The good news is physicians are already programmed to manage conflict effectively — whether or not they know it. As trained clinicians, they utilize the same skills in dealing with patients every day — from analyzing their condition, to diagnosing the problem, to prescribing a course of treatment. “We’re trained in therapeutic assessment skills,” says Gerardi. “We use it to take care of our patients, but frequently fail to transfer those skills to our interaction with colleagues.”
The trick is learning to adapt those skills to engage in dialogue with your peers. As with all things, practice makes perfect. “The more experience you have with managing conflict constructively the better you are able to address conflict and work it out,” says Johnson. “The physicians I’ve seen who have learned to do that have moved mountains.”
One of the most important rules to remember is to keep your emotions in check. “Don’t approach a difficult conversation in a reactive mode,” says Johnson. “One real key mistake I see physicians make is talking when their emotions are running high. That puts the other person on the defense and creates a self-fulfilling prophecy of, ‘Oh, this can’t be resolved.’” Wait a few minutes — or days — before approaching the other physician so you can consider the problem more thoughtfully.
When you do engage your colleague, choose your words carefully. By starting sentences with, “You always” or “You never,” you’re generalizing and placing blame, which undermines dialogue. Another mistake to avoid? Never deadlock the debate by using a policy or protocol to defend your position. This makes it an all or nothing issue and closes the door to further discussion. “That happens often among physicians,” says Johnson. “It’s important to look at the thinking behind your position and theirs. An effective way of doing this is to simply ask the question, ‘What is your thinking about this?’ When you get to the root of the problem that’s when everything can move forward.”
Lastly, you can keep the discussion positive and constructive by acknowledging your own role in the dispute. Remember, it takes two to tango. “Everyone needs to explore their own contribution to the issue so there’s some give and take among both parties involved,” says Gosline. “Ask yourself, ‘What part did I play and what do I need to do differently to make this work going forward?’ That is very hard because typically what happens is attribution or blame, which is a defense mechanism. It requires some maturity to be able to look at our own contribution to the situation.”
In the most extreme cases, where physicians feel their trust has been violated, it works best to start small. “There are cases where you may so fundamentally distrust somebody that the last thing you want to do is suggest it’s probably your fault, or you don’t trust the other party to go through this exercise in a sincere way,” says Gosline. “In those circumstances, it makes sense to think carefully about what you want to say and figure out how many of these steps you can do without making yourself vulnerable. Sometimes these steps can uncover information that may help you understand the other person’s point of view and that can help heal some of that distrust.”
Her suggestion? Pick some issue on which you can find common ground and ask the physician to meet you halfway. You can start rebuilding trust by coming to minor agreements, Gosline says. “You see if that person will follow through on those and then try to move forward on that success. I’ve seen people’s darkest hour where they think a relationship can never be repaired, but it can be.”
For complex issues involving multiple physicians, or in cases where emotions are high, you may even consider bringing in a mediator for third party perspective — someone who can help you move beyond the hurt feelings and blame game to address the problem in a meaningful way.
Educate
Training your staff, formally or informally, to be able to handle tough situations respectfully is also key. “You need to create a common language that gives people who aren’t naturally comfortable with difficult conversations some sort of process,” says Richard Hart, a director with Proactive Resolutions, which provides global conflict management services.
Community colleges, professional associations, and independent practice consultants often offer conflict resolution courses. “There is an advantage to having everyone go through the same program at the same time so you have open dialogue as a workgroup around how these things are effecting you in the office,” says Hart.
Gerardi agrees, but notes physicians themselves must ultimately act as the role models for the group. “Conflict resolution can be learned like any other skill, but training is not enough,” she says. “We really have to be able to support people’s ability to engage dialogue by having practice leaders who themselves are competent and model the behavior they seek in others. They need to put in place a non-adversarial process for dealing with conflict.”
Indeed, in its report, The Joint Commission recommends all healthcare staff be trained on appropriate professional behavior defined by the organization’s code of conduct. The code and education, the commission adds, should emphasize respect and include training in basic business etiquette, including phone and people skills.
Practices should also hold all team members “accountable for modeling desirable behaviors and enforce the code consistently among all staff regardless of seniority or clinical discipline using positive reinforcement as well as punishment,” the commission’s report suggests.
Write it down
For his part, Charles Burger, a primary-care physician for Evergreen Woods in Bangor, Maine, developed his own “principles of practice” document in the 1970s, which is still used in his office today. “The best way we keep issues that are hard to deal with from falling into a finger pointing exercise is to have a clear idea of the mission we’re trying to accomplish,” he says. “It’s like bylaws for the practice and it defines our values and the relationship we want to have with our staff and each other. You have to have a unified mission that everyone can solidify around, something that defines who we are and why we are here.”
Among other things, the document stipulates that all problems “of major concern and any major system changes” require a formal write-up after an appropriate data gathering session. The write-up is circulated for comment prior to the next weekly meeting to facilitate decision making. It states that “personal conflicts between individuals are the responsibility of those individuals to resolve using appropriate conflict resolution techniques,” adding that facilitation is both available and encouraged and communication skill building is an essential aspect of all new employee training.
According to Burger, the development of such documents, or codes, is a useful exercise for more than determining how your practice will resolve conflict going forward. It can also single out physicians who may no longer be a fit with your practice. “I helped one other practice develop their own ‘principals of practice,’ and after they had spent a lot of time on it one of their physicians, who was on sabbatical during the process, came back and said, ‘You know, this isn’t a culture I want to be a part of,’” he recalls. “It can at times come down to that. It’s not right or wrong. It just doesn’t fit and that physician is not going to be happy trying to stick around.”
In the high-pressure practice setting, where physicians deal with life and death decisions, frustration and flair-ups are par for the course. You needn’t be best friends with your colleagues, of course, but for the sake of your practice — and your patients — you do need to have protocols in place to professionally address conflict. Better yet, establish processes to encourage an atmosphere of cooperation and open communication, which reduces tension to begin with. “You don’t have to like who you work with,” Gosline says, “but you have to be able to trust them to be professional.”
Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNN-Money.com, Bankrate.com, and Healthy Family magazine. She can be reached via physicianspractice@cmpmedica.com.
This article originally appeared in the July/August 2009 issue of Physicians Practice.
