How to shape positive relationships in medical practices and hospitals - Part 1: Conflict Management

Physician Executive, July-August, 1999 by Wayne M. Sotile, Mary O. Sotile

THE PHYSICIANS IN PRACTICE Y are notorious for their unruly behavior. Nurses complain about their temper tantrums and verbal abuse. They make inappropriate comments in front of patients and are generally uncooperative and competitive with each other and with hospital staff. Two physicians in practice Y have been accused by nurses of sexual harassment. Not inconsequential is the fact that a substantial proportion of hospital X's gross revenues come from the work of this highly productive, 14-member practice. Finally, under threat of boycotts by staff, the director of nursing at the hospital turned to the vice president of medical affairs for help in intervening with practice Y.

As a physician leader, how would you handle this situation? What would you want your organization to do? Your peers?

Managing workplace conflict is one of the most important, stressful, and time-consuming tasks faced by today's medical leaders. Approximately two-thirds of nurses surveyed report being the target of verbal abuse by physicians at least once every two to three months. (1) Our clinical and consulting experiences with nurses and hospitals suggest that many nurses believe that these data far underestimate the prevalence of this problem.

Poorly managed workplace conflict can alienate patients, demoralize staff, increase turnover, damage relationships with valued referral sources and third party carriers concerned about patient satisfaction, and lead medical practices to costly corporate divorces." Rude, discourteous behavior on the part of the medical staff also increases the risk of litigation from offended patients or staff. And failure to appropriately manage such offenders puts medical administrators and hospital systems at risk of being found liable for negligent retention and vicarious liability. (2)

Moving from conflict management to stress resilience

Physician executives cannot solve the problems caused by disruptive doctors simply by bolstering their own conflict management skills or by policing offenders. The larger contexts within which inappropriate workplace behavior occurs must also be assessed and addressed. The true leadership challenge is to intervene in ways that help to foster a "culture" of appropriate interpersonal dynamics throughout your organization. This requires learning to think and to intervene systemically.

Think "systems"

"Temper-tantruming" physicians may be unaware of the interpersonal consequences of their behavior. (3-5) But mismanagement of relationship dynamics is not the sole domain of physicians. These days, health care professionals of all sorts tend to evidence a coping paradox: (6) The very skills they learn in order to manage their busy, stressful lives damage their relationships; and as relationship tensions mount, they redouble their use of these same coping strategies, only to beget further relationship tensions. For example, we develop the habit of multitasking--doing and thinking more than one thing at once, even while trying to converse with others. We acclimate to chronic rushing and abruptness when dealing with others. Often, we adopt competitive, controlling. and/or cynical attitudes that fuel suspiciousness, impatience and intolerance of individual differences.

In addition, it has been noted that health care professionals may passively or passive-aggressively "resign" from forthright participation In relationships that they cannot control. (7)

In these ways, any member of your organization--not just a disruptive physician--may contribute to mismanaged conflict. The result can be an unsafe work environment that depletes the coping reserves of your organization.

Figure 1 shows how, when people in positions of authority behave inappropriately, two things tend to happen: (1) The targets of the inappropriate behavior are made to feel afraid, intimidated, and angry; and (2) these same "victims" may react with passive and/or passive-aggressive responses that perpetuate further conflict. Soon, both parties are contributing to a dysfunctional dance of perpetual conflict. (8)

Passive reactions to unresolved conflict

To avoid yet another verbal attack by Dr. X, Nurse J. decides to take the risk of relying on her own medical judgement, rather than continuing to request clarification of orders she does not fully understand. The dangers involved in this passive reaction to her conflict with Dr. X do not go unnoticed by this nurse. But she justifies her actions in this way: "Dr. X has cursed me and called me stupid one too many times. From now on, I'll just give it my best guess as to what he means when he writes orders. It makes me uncomfortable; but not as uncomfortable as I feel when he yells at me. I've been through enough hard stuff in my life--I'm certainly not going to go out of my way to get yelled at."

Passive reactions to conflict sometimes takes another form, one that complicates medical staffing needs. (9) We have repeatedly observed health care professionals (including physicians) exercising passive control by missing work on days when the schedule dictates their working closely with people who intimidate them or who otherwise make them uncomfortable.