Fight or flight?

Conflict may be uncomfortable, but it's a fact of life for hospitalists.

Several years ago, when a surgeon refused to see one of his patients in a timely manner, a frustrated Eric E. Howell, MD, FACP, decided to complain to the surgeon's boss, who forced the surgeon to comply. His actions permanently damaged his relationship with the surgeon, but Dr. Howell felt it was a fight worth picking for the good of the patient.

“The relationship was ruined but the patient might have died if I hadn't competed to win,” said Dr. Howell, chief of hospital medicine at Johns Hopkins Bayview Medical Center in Baltimore. The incident taught him a valuable lesson about dealing with conflict, he added: “Sometimes what's more important than the relationship is the actual outcome of the negotiation, particularly when it comes to patient safety and harm.”

Photo by Thinkstock
Photo by Thinkstock.

Hospitalists often face this kind of dilemma when a dispute arises with a colleague: Do you try to make everyone happy, or risk ruining a relationship to get what you need? Dr. Howell was driven to act in order to protect a patient, but other potential disputes may not be worth a fight, he noted.

“If the relationship is more important than what you're arguing over, then what [you] lose in accommodating [you] gain in building relationship capital,” said Dr. Howell, who has led several conference sessions for hospitalists on conflict management and negotiating skills.

Conflict may be uncomfortable, but it is a fact of life for hospitalists who must work with colleagues in every part of the hospital to coordinate patients' care. Instead of avoiding it, experts advise developing negotiating strategies that can turn conflict into a tool for positive change.

Know your negotiating style

Engaging in conflict with colleagues is really about managing relationships, noted Erik A. Wallace, MD, FACP, associate program director of the department of internal medicine at the University of Oklahoma School of Community Medicine in Tulsa. To be successful, you must know your own and your colleague's negotiating styles, he added, because “you can't be great at managing relationships if you lack self-awareness.”

Dr. Wallace, who led a session on conflict negotiation at Internal Medicine 2012, ACP's annual meeting, recommends using the Thomas-Kilmann Conflict Mode Instrument (see sidebar) to determine your dominant conflict management style among five categories: accommodating, competing, avoiding, compromising, and collaborating.

Your dominant style represents your natural tendencies in dealing with conflict, but you can still shift to other styles when necessary, Dr. Wallace noted, depending on the nature of the conflict or the importance of the outcome. Imagine, for example, that when you start your shift you discover a patient's nighttime insulin was not administered, he said.

“If I lacked self-awareness, my first response might be to blame the nurse, but a self-aware person might say first, ‘I'm typically pretty aggressive and I need to understand that going in to be effective. I need to investigate what's going on and manage my emotions.’ Then approach the nurse and ask questions,” Dr. Wallace said.

While it might turn out that the nurse simply forgot the order, a careful investigation might also reveal that the patient's blood sugar was too low or the insulin wasn't delivered on time to the unit or the patient refused treatment, said Dr. Wallace. “There's a whole list of possibilities. If the physician is receptive and understanding, the nurses may be more willing to come forth and explain what happened. But if he is perceived as aggressive and belittling, they may be reluctant to communicate when things don't go well,” he said.

Different situations dictate whether or how to modify your natural negotiating style. For example, it might be wise to avoid a potential conflict when there is a power differential, said Dr. Howell, such as between a staff hospitalist and the chief financial officer of the hospital.

“If I suspect he's going to ask me about a cost reduction program and I don't have that skill set, I may avoid him at first and enlist my physician boss before I engage in a conversation,” he said. “When you're dealing with someone with more power than you, it's wise to seek out someone else on the same power level, such as the chair of medicine, as your advocate who can either come with you to a meeting or tell you what your options are.”

Aside from deciding on a conflict management style, physicians should go into negotiations armed with objective data, said Kenneth G. Simone, DO, principal at Hospitalist and Practice Solutions, a national practice management consulting firm based in Veazie, Maine.

He recommended always separating the person from the problem and being prepared to consider alternative solutions in order to achieve a desired outcome.

Emotionally charged disputes can erupt when two groups have different incentives or motivations, Dr. Simone said. For example, conflicts often arise between emergency department (ED) physicians, who are under pressure to reduce patient wait times, and hospitalists, who are under equal pressure to discharge patients by midday, which may delay their response time in the ED.

“The admitting provider, the hospitalist, has a different goal or incentive than the ED physician,” said Dr. Simone. In order to avoid a major conflict, both sides need to reassess their positions and realize that they have a common goal: to best service the needs of the patient, he said.

Leading by example

Hospitalists have a leadership role in creating an environment conducive to resolving and managing conflicts, said Leonard J. Marcus, PhD, director of the program for health care negotiations and conflict resolution at Harvard School of Public Health in Boston and co-author of “Renegotiating Health Care: Resolving Conflict to Build Collaboration.” “They are required to build connectivity of effort among all others in the hospital—nurses, specialists, social workers, patients, families—to ensure high-quality, efficient care,” he said.

To foster that environment, he said, hospitalists must be prepared to put their own feelings or biases aside and help others when emotions take over during a conflict. For example, a decision to discharge a patient before either the physician or the family feels she is ready can cause everyone involved to feel threatened and go to their emotional “basement,” where raw emotion dominates, he said.

To move a conflict forward, the hospitalist must identify when others are in their emotional “basement” and take steps to get them out of that state. That might mean helping an older patient understand why patients are discharged earlier now than in the past and what supports she will have in the home to provide ongoing care.

Hospitalists' leadership role makes it especially important for them to know when and how to switch among different negotiating styles, said Dr. Howell.

“If you continually avoid and accommodate, for example, the real damage comes to your effectiveness as a leader,” he said. “People will start to walk all over you. They will always negotiate with you and take what you have. If you avoid, you can be seen as passive-aggressive and you will lose the trust of people you are leading because they become frustrated with you.”

While avoiding a potential conflict or difficult situation often seems like the easiest solution, the resulting unresolved feelings can have lasting repercussions, said Dr. Wallace. “When those feelings stew and fester for a long time, people aren't happy or satisfied with what they're doing. But if you engage in the hard conversation, you can move on with your life,” he said.

Successful conflict management is also integral to a successful career, said Dr. Marcus.

“Often people view the role of the hospitalist in terms of what they bring to clinical care, but one very important parameter of success is understanding social care in hospitals,” he said. “It's the combination that is so powerful—those who have top clinical skills with the capacity to engage in a complex social environment will be the most successful leaders within their institution.”