Messy moments: How to feel comfortable in conflict with someone of higher ‘rank’

The hospitalist decides to keep a patient until she’s been afebrile for 24 hours. The supervising resident, after talking with the family, wants to discharge the patient. Neither explains their reasons.

But the attending’s tone clearly declares - The decision’s made: the patient stays.

The resident wonders: “How am I supposed to learn to practice on my own when he shuts me down?” What can she do?

What would you like to happen?

The resident doesn't argue because that can damage the relationship… and her reputation, inviting judgement or future hostility.

Yet she’s upset: she can’t do what she believes is appropriate. She’d like:

• To manage her reactions to being told no
• To improve her clinical skills by understanding the reasons for retaining the patient
• To discuss the options openly with the attending - to improve their relationship and gain confidence in her practice.

Get curious

Investigate what is going on inside you.

• How do you feel? What triggered those feelings?
• What story are you telling yourself about what happened here?
• What do you most want to happen now – for your patient and for you?

Take two minutes in a quiet place. That gives you some space from any difficult emotions. Reflecting creates insights about your priorities now and in the longer-run. So you’ll respond wisely.

You’ll also avoid automatic unwise reactions.

Use your intentions and your long-run vision to decide your approach.

Talk with the hospitalist privately later. (But not much later!) Ask about his thinking and intentions - for the patient and his own clinical hopes?

• Ask open-ended questions. Shift from being the expert to learning everything you can.
  • “What is important for you here?” “What makes that important to you?”
  • “What is important for the care group and the organization?”
• Then listen carefully to how he explains the situation, his thinking and interests. Do you understand his priorities for a good patient-centered decision?
  • “So what you aim for here is to _ _ _ for the patient?”
  • “Do I have it right that you see _ _ _ as a risk if he’s home with is family?”
• Then introduce what you learned from examining the patient and talking to the family. Use non-judgmental, objective language to cultivate constructive conversation.
  • “The family told me that they’ve taken care of him many times with this same problem. And he _ _ _ _ .”

Tips

• Focus on interests. If someone restates their position, return to what they care about, wants that are rarely obvious from the situation.
• You aim to understand. You communicate to be understood.
• Perspective-taking can powerfully soften conflicts. And it helps you be a better clinician.
• Be aware of yourself in this conversation. Are you looking at the attending’s eyes? Does your body show your openness and your careful listening?
  • Nod when you agree or understand.
  • Presence and situational humility invite discussion.
  • Take notes if he makes points you want to remember and/or ask more about.
• We can’t prevent the discomfort in this. It will, though, get easier! He sees you really want to understand. And you’re giving him important information.

What are your rewards?

• You learn what you need despite the attending’s pulling rank.
  • Rank perceptions pervade healthcare. Disciplines, seniority, organization etc divide people deeply. It infuses relationships, meetings and more. Friction floods inter-disciplinary and interdependent work.
  • Everyone continuously questions if they have more or less rank than the person opposite them. Rank cows many people. It makes others crow. It understandably causes a lot of unproductive behaviors.
• This bite-sized conversation fits into a demanding day. [It gets easier and faster with practice].
• You become more human to one another. You cut through assumptions and learn how the other thinks. In the process you find your voice.
• Together you learn to exchange important information without friction. You save time and energy for the next time you’re together. This conflict conversation creates greater respect and improves collaboration
• You also reduce chances of medical error.
• Being ignored or bullied into doing something against your own thinking and belief causes distress for millenial MDs. This conversation reduces anguish
• You both realize you can learn through disagreement and discussion. This proves critical to thrive in uncertainty, complexity and change

This is the 1st in a 4-step evidence-based process that defuses the ‘heat’ of conflict and fosters conflict confidence:

1. Get curious. Identify what you both really care about, That creates solutions that improve things for you both.

2. Enlarge the pie. Find common interests and aspirations – goals, purpose, intentions. You’ll find you have more in common than you thought!

3. Enhance the options. Together brainstorm options you’d never have considered without this discussion.

4. Enjoy a bigger pie piece. Choose an option that satisfies both of you.

We’ll explore these later.

When you last clashed with someone of higher rank, how did you respond? Either aloud or in your head?

What was the outcome? Please email me about it. nance.goldstein@post.harvard.edu

Nance Goldstein, MDc, ACC, PhD, partners with physicians as a leadership coach to find ways through today’s tough times and enjoy medicine more.