Office Culture: Fight the Good Fight

When Richard Hansen recently asked a roomful of physicians he was mentoring on good management practices how many of them approached conflict in their businesses by simply avoiding it, a majority of hands reached for the ceiling. "'I can't stand conflict,' is a statement I hear from physicians over and over," says Hansen, a consultant with the Medical Group Management Association. "I've seen physicians ignore major problems in their practices for years on end simply because they can't bring themselves to deal with them."

Hansen was once brought in as a mediator to intervene in a practice in which two feuding physicians refused to work with one another. "If one of them entered the office from the front, the other one entered from the back," says Hansen. "If one saw the other's car in the back parking lot and knew he couldn't avoid seeing him, he'd call the front desk on his cell phone to cancel his appointments for the day." This example is extreme, but the disruption caused by unresolved office conflict is often severe.

Are physicians more averse than other professionals to dealing with the conflicts that inevitably arise in all business settings? Many experts say yes.

"Physicians have reached their professional standing because they have excelled as individuals," explains Leonard J. Marcus, PhD, director of the Project for Health Care Negotiation and Conflict Resolution at the Harvard School of Public Health. "They have achieved success in medical school, in their residencies, and in their specialties. However, working within a medical practice requires collegiality and collaboration, as individual physicians are part of a larger healthcare delivery system. Successful medical practices require teamwork - not solely individual achievement - but that is not how doctors are typically trained."

Barry Dorn, a practicing orthopedist and associate director of Harvard's Project for Health Care Negotiation and Conflict Resolution, agrees that "many doctors don't have great communications skills."

"We were never taught that in school," says Dorn, "which is kind of ironic, since good communication skills are an essential element of our everyday routines."

Hansen says that patients reinforce this problem when they expect physicians to "have an opinion and stick to it." In general, says Hansen, patients look to their doctors to take charge and solve the problems they present, not to huddle with other docs to come up with the best treatment approach. As a result, Hansen says physicians are generally unaccustomed to being challenged by others, and they don't know how to respond when their authority is questioned.

WHO SUFFERS?

Dorn maintains that when physicians use the "blind eye" approach to conflict within their practices, "It inevitably comes back to haunt them."

"Conflict always builds in a practice," says Dorn. "It's how you deal with it that matters. I once had two younger physicians in my practice who were always at each other's throats. When I asked one of them about it, he said to me, 'Well he did this and this and this to me two months ago.' I asked him if he ever said anything about it to the other physician, and he said no. It was never expressed. The definition of conflict is 'an expressed difference between two people.' If you are upset at someone and you do not express it, all you have is anger. It is when you respond that you set the tone for the conflict. How you express your displeasure is everything."

Dorn says conflict among physicians inevitably affects patient care. "Patients really suffer when doctors have conflicts with one another," he says. When serious conflicts remain unresolved and move into the patient care arena, "I tell [physicians] that they are creating an unsafe environment for patients, and that it is illegal for them to do so."

Marcus says the negative patient impact of physician conflict tends to be indirect, such as when a doctor won't refer patients to, or accept referrals from, the source of their consternation.

What causes all of this ill will? Money is at the heart of much of it. Time is also an oft-disputed commodity, as are issues concerning decision-making authority and patients' clinical care. Hansen says conflicts over office protocol, compensation, and those that occur as a result of generational differences are all common as well.

Regardless of the cause, the fallout from interoffice conflicts within medical practices can range from the mildly annoying to the downright threatening. "Physician conflicts range from feuds in which people aren't talking to one another and aren't working with one another, to where the practice itself is impaired and legal implications are looming," says Marcus. "The latter occurs when conflicts escalate. The earlier a conflict is recognized, addressed, and resolved, the greater the possibility there is to repair the relationship and minimize the damage done."

AN OUNCE OF PREVENTION

The best approach to conflict is to prevent its occurrence in the first place. Of course, not all conflict can or should be avoided, and when dealt with properly, conflict can actually have a positive impact on a practice.

But to avoid unnecessary conflict, mediators recommend that all parties put their cards on the table before deciding to go into business with one another. To this end, the "prepartnership" practice agreement is gaining vogue among physicians who want to ensure they are joining a practice that suits them both personally and professionally.

