How to Talk to Your Partners

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.”

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.