Contrary to popular belief, conflicts are not necessarily bad. In fact, conflicts can spark discussions that can lead to improved processes and quality care. They also can help open lines of communication among practitioners and between physicians and patients.
Of course, not all conflict is positive and discord can be detrimental to patients and to relationships in the hospital. It behooves hospitalists to understand how to resolve conflicts constructively and communicate effectively in emotionally charged and controversial situations.
When resolved effectively, conflicts can lead to positive changes, process improvements, and enhanced quality, says Leonard Marcus, PhD, founding director of the Program for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health (Boston). In fact, conflict sometimes is necessary because it:
- Raises and resolves problems;
- Focuses change efforts on the most urgent and appropriate issues;
- Motivates people to participate in efforts to create positive changes; and
- Helps people learn to benefit from and recognize their differences.
Conflict is problematic when it:
- Hampers productivity;
- Lowers morale and/or hurts relationships;
- Creates more and continued conflicts; and
- Causes inappropriate and/or dangerous behaviors.
Conflicts often arise from everyday occurrences. Poor communication is one of the most common causes of disputes. However, conflicts also may result from insufficient resources, personality clashes, and leadership problems (e.g., inconsistent, missing, dictatorial, or uninformed leadership).
—Peter Prendergast, MD
Anatomy of a Conflict
A primary care physician, Dr. X, tells a patient, Mrs. Y, that she needs to be admitted to the hospital. If the hospitalist examines Mrs. Y and agrees that admission is necessary, there is no conflict. However, if the hospitalist determines that Mrs. Y doesn’t need to be admitted, the potential for conflict is ripe.
“This can create real tension,” says James W. Leyhane, MD, hospitalist director at Auburn Memorial Hospital, N.Y. “The hospitalist can find himself facing a conflict with the patient or the physician—or both.”
These situations can be highly charged and difficult to resolve. “Sometimes the person is adamant that he or she wants to be admitted,” says Dr. Leyhane. “And the stronger the relationship the patient has with the primary care physician, the greater the resistance they may have to what you are saying.”
The most common approach Dr. Leyhane takes to such a situation is to get on the physician’s side. “I will say something like, ‘I understand why Dr. Jones thought you should be admitted. However, after further examination, we now realize that admission is unnecessary,’” he explains.
Once the hospitalist addresses any anger or frustrations patients feel, most are relieved to avoid a hospitalization. But sometimes this approach doesn’t work, and some patients still insist on being admitted. In those cases, Dr. Leyhane will appeal to their pocketbook instead of their emotions. “I will tell them that I can admit them if they insist,” he says. “However, someone else will review their chart for insurance purposes, and they will have to pay out-of-pocket for the stay because it is not medically necessary. This is very persuasive.”
When Hospitalists and Attendings Clash
When such situations create conflict with physicians, they must be addressed carefully and resolved promptly. Dr. Marcus suggests that such conflicts can be minimized or eliminated altogether when “physicians negotiate expectations of their relationships” up front. “It is best for attendings and hospitalists to be communicating on an ongoing basis and understand each other’s positions before situations occur,” he offers.
Peter Prendergast, MD, chief hospitalist at St. Joseph’s Hospital and associate professor of Medicine at SUNY Upstate Medicine Center in Syracuse, New York, suggests that conflicts with physicians in these situations are not common. “Physicians overwhelmingly understand that we have more information by which to make admitting decisions,” says Dr. Prendergast. “We just need to make sure the patient understands that the physician makes the best possible decision with the data set he or she has and that we have access to more information and assessment tools and may draw a different conclusion.”
Nonetheless, Dr. Prendergast acknowledges that there are other situations that present the potential for attending-hospitalist conflict. “You may run into a problem with the primary care physician when the patient presents with a medical problem that previously was treated in the hospital that now is treated on an outpatient basis,” he notes.
Dr. Leyhane offers another common conflict with attendings. “Sometimes the physician will order a test or procedure that will not be reimbursed because it is unrelated to the patient’s reason for admission,” he says. “When this happens and the patient gets the bill, he or she is unhappy with the hospital and not the attending physician.”
These situations generally occur because the physician doesn’t realize that a service isn’t reimbursable or that a protocol has changed, Dr. Prendergast stresses, and not because the practitioner is being stubborn or contrary. Nonetheless, it presents a conflict.
“You need to let the physician know that there has been a change in treatment standards or that there is a reimbursement issue. Once he or she has the facts, you aren’t likely to have another problem,” says Dr. Prendergast. “The physician needs to get a phone call or at least a note in a timely manner.”
Dr. Marcus actually advises that hospitalists talk with the physician before communicating any information to the patient that conflicts with what the doctor has told him or her. “Otherwise,” he observes, “the conflict already has escalated.” Physicians, he says, don’t want to hear about a difference of opinion after the fact.
Roger Gildersleeve, MD, administrative hospitalist at Augusta Medical Center, Fishersville, Va., says conflicts with patients or family members are common situations for the hospitalist. “You may see conflicts when there is a disconnect between the patient’s or family’s expectations and the realities of the patient’s prognosis and outcomes,” he says. “We spend a lot of time trying to bring these two things closer together.”
