How to shape positive relationships in medical practices and hospitals. (Part 2: Conflict Management).

VERBAL ABUSE. SEXUAL harassment. Racial or ethnic slurs. Inappropriate entries in patient records. Noncompliance with practice or hospital policies. Vendettas against hospital administrators. Constant staff turnover. Bickering and unproductive competitiveness. Battles overpower, control, or professional turf.

Disruptive physicians. The problems they cause can threaten the viability of any medical organization. Policing the offenders is a necessary but far from sufficient response to this problem; larger organizational issues must also be addressed.

Managing disruptive physicians requires organization-wide interventions designed to both eliminate negative behaviors and foster positive interpersonal dynamics. The goal is to teach medical professionals how to replace negative interpersonal behaviors with those that are positive. For medical practices and hospital systems, this requires a combination of preventative and palliative strategies. The seven guidelines outlined in Table i can help to structure these efforts.

Seven steps to solving the disruptive physician problem

1. Provide protection

A clearly-stated code of conduct as well as policies and procedures for dealing with violations are prerequisites for developing a medical workplace that allows employees to function in a freer, more relaxed and productive manner. The key is to be proactive. If you wait to adopt a code of conduct in the wake of a complaint, the offending party is likely to perceive the policy as being a punitive, personal attack. (1)

No code can specify every possible violation, and any attempt to do so will be regarded as being overly dictatorial and insulting. In general, the code should flow logically from your organization's mission statement, and it should specify both blatantly unacceptable behaviors--like impairment from substance abuse or sexual harassment--and behaviors that can subtly damage your organization's morale, productivity, or reputation. (2) Table 2 lists examples of subtle behaviors that can undermine group cohesion.

When specifying a procedure for reporting inappropriate behavior:

* Make it easy and confidential. Your complaint system should be uncomplicated and should protect a complainant's privacy. (3) Unless staffers and doctors are trained in how to use the reporting process, it is useless.

* Give feedback promptly and regularly There is no quicker way to lose the trust and respect of the people you manage than to appear to be doing nothing in response to their complaints. At minimum, give the complainant a periodic update, even if it's simply to say, "We are not ignoring your complaint. I'm sorry that I can't say more. But please know that we are following through."

* Develop a special committee. A committee charged specifically with the task of overseeing interpersonal relations may be helpful. In hospitals, this committee is typically comprised of representatives from the boards of key medical groups, the hospital's physician executive, a person from human resources, and an attorney.

For medical groups, the levels of trust and conflict influence the structure of such a committee. If the group has a high level of trust and a low level of conflict, they may elect a committee of their own members. Often, this task is left to the group's executive committee or to the board of directors if it is small enough. However, consultants generally agree that if a group's executive committee or a hospital's board tries to add the role of monitoring professional behavior to it's already burgeoning list of responsibilities, the behavioral issues will be ignored in deference to ever-urgent business items. (1)

When group dynamics are characterized by a low level of trust and a high level of conflict, a medical practice may opt for an interpersonal issues committee comprised of trusted individuals from outside the practice. One example is a committee consisting of the practice manager, a selected physician, an attorney, and a human resources consultant.

Whatever its makeup, it is crucial that this committee functions independently and in parallel to other governing bodies that report to the organization's board of directors, and that it be empowered to investigate, counsel, and discipline violators.

2. Listen, empathize, and avoid communication triangles

The next step is to pay attention to how you respond to complaints. People in conflict tend to complain to a third party, rather than dealing directly with each other. Resist the pull to participate in conflict-escalating communication triangles.

* Stay calm while the complainant expresses his or her concern, and listen actively. Reflect what you hear, and show empathy for the speaker.

* Express regret that this conflict has happened, but don't use inflammatory words, and don't assume a collusive posture. Try to maintain the stance of someone who will facilitate resolution of the conflict, not that of a rescuer or persecutor of any party.

* Ask what the person would like you to do to resolve the problem. Stay focused on the specific problem at hand and state your intention to do all that you can to facilitate resolving it. Only commit to doing what is doable.

* Emphasize that with your help and the administrative structure you have created, the two parties in conflict will be able to resolve their issues and will learn something positive from this experience.

3. Confront offenders with data, authority, and compassion

"I guess we'll keep acting this way until someone stops us."

--A disruptive physician

"I'm afraid of how vindictive she is or I would confront her myself... Why doesn't the hospital administration do something about her? She's an embarrassment to our group and to our profession."

--The associate of a disruptive physician

Sentiments like these suggest that disruptive physicians and their associates struggle with an ambivalence that is important to note. We have found that most disruptive physicians regularly feel remorseful and ashamed of their behavior, and that, at some level, they want help to change. Often, they remind us of acting-out adolescents who rebel against authority, yet relax when confronted with firm, fair limits. Furthermore, even members of a medical group who are disruptive tend to hinge their respect of administrators on how they manage other disruptive colleagues.

