In medicine — and any workplace — conflict is inevitable, and professionals can end up spending time tending to their wounds instead of the actual business at hand. How leaders deal with clashing viewpoints is critical.
If one thing is absolutely certain in the high-pressure and high-stakes world of medicine, it’s that mistakes, misinterpretations and misunderstandings are unavoidable. In the operating room or in a meeting room, conflicts are certain to boil up — sometimes at the worst possible moment. People wind up second-guessing themselves and others, and they spend time combating each other rather than working toward common goals. The consequences can be severe. Conflicts can undermine morale, torpedo productivity and, most important, affect patient care.
Conflict can be uncomfortable, but it isn’t necessarily a bad thing. It can provide insight into processes and performance that can be improved. Open thinking, good communication and cooperation are essential for turning conflict into improvement.
The flashpoints for conflicts are broad, and they aren’t always easy to identify. While most clashes are likely to occur among doctors and other medical practitioners as they interact with one another daily, administrators can wind up in conflict with staff and even create tension and stress through policies, behaviors and actions. Patients, too, can introduce numerous flashpoints for conflict. Their ideas and expectations about therapies and procedures can vary from what practitioners consider appropriate. In addition, they might believe they’re not receiving the attention they deserve.
Yet, conflict isn’t necessarily a bad thing. It can provide feedback about things that can be improved. In fact, when it’s channeled effectively, an organization can use conflict to improve processes and performance.
“Medicine is based on good human relationships,” says Carlos A. Pellegrini, MD, chief medical officer and vice president of medical affairs at UW Medicine in Seattle. “It’s critical to build respect into the fabric of an organization. People must be able to present ideas — and sometimes disagree — in a respectful and productive way.”
The goal, he says, is to encourage open thinking, good communication and cooperation. This results in delivering the best possible care to patients.
Although stress and pressure are part of every profession, there’s no denying that medicine is unlike any other field. Physicians and other health care professionals work in high-pressure but highly collaborative environments. They make decisions that affect people’s lives. Sometimes, different groups — doctors, nurses and technicians — have different ideas about how to apply medicine, or they conflict over basic issues such as scheduling. Adding to the challenge: Research and technology have unleashed major changes in medicine, many health care organizations operate on razor-thin margins, and constantly shifting government regulations translate into changes in policies, procedures and treatments.
All of this sets the stage for ego battles, confrontations and full-blown conflicts. In the heat of the moment, hostile words, second-guessing, belittling statements and passive-aggressive behavior can ensue. A 2016 study reported in The BMJ (formerly the British Medical Journal) demonstrated that 70 percent of preventable medical errors occur from miscommunications and poor teamwork. “Every time there’s a conflict within an organization, it incurs a cost in some form or another,” says Barry C. Dorn, MD, FACS, MHCM, associate director of the National Preparedness Leadership Initiative at the Harvard T.H. Chan School of Public Health and co-author of Renegotiating Health Care: Resolving Conflict to Build Collaboration.
Interpersonal conflicts typically revolve around one of four scenarios:
- Personal differences.
- Informational deficiency.
- Role incompatibility.
- Environmental stress.
Too often, combatants don’t know how to deflect an act of hostility or aggression, recognize when they are engaging in unacceptable behavior, or apologize for a rude comment or brief outburst, Dorn says. The common denominator is that communication breakdowns can trigger alarming and disturbing outcomes, including loud and inappropriate arguments, crying, depression and people walking off the job. It can also lead to dissent and discord that forces chief medical officers and other health care leaders to spend valuable time patching up differences — or hiring new staff.
“Today’s environment creates a predictably unpredictable situation. This adds to the already-high potential for conflict that exists in health care,” says Leonard J. Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard T.H. Chan School of Public Health and co-author of Renegotiating Health Care: Resolving Conflict to Build Collaboration. Although the days of doctors standing as supreme authorities who cannot be questioned by other health care practitioners are over, there’s still a tendency among some physicians to apply a dogmatic and authoritarian approach. However, “decision-making fails miserably when there’s too little input,” Marcus adds. “Decision-making must take place in an inclusive way.”
While it’s tempting to focus on overt hostility and acts of aggression, UW Medicine’s Pellegrini also points out that conflict can result from insidious and subtle behavior that might occur unwittingly. He describes a scenario: “A patient is waiting in an exam room for 30 minutes, gets upset and grumbles to the nurse. The nurse lets the doctor know. When the doctor finally steps in to see the patient, he says: ‘I’m sorry I’m late. Nobody told me you were in here.’ What the doctor has done is undermine the nurse and the entire health care system,” he says.
For a patient, this response can reinforce any notion that medical professionals aren’t particularly concerned. A better tack, Pellegrini says, is to show that the doctor cares by issuing a sincere apology and stating that things simply did not work out according to plan.
In one instance, he says, this exact situation unfolded on a day Pellegrini doesn’t normally see patients. He was busy typing notes in an office when a nurse informed him a patient was waiting and had become agitated. “I stepped in and apologized profusely. I explained that I considered his appointment extremely important and that’s why I had scheduled him on a day that I normally do not accept patients,” Pellegrini recalls. “I told him that things did not operate how they normally do. He was visibly upset when I walked in but calm and appreciative when he left.”