Although such written agreements may not hold up in court, Dorn praises their ability to stimulate conversation among would-be business partners about issues that may not immediately come to mind. He says that all of his associates in his six-physician practice were brought in under the same agreement. The process of discussing such a document, says Dorn, "makes physicians think about what they really want in a work setting."

For example, the principal concern of many newly minted physicians looking to join a practice is the amount of compensation they will receive. Negotiating a prepartnership agreement "helps new physicians explore for themselves what they want out of their career besides money," says Dorn.

And discussing all possible eventualities before taking on a new hire doesn't hurt either. "We talk about what will happen when a physician leaves a practice before his first day at the practice," Dorn says. "You must be willing to have open, honest discussions about what each person's individual self-interests are." Dorn offers as an example the different life goals among older and younger physicians in the same practice: "A younger physician with a new family may want to make larger, riskier investments" with the practice's revenue.

Dorn, the eldest physician in his practice, says that at this point in his life, "time is more important than money."

If left unvoiced, these understandably different perspectives could potentially ignite a battle among physicians over how to best invest their practice's money. "If you can anticipate such problems and deal with them fairly, you will run a smooth practice," Dorn predicts. "In my practice, everything is out in the open. We talk a lot about how we want to run things, but we talk about it together. There is no whispering behind one another's backs."

Hansen agrees that lines of communication must be open among physician partners from the start: "Many practices don't tell doctors joining them what exactly is expected of them in terms of values, not what's in a job description. ... If people understood the mission or purpose of their group before joining it, a lot of conflict would be avoided. ... People would know whether they fit into a particular practice's culture from the start."

DAMAGE CONTROL

But what if you are already mired within a conflict? At that point, it's a bit late for preventive measures.

"It is important for both parties to sit down as early within a conflict as possible to have a constructive conversation about what has occurred and why," says Marcus. "Often, both parties will realize that they agree on more than they disagree. They should use what they agree on as a starting point for working out their conflict. If this is done early on in the life of the conflict, it is most likely that the disagreement will repair itself. It is when conflicts escalate to the point that they are distracting the physicians involved, costing the practice money, and impairing the very existence of the practice, that it is less likely to be effectively resolved."

So to avoid the costly, time-consuming, and emotional havoc arbitration or litigation can wreak on a practice, mediators are often called in. Hansen says when he is summoned into such a situation his most effective tool is listening. "Once people perceive that you will listen to them and that you will not judge, they will pour their hearts out," he says. Hansen recalls a situation in which one physician who had been with a practice for two years was "acting out," and the more tenured physicians were having trouble with him.

"I asked him what was wrong, and he said that in all the time he had been there, not once had the other physicians welcomed him into their homes," says Hansen. "He had come from another practice in which all of the physicians were integral parts of one another's families, and they spent a lot of time together. That was the culture he was used to." When Hansen spoke to the other physicians in the practice, they simply said that the new doctor did not "fit in" with their practice.

"If he had known what his current place was like from the start, he probably wouldn't have joined them," says Hansen. "And he did ultimately leave."

'GOOD' CONFLICT

"All conflict is positive in that it indicates that somewhere there is an underlying problem," says Dorn. It is the manner in which conflict is addressed that determines whether the outcome will be positive or negative.

"Conflict can be positive when it creates an opportunity to perceive, address, and fix what could be a latent problem," confirms Marcus. "If there is an underlying unhappiness within a practice, that could indicate that there is an unarticulated problem that needs to be addressed. It is when people start arguing that it becomes a conflict. If it is addressed early, people are given the opportunity to express what is troubling them and how they can best address it. It is when people become mired in conflict that it produces the greatest problems."

Given this agreement that conflict addressed early on can result in positive changes to an underlying problem, avoidance would certainly seem to be the most detrimental response to it. Yet, among physicians, it also seems to be the most common.

Conflict is never avoidable in any situation; everyone must learn how to effectively deal with it in order to be successful in any personal or professional capacity. The harmony of your practice is at stake.

Barbara A. Gabriel, MA, managing editor for Physicians Practice, can be reached at bgabriel@physicianspractice.com.

This article originally appeared in the April 2006 issue of Physicians Practice.