New skills for
 general practice: 
Assertiveness

In Sonia's previous article, we set out the importance of setting boundaries, and here explains how being assertive can help you set those boundaries.

In my 20s I went to an assertiveness class thinking that I needed to speak up more, and was rather disappointed to find that it was aimed at getting people to complain that their hot chocolate was not hot. Having been more than able to do that politely and effectively all my life, I was left wondering why I had been so critical of the course.

Grasp the subtle nature of assertiveness

I have since worked out that assertiveness in medical settings is a whole new ball game, and that whilst the principles are in fact identical to the hot chocolate scenario, and the thinking behind the actions are fundamentally the same, one needs to inherently grasp the subtle nature of the situation to see when and where assertiveness needs to be applied.

...one needs to inherently grasp the subtle nature of the situation to see when and where assertiveness needs to be applied.

So where does one start when trying to be more assertive in one's professional life, and why might this be an important, even vital, career skill for today’s GPs? The first is a difficult question to answer without having someone presenting with a specific problem to address, but the initial steps are to:

  1. Find out what is bothering them.
  2. Establish whether it is reasonable or unreasonable for them to be bothered by this.

The how to

So having established that the thing bothering them is worth being bothered over, one then needs to say something about it.

This is where things can go horribly wrong with the following possible outcomes:

  1. What on earth to say.
  2. Can't face saying it, as it might upset people.
  3. Say it ineffectively, get no result or a bad result, and never try again.
  4. Say it over the top, get no result or a bad result, and never try again.
  5. Say it in a friendly, calm and firm way that ensures compliance, and then go onto bigger assertiveness challenges in the future with confidence.

Somewhere on the scale

Clearly the 5th option is the one to aim for, and the best way I've found to illustrate this is by drawing a graph (see above illustration). There is a horizontal line halfway up the page to denote neutral: neither assertive nor unassertive. This may at first glance appear to be the goal, but this is not a line any of us should tread as it implies that one is not reacting to the world. The solid blue line is gross over-assertiveness and the solid red line at the bottom is gross under-assertiveness.

There is a horizontal line halfway up the page to denote neutral: neither assertive nor unassertive. This may at first glance appear to be the goal, but this is not a line any of us should tread as it implies that one is not reacting to the world. The solid blue line is gross over-assertiveness and the solid red line at the bottom is gross under-assertiveness. Over-assertive bombastic bullies tend to hover around the top of the page yet interestingly often have an Achilles heel (perhaps their mother!), which makes them topple helplessly on rare occasions into gross under-assertiveness. Under assertive people who hover down at the bottom of the graph often harbour resentment until the point that they can’t take it anymore and explode up into the top part of the graph, with moments of uncontrolled, over assertive behaviour. Others lurch precariously from the lowest part of the graph to the highest, sometimes in the space of minutes.

Choose when to be assertive

But none of the above are being assertive; the goal to being assertive is to ‘hover’ around the midline and ‘choose’, in any given situation, whether to be a little more flexible (very mild under-assertiveness could be better described as willing to go with the flow at that moment), and a little more assertive (which could be best described as being clear about one's wants/needs, and being able to articulate these to others).

Harbouring resentment

So how do you know whether you have the assertiveness dial turned to the right level? I think it is about how you feel internally. If you are feeling that you need to have your own way all of the time, have a controlling nature and go all out to get what you want in all situations, there is a significant risk you are in the over-assertive camp. If however you harbour resentments that your needs are not being considered, it is possible that you are in the under assertive area. It is very clear to me that doctors in general seem to be more in the under assertive group, and that this needs changing as a matter of some urgency.But it is hard to get assertive in the right place, especially in a busy role where demands just keep coming in the door and where they may even be a culture of non-assertiveness. It is however an increasingly important skill for coping with life as a doctor, and it is a skill that I have never seen being taught.

But it is hard to get assertive in the right place, especially in a busy role where demands just keep coming in the door and where they may even be a culture of non-assertiveness. It is however an increasingly important skill for coping with life as a doctor, and it is a skill that I have never seen being taught.

Being assertive is not a difficult thing to do once you know how, but any training for it needs to be applied in relation to the situation and the feelings of the person. Practicing with hot chocolate might be a good start for some, but on its own I predict this will rarely be enough to extrapolate into the complex relationships and discussions one has with patients or colleagues.

As part of our career planning process at Medical Forum, we often find that an ”assertiveness audit” is helpful with some tailored training directly focused on real issues. This can be an important part of getting work-life balance back to something remotely resembling sustainable. In fact, to do in-depth career planning requires that some part of the mind is free to do this. If the brain is constantly occupied with poorly addressed assertiveness issues, effective career planning will be an uphill struggle. Assertiveness is also key in protecting time, which is my topic for the next article.

This article first appeared in the April 2016 edition of The Sessional GP magazine.

Sonia Hutton-Taylor

Dr Sonia Hutton-Taylor is the founder of Medical Forum Career Management and the author of an ebook Easy career change - good career choice.

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