Medicolegal Issues

Medical Mediation


How many conflicts do you witness during your average shift? How many are you embroiled in? Are any of them resolved amicably? How many can you resolve?

“Everyone does conflict resolution on some level,” says Leonard J. Marcus, PhD, director of the Program for Health Care Negotiation and Conflict Resolution, Harvard School of Public Health in Cambridge, Mass. “If you’re in a relationship, if you have kids—we all do it. The difference is that hospitalists do it as part of their professional work, and that requires a different level of complexity.” Dr. Marcus teaches conflict resolution skills in SHM’s Leadership Academy.


Take a Walk

In their book, Renegotiating Health Care, Drs. Dorn and Marcus outline the phases of conflict resolution as “a walk in the woods”:

  • Self-interests: Understand what motivates each stakeholder;
  • Enlarged interests: Examine what they agree on and disagree on;
  • Enlightened interests: Explore creative, imaginative solutions to divergent problems; and
  • Aligned interests: Provide mutual benefits and mutual successes, generating agreement with buy-in.—JJ

Everyone’s Best Interest

Dr. Marcus’ colleague and associate director of his program is Barry C. Dorn, MD, MHCM. Dr. Dorn clarifies: “Conflict is not bad. But unresolved conflict can be costly.”

A good leader can—and should—resolve problems on his team for the sake of the team, the project or work, and the hospital. Understanding that is easy—it’s how to end the problem that can be tricky.

“There are two poles to conflict resolution,” explains Dr. Marcus. “Positional bargaining is the adversarial win-lose approach to problem solving, and many people believe that’s the only way to resolve a conflict. However, interest-based negotiation focuses on what different people want to accomplish. It’s what we call a collaborative, cooperative approach—it’s gain-gain negotiating.”

How Hard Can It Be?

As Dr. Marcus says, everyone resolves conflicts. So is training in how to go about it really necessary?

“Absolutely,” asserts Dr. Dorn. “[Hospitalist leaders] need some sort of training, though a lot of it can be self-taught. I think this training is the most important thing a physician can do. The stresses and rapid changes in healthcare today make people crazy. It’s not just hospitalists—all physicians have conflicts with other groups. That conflict takes its toll; it’s a tremendous waste of time and energy. And it’s very costly to an institution to have people constantly at odds.”

Dr. Marcus agrees. “Given the role of the hospitalist, having specific skills training in conflict resolution is a huge plus,” he says. “They regularly face challenges in engaging other departments and other physicians, which can lead to turf wars and territoriality. They have to go beyond the simple ability to resolve conflicts and get to the core of the issue quickly. That’s where the training comes in.”

Conflicts among Peers

To further complicate the conflicts they face, hospitalists often find themselves managing a group of peers as committee chairs or lead researchers. They don’t have the title or authority to tell fellow hospitalists, other physicians, hospital staff, and administrators what to do. This can lead to some delicate conflict resolution.

“They’re dealing with people who lead individual silos within the healthcare system,” says Dr. Dorn. “And when someone else wants to step into their silo, it makes you and them uncomfortable. Leaders have to make others feel comfortable and learn to speak their language. Hospitalists have to lead across silos as well as within their own silo [of hospital medicine]; then they have to lead up, because hospital administrators have a lot of control. There are many nuances to leadership.”

As group leaders, hospitalists may face a wide range of conflicts, says Dr. Marcus, “from differences of opinion to resistance to downright draw-the-line-in-the-sand and get out of my way. The other piece is that some issues are clinical, whether between physicians, between physician and patient or family member, and some are administrative or managerial. Hospitalists are at the hub of all those issues; they serve as the fulcrum.”

According to Dr. Dorn, physician-physician conflicts can be disagreements of opinion, of training, of personality, and of reimbursement issues. “Physicians are very concerned with reimbursement—they want to know what it is going to cost them in time and money,” he explains.

For a hospitalist serving as a committee chair, says Dr. Dorn, “The critical thing is that when they assume these positions without authority, the only way to make it work is to increase their level of influence. The level of influence over authority is the indication of a good leader.”

You can acquire the necessary influence by learning solid conflict resolution skills.

Resolve to Study

There are a number of resources available for hospitalists interested in studying conflict resolution. Drs. Dorn and Marcus have co-written a book on the subject, Renegotiating Health Care: Resolving Conflict to Build Collaboration. “The conflicts we deal with [in the book] are right at the core of what’s going on in healthcare right now,” Dr. Marcus says.

Dr. Dorn also recommends some general books on resolving conflict. “Most of conflict resolution is interest-based negotiation, and the father of interest-based negotiation is Roger Fisher,” he says. “With Bill Ury, he wrote Getting to Yes. I think a better book for physicians is Getting Past No. It’s very simple and concise. These are basic books on conflict resolution.”

For a more detailed textbook, Dr. Dorn suggests The Mediation Process: Practical Strategies for Resolving Conflicts by Chris Moore. “This is the definitive text,” he says. “I also like Difficult Conversations by Stone, Patton, and Heen.”

Whether you’re in a leadership role or a hospitalist doing straight clinical work, successfully resolving conflicts on the job can be a much-appreciated skill. “[Conflict resolution training] will make your life so much easier, so much more pleasant,” promises Dr. Dorn. TH

Jane Jerrard writes “Public Policy” for The Hospitalist.

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