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You feel the call schedule is unfair. Your patient complains to the billing office about a bruise from an intravenous venipuncture, but had never mentioned it to you. One of the nurses you work with always seems to be angry and unhappy. When you joined the practice, you were promised health insurance coverage after 90 days, but it's been 6 months, and you and your family still aren't covered. One doctor is always late for staff meetings, but no one ever says anything.
Do situations like these sound familiar? No surprise, there. Conflict is part of every medical practice, every workplace.
All too often, people avoid dealing with conflict. If you are just starting oncology practice, you may feel especially hesitant to confront conflicts. “Exposing yourself as the one rocking the boat is a little scary when you're first starting out,” comments a young oncologist who has been in practice just over a year, who asked not to have his name appear in this article. “You feel you don't have the authority. But it's just frustrating when everyone has just adapted to an inappropriate situation and doesn't do anything about it.” Indeed, the young oncologist's sensitivity about having his name used is a further example of how issues related to conflict are particularly difficult for those fresh out of fellowship.
Although confrontation is especially hard for those who are just starting out, or those who are not in positions of authority, avoiding it is a common human trait. “People are fearful of conflict,” explains California-based consultant Stanley Wachs, PhD, who has specialized in conflict resolution for more than 25 years. “We avoid confronting other people about difficult issues because we have three or four basic fears.”
Wachs describes the fears of confronting others as follows:
As discussed here, conflict is not simply disagreement, which can be a healthy and effective characteristic of work groups. Disagreeing—the expression of differing opinions in open discussion—is not laden with negative emotions like those that accompany conflict. Indeed, honest disagreement is often intellectually stimulating, and in effective work groups it is encouraged.
Conflict, in contrast, is associated with negative emotions such as resentment, anger, impatience, and bitterness. You may feel a conflict over a situation without expressing disagreement, and, in fact, the other person may not even be aware of the conflict. Once you recognize that you have an emotionally negative feeling about a situation, the road to resolving it is confronting the other person, and that's the challenge.
Wachs notes, “My clients always refer to the work I do as ‘conflict resolution.' But I like to think of it as knowing how to have discussions about difficult issues.” This is easy to say, but how do you do it?
Wachs teaches skills that are “learnable and practicable” to help people confront difficult issues. Using these skills does not eliminate the fear of confrontation, he says, but people can learn the skills to manage their own emotions, their own vulnerabilities. Having such a skill set can help people stop avoiding confrontation—and start those discussions that they need to. For physicians, he draws a comparison to the skills learned during residency and fellowship training. “Physicians do things now that once frightened them, because they learned and practiced the skills.”
Wachs was asked to explain how he would advise confronting this real-life situation described by an oncologist we'll call Susan:
At the weekly tumor board held at a community hospital, one particular pathologist is chronically ill prepared. He's been there a long time and is basically not doing his job. He is supposed to familiarize himself with the cases beforehand, but makes no effort whatsoever. He's not helpful to the basic goals of a workable conference. When guest speakers attend, it's embarrassing and affects our current initiative to develop an ongoing relationship with regional specialists.
In confronting this issue, Susan has completed the first step—assessing the situation. These are the subsequent steps Wachs advises to deal with this conflict:
“The skills for confronting difficult situations like this can be learned,” Wachs states.
Harvey Bichkoff, MPH, CEO of California Cancer Care, a 10-physician group in Northern California, agrees. Bichkoff's group worked with Wachs in 2007 to develop conflict resolution skills at the group's annual retreat. “We learned a set of skills to deal with conflict,” he says. “On the second day, after role playing and practice, we participated in a very constructive exercise of confronting one another.”
Bichkoff, who has been with California Cancer Care for 13 years, encourages those who report to him to work out conflicts directly with each other. “They're the ones who are going to have the working relationship.” The group's retreat on conflict resolution reinforced that approach, he says. “The take-home message is that confronting conflict is healthy. Dealing with it makes for better relationships in the long run.”
The children's chant, “Sticks and stones may break my bones, but words will never hurt me,” is far from the truth. A biting criticism or personal attack can stay vivid in one's memory for years.
In addressing a difficult issue, words take on special importance. Avoid making generalized or absolute statements, such as “You never finish your charts on time” or “This behavior is destroying the office morale.” Avoid the use of superlatives such as worst, most, or highest. Instead, use moderating terms such as sometimes, often, a few times, and possibly.
Use of the word “but” is also a red flag in conflicts. For instance, telling your boss “I really like working here but I feel the call schedule should be changed” is likely to elicit a defensive response. Replace the word “but” with “and” by saying something like “I really like working here and hope the call schedule can be revised in some ways.” Using “and” instead of “but” can open the way to a constructive discussion and resolution without raising the other party's defensiveness.
Be especially wary of labeling people, even in your private thoughts. It's common to categorize or label certain people whom we consider difficult: “Mariella is a whiner”; “Johnson's just dead weight”; Connelly's a real blowhard.” Such labeling is a way we work to classify and organize information, including people, but it can set up negative expectations and generalizations that can be counterproductive. Work at broadening your own views of others to see them as a whole person, not as an embodiment of a specific irritating behavior.
Whether in a private practice or a teaching environment, you may be called on to help others resolve conflicts between them. Avoid the temptation to take responsibility for resolving the conflict; as a mediator, your role is to help the parties in conflict explore acceptable options and develop agreement. Even if one of the parties is a “difficult personality” whom you yourself have had problems with, as a mediator you must demonstrate objectivity and fairness, giving the parties equal time and attention, and sufficient time to express themselves.
