truly create psychologically safe environments. And I wanna say right up front, I don't at all believe that psychologically safe environments are comfortable environments.

Mm-hmm.

I think there's a lot of discomfort and growth that has to occur for both leaders and followers in a truly psychologically safe environment. And I think making learners believe that we are there for them and that they can ask any question and there will not be Any consequences to that is a huge part of creating an environment where people can grow and learn and fall into the roles they need to be in to get the help they need. And I think a big part of that is leaders admitting when they don't know. All right. That is one of my biggest learner points for a lot of our critical care fellows or critical care residents. On rounds tomorrow, I just want you to say one time, That you just don't know. And get in the habit of admitting that freely and comfortably so that we all know that we aren't supposed to know everything all the time, but we can all learn that together. 100%.

Okay. There's so much I wanna get into about with what you just said, cuz it's amazing. And I'm gonna go backward because there's so many things. But when you were talking about this idea of comfortably able to say, I don't know, and getting people comfortable with that concept. I teach martial arts. I've taught martial arts for 20 years. My kids are black belts. I'm a black belt. It's something that we've were able to do together, and we still do together, which is wonderful.

I'm terrified of your whole family, Lee.

We've had people say that. It's like, I wouldn't want to meet your family in a dark alley. But it was a wonderful, really great family experience for all of us. But of course, you know, to move up in rank, you have to go through belt exams. And so as the kids got older, and they were also instructors, and I was an instructor, you know, the kids are doing their forms and their sparring, but they're also getting asked questions at belt And so we have already given them lessons. Someone's going to ask you, why do you tie your belt evenly? Why are your patches round? And so these were answers that we had taught them before, but of course it's a pressure situation. And so one of the things we also taught them to say is an acceptable answer at belt rank testing is, I don't know, but I will find out. And we drilled that into them. And I still will give that to medical students. An acceptable answer is, I don't know, but I will find out. And that is an acceptable answer to your peers, to your higher levels, and to your patients. Those are all acceptable places to use that. And I have never in 26 years said to a patient, I don't know, but I'll find out, and have them not receive that well. I love that you are making them comfortable.

Yeah, I think there's one caveat to that, Lee. Which is that you actually have to find out and you have to follow through and you have to let them know that you know the answer and that you're gonna educate them on the answer and you're gonna move forward together. And I think we lose that sometimes. We spew out the, I don't know, but I'll find out, and forget to go back and follow up once we have found out.

And that's brilliant. And you're absolutely right about that. Those two inherently are connected. And if you're talking about trying to build trust with within those relationships, the importance of the follow-through. You know, you've given some humility and vulnerability to your part of that relationship, which especially if there's conflict potential, that's so important. But then building trust by actually finding out and then circling back and communicating, that's just part of that strengthening bond that when conflict does arise, you've already got a leg up. Because there's already trust in that system. But that's also why I love the way you talk about psychological safety, because I think this is something that so many people in medicine right now are aware is so vital that we don't have psychologically safe spaces in lots of places in medicine. And more and more hospitals, academic centers are understanding how important it is. And so they're trying to build That kind of safe space. But I love how you illustrate the idea that safe doesn't mean comfy-womfy.

Yeah.

That's not what that means, because I think a lot of times people start to build those spaces, that is sort of the question. Can we make everybody feel comfortable? It's like, but we also want them to grow.

Correct.

So there is a balance in building those kind of safe spaces. What kind of things did you do as a program chair and as somebody who recognized how important it was? Were there specific things that you did? to begin to make this a safe space?

Yeah, I think there's 3 very distinct and very important steps to setting up a truly psychologically safe environment. The first part is setting the stage. You started the statement by saying, I think everyone knows that. I don't know that everyone knows. I think people have a lot of misconceptions about what psychological safety is. So I think having some baseline education for everyone, from students to senior faculty about what it means to have a psychologically safe environment, why it will be beneficial to have that, how it will increase innovation, how it will increase retention, how it'll increase job satisfaction, all of those factors. So, setting the stage for why this matters so much. I think that's factor one. The next part is that it's not about one person. It's not about the leader who creating a psychologically safe environment. It's about inviting everyone's participation. And in order to do that, you have to have humility about, I don't know all the right, best answers. And so, I'm gonna ask, and I'm gonna ask really to get the answers and to use the information that others are giving me. So, creating a team environment, creating humility among everyone, and creating team participation is step 2. But to move on to step 3, which I actually think is the most important step, is learning how to respond when you don't know the right answer, or how to respond when you get feedback that's uncomfortable without lashing out, without getting defensive, and role modeling, I actually do want your constructive feedback. I actually do want to make this environment better. So give it to me. I'm going to accept it appropriately in real time. And then, as we were just saying, I'm going to act on it, and I'm going to let you know how I acted on it so that you know that I respect and need your opinions, and we're going to use your information. I don't have all the answers. No one else has all the answers. It has to be everyone engaged in giving each other feedback, creating a culture of feedback, And responding to feedback in a way that is productive for everyone.

Wow. That is beautiful. It's very precise, but also you're inviting everybody into this process. I think there is this idea that sometimes this is a top-down or a leader-driven idea, and it's really not. This is really a community effort to build this psychologically safe space.

But I do— It does take the leader being the first person that says, I want your constructive feedback, and I'm gonna do something with it, as opposed to getting defensive or pretending like you know the right answer or have all of the answers. I think that will ruin, even if everyone else is trying to create a psychologically safe environment, that leader must be committed and must have humility.