While the concept of good communication is simple enough to understand, establishing a framework to support it — and deal with inevitable problems — can prove daunting. At DaVita, a major national provider of kidney dialysis treatments, Robert Provenzano, MD, FACP, FASN, chief medical officer of Nephrology Practice Solutions and vice president of medical affairs, starts with the thinking that “it’s OK for conflict to occur. But you have to design the parameters by which people address conflict so that you can turn it into a positive force.”
DaVita has developed structured processes to short-circuit conflicts across more than 2,500 locations with 65,000 employees. Any employee can send an email to the firm’s CEO with a question or concern. There are also regular face-to-face meetings with supervisors and managers to discuss concerns and problems. There are specific rules of engagement, including how people should communicate with one another and how to deal with concerns and difficult situations. And the company provides training to practitioners and staff about how to manage conflicts with patients as well as other employees.
One important factor is that any staff member can call “time out” if he or she thinks things are going in the wrong direction. This puts any decision on pause and starts a discussion that follows set rules. “When you slow things down just a bit you open the channels of communication,” Provenzano explains. “You empower people and patients, you build trust, and there is less of a chance of an issue blowing up. An authoritarian style is a dangerous approach to patient care. It’s important to look at the data and consider the expertise of other professionals.”
UW Medicine has adopted a similar approach. Pellegrini says nurses, residents and others are encouraged to question anything and everything that doesn’t seem right and request an explanation for anything they don’t fully understand. There are no exceptions and if anyone speaks up, everyone in a group must listen and participate. “The philosophy we promote is that it isn’t your right to question things that are taking place, it’s your obligation to do so. We want to avoid errors and mistakes. It’s important for everyone to understand that we’re all trying to support each other and take care of the patient in the best way possible.”
Formal training methods also help equip staff with tools to better navigate conflicts. For example, UW Medicine focuses on a teamwork-based training framework called Team Collaboration for Organizational Excellence, or TeamCORE. It revolves around four key principles: leadership, situational awareness and monitoring, communication and an emphasis on mutual support. Hundreds of practitioners have participated in the program, which has generated valuable feedback that led to process improvements, including how doctors and nurses handle daily rounds. As a result, UW Medicine has boosted productivity, reduced conflicts and improved patient satisfaction scores.
At University of Utah Health Care, which has more than 1,400 physicians and 5,000 health care professionals, a variety of training methods are used to improve communication and reduce destructive conflicts. One program relies on live actors to role-play with staff so they can learn coping skills and de-escalation techniques. “We have worked to develop a framework where physicians, nurses and social workers have tools for carrying out conversations and resolving problems,” explains Edward B. Clark, MD, associate vice president for clinical affairs at University of Utah Health and president of the University of Utah Medical Group. “Adversarial behavior not only erodes the esprit de corps, it actually increases risk for patients and for the chance of errors.”
When Thing Go Wrong
Of course, no amount of training can prepare physicians and other staff for every possible situation. “There is absolutely no way to eliminate conflict from health care or any other aspect of business or life,” says Jeff Boss, a former Navy SEAL and leadership coach who specializes in conflict resolution through his firm, Chaos Advantage.
Boss, author of Navigating Chaos: How to Find Certainty in Uncertain Situations, says it’s crucial to identify people who are toxic and then disarm these “social hand grenades.” This may involve private discussions or mediated face-to-face discussions between conflicting individuals and groups.
“Sometimes, people aren’t aware of how they come across, and simply discussing the matter with them makes a difference,” says Boss, who works with health care firms. “If you get people together and get things out in the open, it often defuses the problem.” However, if a person continues to cause problems, it might be necessary to take more drastic steps. As people become frustrated and the culture of an organization begins to shift toward disrespect and dysfunction, the bad behavior often metastasizes and becomes more common — and even normalized. “Conflicts snowball and create additional conflicts. At some point, management may find itself running around and attempting to stamp out one problem after another,” he says.
It’s a topic that’s taken seriously at University of Utah Health Care. When a serious conflict occurs at the institution, a physician and a nurse or social worker typically meet with the patient or medical professional to discuss and explore the problem. Both are trained to listen carefully, provide feedback and guidance, and watch for signs that a person is becoming agitated. If a physician or other practitioner is the source of too many conflicts or undermines morale on a regular basis, Clark prescribes counseling and coaching. He also has found that transferring a person to another department can help, in some instances.
In a worst-case scenario, bad behavior can result in a request for resignation or termination. As Provenzano explains: “If a person is in conflict on a regular basis and he or she doesn’t respond to counseling and coaching, then it’s in the best interest of all parties to move on. If a person can’t cope with the pressures and stress of health care, it’s not the right profession.”
Pellegrini says he first attempts to identify whether there’s an alcohol, drug dependency or personal problem involved. If so, he works to help the physician or other professional get back on track and he may request the person take a leave of absence. “We try to do everything possible to provide support before we get to the point where it’s necessary to part ways.”
To be sure, developing a culture that places a premium on trust, honesty and good communication is an ongoing challenge. It requires that leaders model, support and reward good behavior and put programs and procedures in place to stamp out destructive and dysfunctional interactions. Yet, when a health care organization builds a solid framework for communication, the results are often impressive: physicians, nurses and other staff are happier and more productive, patient care improves, and financial metrics rise. Concludes Harvard University’s Marcus: “The ability to work through conflict is crucial. It can have a profound impact on performance and outcomes.”
Samuel Greengard is a business and technology journalist based in Oregon.