Define your mediator role as one of supporting “winning” for both parties. A key to success is for each individual to change from thinking of the other as an adversary to considering him or her a partner in reaching a solution. When both people win, both are committed to the solution because it actually suits them.
Remain neutral and be an active listener. Focus your full attention on the individual speaking. Don't allow distractions or interruptions. Show that you are taking the situation seriously and are committed to the problem-solving process.
Create an environment in which people feel safe to open up. Use caring language. Actively discourage judgments about who is right and who is wrong. If necessary, set ground rules that prohibit behavior such as put-downs, blaming, threats, bringing up the past, or getting even.
Slow down the conversation when needed. Keep your voice low and modulated, and use a relaxed body language. For instance, folding your arms can be off-putting.
Take personalities out of the definition of the problem. For example, state the problem in objective terms, such as “determining an equitable holiday call schedule” rather than “deciding if Brent or Marsha should have a 3-day holiday.” Be prepared to revise the statement of the issue as your understanding of the conflict evolves. Be objective and resist advising. Your role is to steer the process, not the content.
Use open-ended questions such as “By difficult you mean …” and “Help me to understand what you mean by… .” Be aware of nonverbal cues and point out the triggers that are escalating emotion or being used to avoid discussing the issue. For example, if someone points a finger or rolls his or her eyes, calmly mention this behavior and explain that such body language is counterproductive.
Invite both parties to state their impression of the problem at hand. Find out what matters to them. Ask thoughtful questions about what they want and what is important to them. Focus on the “why,” not the “what.” An individual's position is usually based on a deeper interest or need, so listen carefully to explore the hidden or underlying assumptions of each party. The better you understand why something matters to individuals, the better you will be able to explore options that will satisfy their real interests.
If they do not express their feelings, solicit the information: “How did that affect you?” or “How did you feel about that?” Assess nonverbal cues as well as what is actually articulated.
In addition to finding out about the individuals' needs and concerns, obtain background information. Be sure the facts are all out in the open. Ask questions about details that haven't been expressed: “How much will it cost?” “What happens when the informed consent is not signed?” “How often does this happen?” If someone makes a general statement such as “I thought it was out of line,” ask for specifics about to what aspects he or she objects.
Paraphrase what you hear the parties saying, and at various points ask each to state what he or she heard the other one say. Sometimes individuals are surprised when they hear their perspective articulated by someone else.
Invite the parties to suggest ways to reach agreement. Ask them to list their choices and the consequences of each.
Focus on the issue, not on personalities. Reinterpret an attack on a person to focus it on the issue. This will help individuals not to be defensive. Where possible, turn to outside sources for guidance or data. Using objective resources can also sometimes make it possible for individuals to back down without feeling humiliated, by justifying a change in their opinion or their position because of new information.
Identify the solutions that seem to have the greatest potential to address the interests of all parties. Lay out the solutions for discussion, watching for cues from all parties about which options are most appealing. The parties must believe the agreement is fair and recognize that they have gained something.
Returning to our example at the beginning, what if you are that oncologist who has been with the group just 6 months, and the promised health care coverage has not come through? You've followed up with the office manager several times already, but you are afraid to confront the group president about it. You have several fears about talking to him. Maybe the partners aren't really happy with your work. Also, he's very aloof and a little brusque, and you've always felt ill at ease around him. Finally, he might think all you care about is your compensation package instead of focusing on the patients.
Presented with this scenario, Wachs goes right to the protocol outlined for starting a difficult discussion. “It's the same approach whether you are equals or not,” he says. “You start the discussion—‘I need to talk to you about a difficult issue.' You admit your reservations and explain why you are doing it anyway: ‘I hesitated to bring this up because I felt it was just a paperwork problem and I felt anxious about bringing a trivial thing to your attention. I'm mentioning it now because I feel the lack of insurance is putting my family at risk.' You state the facts and ask how he sees it.”
Wachs admits that it really takes courage to confront difficult issues. “We do feel vulnerable and anxious about conflict. But we have to find the compelling reason within ourselves to do it anyway, despite the fear. We say to ourselves, ‘I'm finding the alternative so unbearable, or so inappropriate, I don't want to live like this.' It's really about affirming ourselves as people.”
Use “I” messages when you talk to someone about a problem. “I” messages state a problem without blaming someone for it. This makes it easier for the other person to help solve the problem without having to admit that he or she was wrong. For example, say, “I felt my suggestions were brushed off” rather than “You didn't even listen to what I had to say.”
“You” messages suggest blame and encourage the recipient to argue. Responses to a “you” statement such as “No, I didn't,” or “Well, you were way off-base” are likely to escalate emotions and are not conducive to resolving the situation.
Using “I” messages takes practice—it's a skill that has to be learned. Use of “I” statements doesn't come naturally, because we aren't used to talking about our feelings. In addition, it's a normal response to see a conflict as the fault of the other person. Thus, expressing the problem in terms of a “you” message just feels more natural, because it's more consistent with our perspective about the problem.
But it's worth the effort to change our language. Using “I” messages not only diminishes the negative responses of the other person, it helps reframe the way we think about the conflict ourselves, thereby increasing the likelihood that a resolution can be found.
Deciding About Practice Options—July 2006, page 187
The Interview: Make It Work for You—September 2006, page 152
Employment Contracts: What to Look for—November 2006, page 308
Joining a Practice As a Shareholder—January 2007, page 41
Principles and Tactics of Negotiation—March 2007, page 102
Professional Advisors: They're Worth It—May 2007, page 162
Building and Maintaining a Referral Base—July 2007, page 227
Malpractice Insurance: What You Need to Know—September 2007, page 274
Develop Effective Communication Skills—November 2007, page 314