American College of Physicians: Internal Medicine — Doctors for Adults ®


How to handle conflicts with your medical team

From the October 1995 ACP Observer, copyright 1995 by the American College of Physicians.

By Christine Wiebe

Every day at the hospital, residents juggle competing roles: As physicians, they are expected to assert their professional authority, but as trainees, they must consult and defer to others on their medical team. Sometimes that balancing act proves too difficult and professional conflicts explode.

In one recent episode, a resident caring for a dying elderly woman disagreed with the attending's decision to withhold the diagnosis from the patient, as her family had requested. After engaging in a shouting match with the attending, the resident proceeded to inform the woman anyway, recounts Lawrence Smith, FACP, program director at Mount Sinai Hospital in New York.

The "nuclear fallout" from that incident could have been avoided if the resident had tried to iron out the conflict respectfully, using his program director as a mediator, Dr. Smith suggests. Unfortunately, residents sometimes get so caught up in defending what they think is right that they lose sight of the bigger picture, he says.

Residents see it differently. They say their actions usually result from an overriding concern for their patients. Mark Adrian, ACP Associate, says he has had numerous professional conflicts during his three-year residency at Mercy Hospital in San Diego: A hospital technician recently called him "arrogant," a nurse once threw a clipboard at him, and he has appeared before the hospital ethics committee to challenge an attending's orders.

"[If] I look bad to someone because I'm very assertive and want the patient to get the best care possible, that doesn't bother me at all," Dr. Adrian says.

Experts agree that there are times when residents should stand fast in their beliefs, namely when a question of medical competence or unethical behavior arises. In most instances, however, basic communication and negotiation skills can help avert destructive conflicts, they say.

Setting ground rules

One of the ground rules is respecting all members of the health care team, from nurses and orderlies to other housestaff to attending physicians. "Young physicians who are not sure of themselves often have professional problems with other non-physician professionals," says Dr. Smith. New residents who doubt their own competency may act hostile and defensive, he says, whereas more senior residents may feel confident enough to acknowledge that a CCU nurse knows more about certain procedures than they do.

"We always tell people that the fastest way to get into deep trouble is to blindly not listen to someone," Dr. Smith says. "If everybody respects each other and listens to each other, professional relationships can flourish."

In addition to respecting individual members of the medical team, residents need to respect the hierarchy of that team and accept their role in that hierarchy, says Lisa Kettering, ACP Associate, a third-year resident at St. Joseph Hospital in Denver. "If you're asked to do something that benefits the patient and is part of patient care, it is part of your role," she says. "There are going to be times when you have to abide by the wishes of others, [wishes] that are not your own."

In many situations, however, the lines of power are not so clear cut. Some attendings see residents as the team leader and expect them to take more responsibility, even becoming hostile when asked for consults, says Molly Cooke, MD, professor of medicine at the University of California at San Francisco. Other attendings want to be consulted every step of the way, she says. "There is a delicate dance on both sides over control."

Unfortunately, residents rarely learn explicitly how to handle that power struggle, she says. "It requires an ability to read nonverbal signals and to individualize your approach across different attendings."

At the same time, residents need to realize that attendings are struggling, too. "If something really screws up, I can't say, 'Well, that's what the resident wanted to do,' " Dr. Cooke says. Although she generally tries to let residents proceed in their own manner, she occasionally has to step in and say, "Look, we've negotiated about this for a few days and I can no longer stand what's going on."

Dr. Cooke recalls a case where a resident insisted on tube feeding a dying HIV patient despite nurses' protests. When the team changed and a new resident reviewed the case, he agreed to allow the patient's mother to feed him food brought from home. "When I saw what happened, it was so obviously right that I was really sorry I had let the first resident get away with another week of bad management," Dr. Cooke says.

A chance to learn

Unfortunately, she says, "there is probably not enough analysis on either side when there are a couple of management options on the table." Ideally, differences of opinion can become an opportunity for academic investigation, Dr. Cooke adds. She frequently retreats to the library to find substantiation for a medical decision, she says, and residents should do the same.

In fact, keeping the focus on education can eliminate many professional conflicts, advises Kelley Skeff, FACP, program director at Stanford University. If residents view each of their colleagues as a teacher or learner, they will be more open to a free exchange of ideas across all levels, he says.

Residents often underestimate their value to attendings, Dr. Skeff says. "Residents are extremely powerful," he says, and they can influence patient outcomes dramatically if they handle interactions with attendings appropriately. Faculty are very interested in residents' opinions, he insists, but housestaff who ask questions in a threatening way can suppress discussions. A more constructive debate can be held if the other person's experience and abilities are acknowledged and he is not put on the defensive.

An active interest in learning also helps minimize conflicts, says resident Dr. Kettering. "Just showing up and going through the motions doesn't cut it," she says. "I go into every new month, every new situation, every new group saying, 'I know what I have to offer and I know what I want back.' " Even if she does not get what she expected, she finds that everyone has something positive to contribute toward her learning experience.

Sometimes, however, despite the best efforts, professional conflicts still erupt. "In the fire of being a resident, it's often difficult to do everything you want to do," says Stanford's Dr. Skeff. Residents can always go back to a colleague, express regret at how a situation was handled and discuss ideas for improving future interactions, he suggests. "I think if we practiced that more we might get better at it," he adds.

Educators agree that residents could benefit from more direct training in negotiation skills, and a few programs are trying to address it through teaching workshops and orientation programs. "I'm convinced it's important, and missing in education right now," says W. Scott Richardson, MD, assistant program director in the primary care program at Rochester General Hospital in Rochester, N.Y. He and Dr. Smith are working to package some guidelines on negotiating clinical disagreements for residents in the near future.

In the meantime, they recommend reading the book "Getting to Yes," a resource on negotiation skills. "I'm convinced that the key is communication and respect," Dr. Smith concludes.

Christine Wiebe, of Providence, Utah, writes frequently on issues related to medical residency.

Handling conflicts: 6 tips

Experts agree residents can do a lot to lessen on-the-job tensions. Here are some general guidelines:

1. Show respect for co-workers and acknowledge their expertise.

2. Keep an open mind and listen to others' suggestions.

3. Admit your own weaknesses.

4. Avoid questions or comments that will make colleagues defensive.

5. View colleagues as co-learners in an educational venture.

6. Show an active interest in learning.

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