Show firmness and compassion when confronting an offender. Vague, tentative, or indirect confrontations seldom work. On the other hand, retaliatory, vindictive, or simply punitive responses to offensive behavior may serve a policing function, but they do not foster the development of a positive interpersonal culture.

The following lists integrate advice from conflict resolution experts. (1-6)

Who should be included in a confrontation?

* Don't do it alone. A group confrontation provides more balance and force, and group input is harder to deny or dismiss as being a personal disagreement. Include a supporter of the person to be confronted, but be sure the supporter does not condone or minimize the bad behavior.

* Try not to make the meeting too contentious, Keep out the offender's lawyers, at least at first.

How should the confrontation be orchestrated?

* Remind the offender that your feedback is based on the norms that he or she helped to develop or agreed to upon joining your organization (i.e., the code of conduct).

* Let peers take the lead. Physicians are more likely to accept criticism from other doctors; nurses from other nurses; administrators from other administrators; and so on. With a "barrage" of feedback, have each participant cite detailed examples of how the offender's behavior has been unacceptable or damaging to the organization.

* Focus feedback on specific behavior that has been documented, not on personality. Avoid the use of any judgmental or interrogative tones.

* Along with constructive criticism, point out the offender's special skills and his or her importance to your overall operation. But bear in mind that no one is irreplaceable to an organization.

Take time to listen

* Solicit the offender's side of the story. Here, you might say: "Regardless of why it happened. the inappropriate behaviors we have specified are unacceptable; they must stop now. However, given that it is our goal to improve relationships. not simply to police bad behavior, we want to explore why this has happened<"

* Work together to create a plan for change. Here, useful questions might include the following:

* "What do you think will happen if this does not change?"

* "Have you ever faced situations like this or received this sort of feedback before? If so. what helped you to modify your behavior?"

* "What new skills, support, or changes would help you now?

* "What kind of support do you need from me (or us)?"

Offer concrete advice for positive change

* Express confidence that the offender can and will change, and offer concrete suggestions for making the desired changes. If appropriate, share from your own experiences with similar situations.

* Depending on the severity and duration of the problem pattern, offer or insist upon the offender receiving outside help to learn appropriate behavioral control.

If possible, facilitate face-to-face dealings between the parties in conflict

* Relationships mature if conflicting parties are helped to deal directly with each other in positive ways. Wait to conduct face-to-face meetings until defensiveness, embarrassment, and anger have calmed.

Close with compassion, but firmly underscore that the disruptive behavior must change

* Express regret that this difficulty has occurred and acknowledge that the offender is a good person who has made poor choices.

* Challenge the offender to shape up or else face progressively serious consequences.

* Emphasize your commitment to safeguarding against any subtle or obvious acts of retaliation against the reporting parties. Make it clear that human resources professionals will meet with complainants to make sure that harassment stops.

4. If needed, get outside help

Outside help may be required for disruptive individuals and/or for your organization. Contacting your state or county medical societies can help to identify organizations for assessing and treating impaired employees. (Please see the partial listing of organizations below.)

It is unfair to expect an individual to learn to function adaptively in an unhealthy system; unless your organizational culture promotes positive interpersonal dynamics, you will be doomed to a series of episodes of conflict, each serving as a symptom-bearer for the dysfunctional system.

5. Offer workplace training and experiences that foster positive relationships

Interpersonal dynamics improve when both staff and physicians learn to view each other with compassion and to anticipate and control the difficult interactions that come when high-powered, busy people work together. Three sorts of interventions can help here: continuing education programs that teach about the psychology of physicians; workshops on the use of positive interpersonal skills; and expanded venues that foster staff/physician interactions.

Ideally, educational sessions that address relationship dynamics should be spaced throughout the year and presented in a fashion that allows all staff to attend. Alternatively, organizations may choose to have a one-day intensive training session, with joint and concurrent workshops for staff and physicians.

In addition to education, workplace relationships are strengthened by experiences that prevent conflicts from escalating and that expand individuals' perspectives of each other. Herein lies one of the values of holiday parties or retreats. Sharing meals or participating in informal gatherings in break rooms also helps. In practice settings, mandated attendance at regular group meetings is a team-building must.

To prevent escalation of conflict and underscore your commitment to holding everyone accountable for behavioral issues, have nursing representatives from targeted hospital units meet regularly with physician representatives from the practices that serve those units. Some hospitals have nurses on each unit elect physicians they trust to serve as their representatives to the physicians' respective practices. Such arrangements serve the important role of informally encouraging collegial repair attempts when doctors and nurses experience low-level conflict, before attitudes harden.

We are not suggesting that all members of an organization must become friends, but periodically expanding our perspectives of each other can increase mutual tolerance and empathy, even during times of conflict.