One key to resolving these problems is to make a quick study of the situation. “You usually can read patients and families—by their body language and facial expressions—when you enter the room,” says Dr. Gildersleeve, “and you can detect tension and hostility.”
Dr. Prendergast agrees. “When you see patients and families in certain situations—such as 2 a.m. in the ER—you can make some reasonable assumptions about what they are thinking or feeling,” he says. “You can predict what these people’s concerns are, and you can address them even before they ask. Acknowledging their position and concerns is important.”
When possible, preparing for family and/or patient encounters can make a difference. “Before seeing a new patient, I try to learn as much as I can about him or her,” says Dr. Gildersleeve. “We have a good computer system, so it’s pretty easy. I use some of what I’ve learned in my opening comments, and this gives patients and families more confidence in me and my ability to deal with them as individuals.”
This is especially important for hospitalists, who have to establish patient relationships in a relatively short period of time.
Of course, it is impossible to prevent or avoid all conflicts. “To some degree, conflicts are inevitable,” says Dr. Marcus. “It’s the nature of medical practice.”
When conflicts occur, many of them can—and should—be resolved before they escalate into a dangerous confrontation or litigation. Listening is key to resolving conflicts quickly. “By listening, you can prevent a lot of conflicts from escalating or even starting,” says Dr. Prendergast. “We teach our physicians to listen, then repeat back what they heard—‘I’m hearing that you’re upset because … .’ If you get it right, the person knows that you are listening and that you understand their concerns. If you miss, they are likely to state their concern directly.”
Dr. Marcus believes conflict resolution may be particularly effective and satisfying when interest-based negotiation (IBN) is employed. IBN is a problem-solving strategy that focuses on satisfying as many interests or needs as possible for all involved parties. Because this technique addresses people’s needs and interests and separates people from the problem, it enables the parties to reach an integrative solution rather than creating a win-lose situation.
IBN enables those involved in a conflict to work together to reach a mutually satisfactory conclusion. The technique commonly results in creative and durable solutions, as well as enhanced relationships.
Conflict resolution efforts are more likely to fail, says Dr. Marcus, when the physicians and others involved apply position-based negotiations. With this conflict-management method, the parties argue only their positions, and their underlying interests may never be stated explicitly or understood. People are more likely to reach an impasse when they employ position-based negotiations, and they are more likely to see the situation as having a clear-cut winner and a loser.
“When you negotiate based on positions,” explains Dr. Marcus, “that is when situations are likely to escalate.”
While clear hospital policies and procedures can help resolve or prevent some conflicts involving physicians, more layers of policy are not necessarily the answer. “I think the time it would take to establish these policies would be better spent developing pathways for easier and better communication,” says Dr. Gildersleeve. “You see few of these hospitalist-physician conflicts when there is good communication between all the players.”
Professional mediator Pat Costello suggests that policy changes actually can help resolve some disputes. “Continued conflicts might suggest a need for a policy change or a new policy,” says Costello. “I have mediated a lot of situations that were resolved by policy changes.”
15 Seconds to Make an Impression
Hospitalists must remain cognizant of mistakes they can make that actually exacerbate conflicts with patients and families. “When physicians use an overbearing approach, they can’t accomplish as much,” says Dr. Marcus. “You have to take care to treat patients and families with care and concern and the same respect they afford their colleagues.”
It is important for hospitalists to be aware of how they come across to others, stressed Carole Houk, Esq., president of Carole Houk International, Alexandria, Va.
“You make a snap judgment of whether or not you like someone in about 15 seconds,” says Houk. “Studies show that physicians who use a dominant tone of voice are more likely to be sued than those who don’t.
“Explain what happens and why—and put a lot of focus on your tone of voice,” she says. “Rather than coming down imperiously, reach out to patients in a compassionate way. You need to be seen as someone with a heart and not a gatekeeper for the insurance company.”
When Hospitalists Can’t Resolve a Conflict
Unfortunately, some conflicts can’t be resolved easily. While hospitalists require some conflict resolution skills, they must also be willing and able to recognize when they need assistance. For example, suggests Houk, “We have ombudsmen in some hospitals who serve as conflict coaches. They are trained for this purpose. Hospitalists and others can go to these people for help resolving conflicts.”
Elsewhere, she notes, “We are training risk managers on conflict skills so that they can help resolve disputes in their hospitals and serve as informal mediators.”
On rare occasions, it may be necessary to seek the involvement of an independent professional mediator. Mediator Costello says this might be necessary in instances where there is an ongoing and escalating lack of communication, repeated conflicts (despite attempts to resolve them), physical altercations or threats of violence, and/or imminent risk to a patent’s safety.
While there may be conflicts that hospitalists cannot resolve, overall they are well equipped to communicate effectively in a way that minimizes disputes. “Many of us were attracted to this profession because of the opportunities and challenges of working with a wide range of situations and colleagues,” says Dr. Leyhane. “We know that communication skills are important, and we get a lot of practice during our interactions with physicians, families, patients, administrators, and ancillary staff.”
Houk agrees: “This field seems to attract people with big hearts. They understand the importance of understanding and acknowledging the needs and feelings of others.” TH
Joanne Kaldy writes regularly for The Hospitalist.