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Bushardt, Reamer L. PharmD, PA-C, DFAAPA

Journal of the American Academy of PAs: November 2017 - Volume 30 - Issue 11 - p 7–8
doi: 10.1097/01.JAA.0000525918.07259.8b

Reamer L. Bushardt is professor and senior associate dean at the George Washington University School of Medicine and Health Sciences in Washington, D.C., a clinical, translational scientist in the Children's National Health System in Washington, D.C., and editor-in-chief of JAAPA.



Chewing gum with your mouth open. Children who do not say “please” and “thank you.” Substituting Pepsi for Coca-Cola.

At some point, we are all subject to the effects of triggers—those things (or people) that seemingly flip the on-switch to fight or flight reactions. The initial examples have consistently irked my wife for as long as I can remember. Patients with celiac disease have wheat. The atopic child likely has myriad allergic triggers. The president of the United States and the press have each other. Triggers are everywhere.

The commonality is that the trigger seems to drive a natural reaction. Problems arise when that reaction is undesirable. Sometimes, the relationship between trigger and reaction is simple and easy to recognize. We can intervene to prevent an undesired reaction or mitigate its severity, through strategies such as irritant avoidance, pharmacologic intervention, or heightened self-awareness. At other times, the relationship may be an enigma. Recognizing these triggers may be complicated by the subtlety of its effects, an inconsistency in the reaction, or a multifactorial relationship that is inherently hard to understand. Fields such as epidemiology, anthropology, and psychology fascinate me, but my self-declared authority to editorialize this issue is not degree-related. In keeping with being a PA, most of my lessons have come from on-the-job-training: as healthcare professional, parent, spouse, employee, or boss. Let me share some personal observations and highlight a couple of issues of greater societal significance that concern and perplex me. Maybe together we can formulate some diagnoses and recommend a management plan.

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People who do not own their mistakes are a trigger for me

One of the most inspiring qualities of great leaders is their ability to admit and be accountable for their own mistakes. After all, mistakes are unavoidable and essential to learning and personal growth. In the clinical environment, we all know that medical errors are common. Although we strive to prevent and learn from harmful errors, some error is inevitable.1 Experts and the published literature remind us that honest disclosure is the best policy when it comes to medical errors. Healthcare systems and providers that adopt this policy demonstrate character-based leadership. Human beings are naturally ego-driven, so owning up to our own mistakes can be hard. Cognitive dissonance, a form of mental anguish, may arise if our thoughts or behaviors or the criticisms of others challenge our own self-image. To arrest this dissonance, we have two choices: admit our mistake or justify it.

Individuals who do not own their mistakes have triggered some memorable, undesirable reactions in me. Experience and increased age have helped me unravel this trigger and formulate better situational management plans. Acknowledging a mistake is an act of honesty, and there are few things in this world I despise more than dishonesty. Being honest about an error or a bad decision takes moral courage, and many of my personal heroes embrace this type of courage, which is a prerequisite to integrity and foundational to character-based leadership. I have learned my brain is wired for continuous quality improvement. When a member of my team admits a mistake, I get excited and view it as a step to strengthening the overall capacity of the team. Opportunities to improve are illuminated; process gaps can be closed. A leader who owns up to a mistake demonstrates humility and fosters a culture of trust and accountability. Owning up invites others to do the same without fear of shame or humiliation. It took me a while to understand this trigger and the pattern of emotional reactions it provoked. Through self-awareness, patience, and intention, I have learned to control it versus letting it control me. A culture of high accountability, not just responsibility, is important to me. I constantly remind my team (and myself) that being accountable means not only being responsible but also being prepared to answer for our actions.

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People who lack civility and respect are a trigger for me

When I was being considered for my current job, an interviewer (now my boss) delivered an unwavering condition. He said, “No matter what happens or how outrageously someone may act, you must commit to treating everyone with respect.” He elaborated, “We will be tasked to deliver difficult feedback and react to poor decisionmaking, which may in consequence end a career or dissolve a longstanding aspiration, but we must always preserve the dignity of those we lead.” I was so moved by his conviction at the time, and continue to be inspired as he practices what he preached. In doing so, my supervisor reveals some of his own triggers—microaggressions, indecency, hate, any environment or team that lacks empathy or is hasty with judgment. This leader expresses humility and acknowledges that he periodically experiences unkind thoughts; but even if those thoughts are justified, he commits to manage his reaction and preserve dignity. It illustrates that we do not have to be subservient to our triggers.

Understanding and being sensitive to the hot buttons of our supervisors, colleagues, and patients can facilitate shared decision making and high-performance teamwork. Patients reveal their faults, mistakes, and intimate details of personal struggles with PAs every day. Just as we seek to listen with compassion and without judgment, we can apply the same approach to others outside of a therapeutic relationship. I have always encouraged (sometimes required) the PA educators whom I have led over the years to stay regularly engaged in patient care. Beyond the benefits of maintaining sharp clinical skills and awareness of emerging issues, routine interactions with patients and families translate into positive benefits for how faculty interact with one another and with students. Clinical practice also can remind us of what real suffering looks like and illustrate the importance of empathy. I was encouraged to read in a 2015 PA faculty and directors survey that more than 85% of PA faculty continue to practice clinically.2

Often, the art of medicine is an exercise in learning how to manage your own triggers and implicit biases in pursuit of delivering compassionate care for every patient. Civility and respect are under assault in the United States today. Economic and structural forces are contributing to various forms of segregation, protectionist behaviors, and pervasive distrust. It seems to me that Americans are more susceptible than ever to triggers, and social media and sensationalism in the media are complicating factors. For healthcare professionals and PA educators, this new reality contrasts starkly with our aspirations for more collaborative care, interprofessional education, and teamwork. We know that awareness is a key to recovery. So, let us seek to understand and acknowledge our own triggers. Help colleagues and patients do the same. Once our triggers are identified, we can formulate strategies to manage them, so they do not manage us. Just keep in mind, if you try to offer my wife a Pepsi instead of a Coca-Cola, you're on your own.

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1. Kohn LT, Corrigan JM, Donaldson MS, eds. Committee on Quality of Healthcare in America, Institute of Medicine. To Err is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
2. Physician Assistant Education Association. By the numbers 2015: faculty and directors survey report. Accessed September 14, 2017.
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