6. Follow-up

Dealing with a conflict may be an event, but shaping positive interpersonal dynamics is a process that requires follow-up. Reinforce your organization's commitment to promoting a caring, professional interpersonal culture by routinely offering in-house training in interpersonal skills. Newsletters, awards, and other incentives that reward outstanding examples of collaboration can also help reinforce progress. The key to conflict management is to continue to surround any episodes of conflict with ever-growing, concentric circles of positive relationships.

7. Practice what you preach and get support for yourself

The most effective physician executives lead by example. But being a medical leader is often a thankless job that can leave one feeling drained, lonely, and angry. Practical self-care guidelines for busy medical professionals are available. (7-10) Without appropriate self-care and support from peers, family, and friends, you will run the risk of suffering the very ailments you are trying to avoid.

Conclusion

Today's competitive health care marketplace mandates that we build stress-resilient medical organizations. This cannot be done by simply policing and eliminating disruptive behaviors in the workplace; we must shape organizations that are positive interpersonal cultures. The self-assessment and intervention guidelines discussed In this series of articles can help you to move beyond struggling with episodes of conflict to shaping truly stress-resilient medical organizations.

TABLE 1

GUIDELINES FOR PROMOTING POSITIVE INTERPERSONAL DYNAMICS IN THE MEDICAL
WORKPLACE


1. Provide protection

2. Listen and empathize, but avoid triangulation

3. Confront offenders with data, authority, and compassion

4. If needed, get outside help

5. Offer workplace training that fosters positive relationship skills

6. Follow-up

7. Practice what you preach

--Wayne M. Sotile, PhD, & Mary O. Sotile, MA

TABLE 2

SUBTLE BEHAVIORS THAT UNDERMINE GROUP COHESION


* Secretive decision-making

* Lack of or indirect communication.

* Lack of response to input or suggestions from partners

* Cold, aloof behavior

* Passive/aggressive behavior
     (for example, chronic absence or tardiness from group meetings)

* Inconsistency or mixed messages from practice leaders
     (for example, refusal to follow group policies)

--Modified from Ryan, K.D. & Oestreich, D.K. Driving Fear out of the
Workplace, Second Edition, San Francisco, California: Jossey-Bass, 1998

References

(1.) Lowes, R. Taming the disruptive doctor. Medical Economics, 1998: October 5:67-68,73-74,77-78,80.

(2.) Ryan. K.D., Oestreich, D.K. Driving fear out of the workplace: Creating the high-trust, high-performance organization. San Francisco, California; Jossey-Bass. 1998.

(3.) Moore, H.L., Cangelosi. J.D., Gatlin-Watts R.W. Seven spoonfuls of preventive medicine for sexual harassment in health care, Health Care Supervisor, 1998:17(2):1-9.

(4.) Sotile, W.M., Sotlie, M.O. The angry physician 1: The temper-tantruming physician. The Physician Executive, 1996;22(8):30-34.

(5.) Sotile, W.M., Sotile, M.O. The angry physician 2: Managing yourself while managing others, The Physician Executive. 1996: 22(9):39-42.

(6.) Pfifferling, J-H. Managing the unmanageable: The disruptive physician. Family Practice Management. 1997: Nov/Dec: 77-78,83,87-88,90,92.

(7.) Sotile. W.M., Sotile, M.O. Effective emotional management Keys to the balancing act facing contemporary administrators. Journal of Cardiovascular Management, 1996: 7(2):18-23.

(8.) Sotile. W.M., Sotile, M.O. Supercouple Syndrome: How Overworked Couples Can Beat Stress Together New York, New York: John Wiley & Sons. 1998.

(9.) Sotile. W.M., Sotile, M.O. The Medical Marriage: A Couple's Survival Guide. New York, New York: Birch Lane Press, 1996.

(10.) Sotile, W.M., Sotile, M.O. The key to excellence: Successful executives keep the flame alive at work and at home! Journal of Cardiovascular Management, 1999: 10(1):10-15, 1999.

RELATED ARTICLE: RESOURCES FOR INTERPERSONAL AND BEHAVIORAL ASSESSMENT, INTERVENTION, AND TRAINING

The following is a list of organizations that address interpersonal and behavioral issues is health care organizations:

Abbott Northwestern Hospital

Professional Assessment Program

Minneapolis, Minnesota 

612/863-8290

[e-mail]

Bayer Institute for Health Care Communication

400 Morgan Lane

West Haven, CT 06516

800/800-5907

www.bayerinstitute.org

Center for Professional Well-Being

21 West Colony Place Suite 150

Durham, NC 27705

919/489-9167

www.cpwb.org

Menninger Clinic

Professionals in Crisis Program

Topeka, Kansas 

800/351-9058

www.menninger.edu

Sotile Psychological Associates

1396 Old Mill Circle

Winston-Salem, NC 27103

888/629-2313

www.sotile.com.

Wayne M. Sotile, PhD, & Mary O. Sotile, MA

Wayne and Mary Sotile are keynote speakers and health care consultants from Winston-Salem, North Carolina. They can be reached by calling 336/765-3032 or via email at [e-mail].