100%. And I love how you state this because I do think Especially sometimes in medicine, I feel like people do feel like leader means has all the answers. Leader means that I'm the person who's the smartest in the room. Absolutely not. No, no, you're never, especially in looking at a room full of doctors who are all brilliant people, because you wouldn't be there if, you know, the idea that we all have knowledge, we all have things we can contribute. And where I am weak, you're going to be strong, but that's why we're going to work together well.

Yeah. Or on top of that, there's environments where none of us have the answers. So I'm going back to being an intensivist during COVID Every day we were treating patients differently because every day we had new information coming in.

Yeah.

But I think as long as we lead consistently through that uncertainty and we admit what we know and what we don't know and why we are doing something differently today than we did it yesterday, so that there is an understanding of the changes in our behavior. And that again, we have the situational humility, the educational humility. During COVID for me, a lot of times the students actually knew better what to do than I did because they often had more time to be reading or to dig through the internet or to be on a WhatsApp chain with a lot of really smart people or to be on Med Twitter at the time was a big thing to sort of get through COVID. I remember that. And so I think there's times when none of us know the answers. The future is uncertain. The correct treatment is uncertain. If we can learn to communicate that uncertainty effectively and in a manner that does not overexcite people, but actually creates some calm and some understanding and some communication, I think that can really work. Wow.

This is beautiful. The idea that we can train and we can actually learn how to communicate in such a way That we are not only communicating our receptiveness, that we are allowing ourselves to respond and not react, which I think is really something that we do have to practice. And you mentioned role-playing earlier. I think that's huge. What are some tools and some things that you have done or you use in your coaching that help people really learn how to communicate in that very effective way?

Yeah, well, a huge area for me of growth over the past 3 years or so has been diving into the world of civil discourse and understanding the most effective ways to go about communication across difference. And I wanna start that conversation by saying what civil discourse is, 'cause I think that's another area where we have a lot of misconceptions. Mm-hmm. I think people think of civil discourse and they either think, yeah, yeah, we'll all be very nice, like civil, like we're gonna be very kind to each other. We're not gonna say anything we don't mean. Anything we say, we're going to say very kindly. And that is not what civil discourse is. Civil discourse means that I'm gonna communicate to you with respect, even though we disagree, but I'm gonna do it in a way that makes you believe that I'm listening to you and that makes us both have a wider lens on the world when we walk away. I think the other misconception is that civil discourse is debate. And that's definitely not true. We don't wanna go into any situation with civil discourse saying, well, I'm gonna come in with 15 stronger articles than you're gonna bring, and I'm gonna convince you that my answer is the right answer. That's debate. That's not civil discourse.

Mm-hmm.

And if we go in trying to change someone's mind or trying to win an argument, we are not able to effectively listen to someone. And we're not able to effectively broaden our lens on the world. So I think it's important going into that to know what civil discourse is. And when I was first starting to teach civil discourse at our institution, I struggled to find a model that was going to be effective in a science and medicine world, but was also going to connect and be effective. And so what I did was I read a whole bunch of books. I read about 10 different books at that point, and I tried to pick and choose the best parts from each of those. And so I did dive into a lot of psychological safety. I dug into a lot of Adam Grant and Rethinking. I dug into a lot of Julian Treasure, who is a communication scientist, to find out more about active listening. And I created what I call a clear framework. framework for civil discourse. CLEAR being the C-L-E-A-R. So the C is creating that psychological safety. The L is listening, but using active listening skills. So we truly pay attention to what's being said between the lines. We encourage more communication to us by actively listening. The E is establishing common ground. So that we can start at a place where we're all much calmer and in agreement and then move to our disagreement from there. The A is adjusting our thinking or practicing some rethinking skills. And then the R is to respond skillfully. And that means having some techniques where you can decrease your own defensiveness or anxiety about the conversation. Learning how to call people in. For further conversations instead of calling them out and shaming them. Learning to approach situations where you talk about the ideas, you don't attack the people. So I think there's some very basic conversational skills that we need to work on and learn to respond skillfully. And I think if we set all of those pillars in place, psychological safety, the active listening, the common ground, the rethinking and those conversational skills, then we're set up to have successful discourse in any environment.

That is amazing. Okay, first of all, I love how you start this with, this is not about debate. This is not about winning and losing. And I feel like right from the jump, when you framed it in that way, you have brought it into a space where people kind of lose that That idea is that I have to beat you, I have to win, which I think is so destructive to communication and conflict. So right from the start, we're saying this is not about winning and losing. And I think that's such a beautiful place to start because already you've gotten people in that mindset. This is more of a cooperative experience and not one up and one down. So that's incredible. If people are interested in all levels leadership or they have questions for you about CLEAR or civil discourse, How would they best find you?

Yeah, so you can always reach me at jess@allevelesleadership.com, and I would love it. Like I mentioned earlier, I'm a believer in this methodology, and if I can help anyone have more effective conversations, if I can help folks communicate better with their chains of command, with their patients, with their kids, whatever it might be, I'm in. I can do workshops at any level. I'm happy to do lectures at any level. I just do believe that this can change the way we feel about our workplaces and the way we feel about each other. And so I'm fully in. So jess@allevelesleadership.com is where you can reach me.

Fantastic. And we will put that in the show notes as well. Thank you so much for being here. I really appreciate it. This has been wonderful.

Lee, it's been a pleasure. Thank you.

For all of us who joined the Chaplain's Corps today, for all of you who are here My peaceful warriors, thank you so much, and until next time, be at peace.