Editor’s note: First of a two-part series.
Think about the last time you found yourself in the middle of a contentious conversation with another doctor about whether a patient should be admitted by you, the hospitalist, or by a doctor in another specialty. Such conversations can sometimes move quickly from respectful disagreement to posturing, drawing lines in the sand, or worse.
Respectful conversations between doctors with differing opinions about the best plan of care for patients are valuable. But disagreements that lead doctors to talk at rather than with each other risk creating quality-of-care issues for the patient, demoralize other hospital staff, and can result in lasting harm to the relationship between the doctors involved. I’d bet the frequency of such disputes could serve as a reliable predictor of overall quality of care, and might correlate with cost of care. Doctors in all specialties should work diligently to reduce the chance that such conversations lead to conflict and stress.
This conflict arises most often when an ED doctor is calling about a patient needing admission; the way communication between ED doctors and other physicians happens nearly everywhere is one reason the problem is so difficult to eradicate. (To be clear, I’m not faulting ED doctors for causing this problem; I think they usually try very hard to prevent it.)
Because the ED doctor is often in the middle of the chain of communication (disagreement), those whom the ED doctor is asking to admit the patient often are emboldened to take more unreasonable or extreme positions. It is a lot easier for Dr. Perry to make a case to the ED doctors that Dr. Mercury should admit a patient than to present the same rationale to Dr. Mercury himself. In many cases, the ED doctors can make the problem go away, or at least extricate themselves from the disagreement, by insisting that Dr. Perry and Dr. Mercury speak directly to each other.
Of course, things can sometimes go so badly that they refuse to speak directly with one another and force the ED doctor to settle the dispute a power given to the ED doctor by the medical staff bylaws at nearly every hospital. Or maybe they do speak directly and that leads to greater conflict (i.e. shouting or an abrupt hang-up).
Improved Social Connections
Most hospitals I’ve worked with seem to feature harmonious and collegial relationships between the ED doctors, hospitalists, and other specialties. But for some, divisive conflict crops up frequently. A first step for those hospitals laden with conflict could be to deliberately work to improve the social connections between the physician groups that often disagree. I’m not Pollyannaish; sometimes relationships are beyond repair, or one of the doctors involved might have a character disorder that requires more significant interventions.
A few years ago, I visited a place where years of conflict between ED doctors and hospitalists had led to remarkably adversarial relationships. Both of the lead physicians for the ED doctors and hospitalists were pleasant, professional, and highly regarded by others. Nonetheless, they both were fed up with the ongoing conflict and found themselves in such an adversarial relationship that I worried the next nighttime dispute could come to blows (literally). With a combination of support and pressure from hospital leaders and physician peers, they committed to a series of dinner meetings, just the two of them. They agreed to meet monthly, away from the hospital, and for the first few meetings avoid any conversation about work-related issues. The point was for them to build social connections so that they could find new ways of communicating, thus regain respect for the character of the other.
Some months later, I heard from the lead hospitalist, who said that the meetings had proven very valuable and things had improved dramatically between the department heads. He also said they were working together to improve the way their whole groups interacted. This wouldn’t work so well everywhere, and would have failed if not for the good character of both the doctors. But I’m struck by how infrequently the formation of social ties is included in any plan to reduce physician conflict. It is valuable, regardless of which specialties the doctors work in.
Hospitals have figured this out. Most provide a doctor’s lounge where meals might be served to provide a place for socialization. Some arrange periodic retreats for physician and hospital leaders to spend a weekend in a nice setting (with some time devoted to business and ample time for recreation and socialization). Expensive “perks” like these probably pay dividends in improving culture and reducing conflict. They also might soon be a thing of the past due to cost pressures. If so, we should all think deliberately about other ways hospitals can preserve and enhance the social fabric of what is becoming a more segregated medical staff as doctors narrow their sites of care and specialty focus.
The Universal Admitter
The most effective way to eliminate disagreements in admission decisions is to have the hospitalist admit all of them—that is, make the hospitalist a universal admitter.
Some hospitalist groups are nearly universal admitters already. No, they aren’t admitting all patients, including women in labor and some others. But they do admit and serve as attending for patients with hip fractures and other trauma and surgical issues, scheduled chemotherapy patients, etc.
I’ll save of my comments about the appropriateness of hospitalists as universal admitters for a future column. But I think that it is overkill to move to that model solely to address disagreements regarding which group admits a patient.
Another way to reduce conflict over which physician group will serve as admitting/attending physician is to develop service agreements, or “compacts,” between different specialties. The idea is to create a set of clear, written guidelines or rules that determine which group admits the patient. For example, should the hospitalist or the surgeon admit?
ED doctors usually are delighted when the hospitalists and surgeons have met to create such an agreement. It could mean the end of disputes about who admits the patient. But does it?
I’ll discuss these agreements further in next month’s column, including elements that should be addressed, how to maximize compliance with them, and why they almost always fall short of realizing their hoped-for potential.
Dr. Nelson has been a practicing hospitalist since 1988. He is co-founder and past president of SHM, and principal in Nelson Flores Hospital Medicine Consultants. He is co-director for SHM’s “Best Practices in Managing a Hospital Medicine Program” course.