The six physicians at a rapidly growing surgical group in the Pacific Northwest knew they needed to modernize to remain competitive. But that’s where the agreement ended. Some doctors were prepared to incur the expense of a new EHR. Others were not. A few were focused on team-oriented patient care; most were reluctant to surrender their autonomy. “They were having operational issues and some wanted to address it, but others were less enthused,” recalls Chuck Kilo, a physician and chief executive of GreenField Health, a primary-care practice in Portland, Ore., which also provides consulting services. “The practice had three or four different offices and the doctors were treating patients in at least that many hospitals so they were all carting their charts around in their trunks. Scheduling was a nightmare. They could talk about implementing an EHR, but they could not address their other management issues, because it was so intimidating to them to think about opening that can of worms.”
Unable to discuss their challenges without ruffling feathers, let alone reach consensus, the physicians were never able to decide how best to forge ahead. “To this day, they’ve still not addressed it as effectively as they need to,” says Kilo, noting at least one surgeon has since left the group. “It creates not just organizational inefficiencies but ongoing headaches and heartaches when you don’t confront business challenges head on in an open fashion.”
Such scenarios are all too common in medical practices, many of which still adhere to an “eat what you kill” business model. “Everyone is financially dependent upon themselves and that creates an environment of relatively immature organizational structure and leadership systems,” says Kilo. “Autonomy is a critical part of our culture, but it’s not conducive to the give and take necessary [to resolve conflict].”
The other leading reason doctors fail to engage conflict, of course, is the natural tendency to avoid difficult conversations, be they interpersonal or those involving the business itself, because of fear it will breed ill-will. Big mistake, says Barbara Johnson, vice president of development and organizational change for TransforMED, a subsidiary of the American Academy of Family Physicians that helps practices adopt the patient-centered medical home model of care. When conflict isn’t openly addressed, it “goes underground where it is much more difficult to manage,” she says. “Conflict is a continuous part of work places and it’s become an increasingly important topic as practices move from being physician-centered to being team-centered.”
Physicians, she notes, are increasingly being called upon to coordinate the continuum of care for patients across the entire healthcare system and as such “need to learn how to recognize constructive versus destructive conflict resolution” and find ways to prevent conflict to begin with.
Why it matters
The consequences of failing to do so are almost too numerous to name. For starters, conflict avoidance creates a culture of toxicity in which practice leaders set the stage for unprofessional conduct. By allowing frustrations to fester, physicians (and all members of the staff) are far more likely to erupt out of anger. That, in turn, leads to costly employee turnover. “Nobody likes to work in an environment where conflict exists so you end up losing your best people because those are the ones who have the ability to go someplace else,” says Ann Gosline, an attorney and mediator with Gosline & Reitman in Litchfield, Maine, which specializes in dispute resolution.
At the same time, an inability to confront challenging topics — and one another in a professional manner — weakens the organization’s ability to handle external pressure and exposes the group to the threat of lawsuits from disgruntled patients and employees. “Practices can’t address changing circumstances and deal with tough times when they lack the ability to communicate with each other,” says Gosline.
There’s also patient safety to consider. “When there are ongoing conflicts that go unresolved we tend to develop barriers to communicating with each other, and that impacts whether someone will have conversations with their colleagues,” says Debra Gerardi, a registered nurse and president of healthcare dispute resolution firm EHCCO, LLC in Half Moon Bay, Calif. “It leads to a lack of trust so practitioners tend to work around each other instead of with each other, which impacts both quality and safety of patient care.”
Indeed, in its 2009 leadership standards for conflict management, The Joint Commission urges healthcare organizations to address behavior problems that threaten the performance of the team — including everything from intimidation, verbal outbursts, and physical threats to more passive behaviors like refusing to perform assigned tasks or uncooperative attitudes during routine activities. Such actions, the commission notes, can “foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication and a collaborative work environment.”
Business challenge blockades
Some of most common sources of contention in a medical practice include differences of opinion over practice direction or capital expenditures, which frequently occur when a practice merges or expands. That can include decisions over whether to raise staff salaries or let someone go, how to govern the group, or whether to purchase an EHR. “These are circumstances where the practice needs to change the way it does business, which involves complex problem solving,” says Gosline. “There is a need for the physician partners to figure out together how to address that issue.”
When facing such decisions, physician leaders should set aside time to address the matter without distraction. “Don’t try to discuss it on the fly,” says Gosline. “It’s also worthwhile to spend a few minutes agreeing on the problem. It’s surprising how often people jump into throwing out solutions, and the reason they can’t ever agree is that there’s not been an agreement on what the underlying problem is.” Throughout the meeting, be sure to keep the discussion as open as possible to encourage creative solutions — especially if you’re inviting input from all members of the staff. “Be open to hearing some great ideas from places you didn’t think you were going to hear them,” says Gosline. “People should feel sufficiently free to put ideas on the table without having someone dismiss them. You want to bring in everybody’s collective brainpower.”
Play defense
Regular meetings, in fact, are a great way to preempt the discord. Charles Cutler, a general internist with Norristown Internal Medicine near Philadelphia and fellow of the American College of Physicians, avoids conflicts with his partner of about 30 years by talking regularly, “so things don’t fester under the surface to the point where there’s hostility or anger between us,” he says. “We meet weekly to discuss whether the patients are being taken care of and whether something got missed.”
At the same time, practices should govern themselves in a way that gives staff input into key decisions, but ultimately empowers a decision-maker to act in the best interest of the group. “You need to decide as a group how you’re going to make decisions going forward,” says Johnson. “A lot of conflicts happen because there’s no structure, which creates power struggles.”
For example, you might agree that for issues involving overhead, compensation, patient flow, or overall mission the group will be granted a week’s time to offer input upon which the decision-makers will render their final decision. “Often physicians blend the boundary between making decisions and gathering input,” says Johnson. “Make it clear to everyone how things are done. When you introduce the right tools it’s amazing how it reduces conflict.”
Interpersonal disputes
Though business problems can be vexing, interpersonal disputes are far more challenging. Disagreement between physicians may arise in the wake of a negative patient outcome, which must be resolved first with the patient’s family and then internally among the physicians.
In other cases, it’s a personality clash, where one physician may feel that another has taken advantage of him or acted unethically. “Those are the conflicts that require extra care and preparation and they are the most difficult of all to address, but it’s incredibly important to address them because they fester,” says Gosline. “Next to our family, working relationships are the closest relationships we have in this world so the sense that one has been betrayed is incredibly difficult and painful to overcome.”
