Conflict management, prevention, and resolution in medical settings - Conflict Management

Physician Executive, July-August, 1999 by Louise B. Andrew

CONFLICT MANAGEMENT IS especially difficult for physicians to embrace, because most of us are highly confrontation adverse. This is not hard to understand if you look at "typical" personality traits of physicians. According to Vaillant (1) and Gabbard (2), physicians tend to be compulsive, perfectionistic, guilt-prone, with an exaggerated sense of responsibility, limited emotional expressiveness (especially with respect to anger), and significant communications deficits, in particular an inability to ask for help. We are workaholics and chronically over-committed.

Most of these attributes are highly adaptive to doctoring, reinforced by medical training and rewarded by society. And being over-committed gives us a very convenient (and societally condoned) mechanism by which to avoid unpleasant confrontations or controversy. Our attendance to the "jealous mistress" of medical practice, especially in today's increasingly demanding practice environment, leaves little time for physicians to learn and practice conflict management, an essential life skill.

Conflict management

Conflicts encountered by physicians In the workplace parallel, to a surprising degree, those experienced in their own families; and conflict resolution skills employed by most physicians mirror those that were modeled by parents or significant others at home (who had no idea they were being mentors while behaving instinctually--often at their very worst). Not surprisingly, the outcomes of our attempts at work-related conflict management based on these models are frequently mediocre and sometimes disastrous.

One extremely common technique used by physicians in their own families--namely, postponement (until the issue cools off) (3), in reality a nearly unassailable technique of avoidance--is even less successful at managing work related conflicts in the health care setting than it is in medical marriages. This is because:

1. Physicians can't avoid showing up at the practice site because of a "higher calling." This is the "higher calling!"

2. Maintaining collegial relations and collaboration is essential to ensure the safety and the highest level of care for patients.

Failure to confront and manage conflict

It is a shameful secret that nearly every health care administrator and almost all hospital staff can recall delays or inadequacies in patient care caused by a provider refusing to consult the "on call" physician or group for a problem outside of their area of expertise because of some unresolved past conflict between the physicians. Actually, it's no secret. Plaintiffs attorneys are always on the lookout for this particular result of physicians failing to manage conflict effectively (if at all). So failure to manage conflict can be directly hazardous to our own personal and professional well-being, as well as that of our patients and institutions.

When interpersonal conflicts in medical settings inevitably spill over into patient care or staff relations, physician executives and administrators are called upon to simultaneously put Out fires and resolve deep-seated conflict or long standing problems between providers--STATI This exercise is not only impossible, but can hijack hours if not days of valuable time from other significant endeavors, invariably at the worst possible time.

And, in reality, even physician executives generally lack formal training in conflict management. So typically, as administrators (who are assumed to have special expertise in dealing with physicians: after all, we are them) we do our best, under the most trying circumstances, and sometimes are successful at calming the waters--for a time.

But the toll on our organizations and ourselves, in terms of spectacularly unproductive time, unsatisfactory or only temporary resolutions, continuing or even escalating ill-will, and deteriorating public and staff relations is often significant both in monetary terms and in human costs. More than a few "Hostile Environment" discrimination claims by subordinates have sprung from institutions failing to manage conflict between physicians. In one large group practice that consulted us, the frustration of dealing repetitively with fallout from a longstanding blood feud between practitioners had resulted in the CEO's resignation.

Conflict prevention

The best way to manage conflict, of course, is to prevent it. Contracts are a common technique well established for this purpose by the business community, though their use is a surprisingly recent development in the medical profession. The essential skill of contract drafting by attorneys is an attempt to predict and define every possible contingency in the formal relationship, and for the parties to agree in advance to defined solutions.

A well-drafted contract can prevent some conflicts and prescribe the mechanism for dealing with others. This can be automatic (sanction specified in the contract), or require further processing, such as arbitration or mediation. In the absence of a specified alternative. courts will attempt to enforce the contract. But it is unrealistic to expect any contract to cover all the possible contingencies in any human relationship, nor would such a contract be enforceable for the simple reason that the cost of litigating issues not essential to the business relationship would be prohibitive. And if we are willing to be perfectly honest, many behaviorally based conflicts in medical settings are not the sort of things for which physicians (or administrators) would willingly visit a public courtroom--or even a lawyer. So what is an administrator to do?