Managing low-to-mid intensity conflict in the health care setting. (Part 2: Conflict Management).

CONFLICT MANAGEMENT skills are essential in the portfolio of an effective physician executive and will become even more critical as complexity and urgency trigger more discomfort and fear among the diverse contributors to the health care industry." The July/August issue of The Physician Executive cited a flashmail survey to which 115 members responded, saying they spent at least 20 percent of their work time dealing with conflict. (1) A number of helpful articles in that issue emphasized appropriate use of formal negotiation, mediation, and other alternative dispute mechanisms in health care settings. This article focuses on the application of five major conflict management strategies to the low-to-mid intensity conflicts plaguing most physician executives.

Conflict may be defined as a situation In which two or more people cannot agree on the actions that one person takes or that he or she doesn't want the other to take. (2) This definition embodies the three themes that Kenneth Thomas suggests are common to most definitions of conflict: (1) perceived incompatibility of Interests; (2) some interdependence of the parties; and (3) some form of interaction. (3) Thus, conflict is not inherently negative or destructive; like most other experiences, it is what one makes of it.

Continuum of conflict intensity

Despite the common tendency to conclude that conflict implies fight, struggle, or baffle, interpersonal conflict in the workplace actually occurs along a continuum of intensity (please see Figure 1). Conflict at the low-to-mid intensity end of the continuum--disagreement, clash of personality types or personal styles, and hostility--is common, often a daily occurrence, in the life of the physician executive.

Such conflict compromises productivity, saps the energy of participants and affected parties, reduces the joy in work, and contributes to the consumption of antacids. All too frequently busy physicians and physician executives avoid such conflicts In hopes that they will go away; indeed, conflict avoidance may be part of the culture of the health care organization. Unfortunately avoidance often triggers an increase in the intensity or density (number of people involved) of the conflict.

In addition to the dimension of intensity, conflict in the workplace can be categorized according to issues and duration (acute, subacute, chronic, and interminable) . When a participant in conflict, it may be helpful to determine whether the issue is: (1) something you want or want to avoid, (2) something you have and want to keep, (3) some belief you hold, or (4) some action you want or don't want to take.

Conflict also arrays along the dimension of relationships. When, in the course of our work, we have asked physicians to identify the types of conflict that they find mast troublesome they cite situations with peers, people they supervise, and people who hold authority over some aspect of their professional lives. Common examples are listed In Figure 2. These three categories provide a frame from which we will describe typical conflict scenarios, evaluate specific approaches, and recommend general behavioral guidelines. These relationship categories naturally sort the conflicts according to the possible differences in power and position within the organization. Power and positional differences dramatically affect the dynamics in disputes, making some tactics and strategies more appropriate than others. The direction and nature of the relationship with the other person affects an individual's confidence level, perception of conflict management options, and the value or risk of a direct approach.

Even with low-to-mid intensity conflict, the effects often extend beyond the parties involved; conflict poorly managed may have an adverse impact elsewhere in the organization and conflict well managed may have broad positive effects. The physician executive skilled at effectively managing the common low-to-mid intensity conflicts in the workplace is more likely to get more of what he or she wants and less of the griping, sniping, and gossiping that waste time and undermine productivity.

Approaches to conflict management

Conflict management is defined herein as the use of strategies and tactics to move all parties toward resolution, or at least containment of the dispute, in a manner that avoids escalation and the destruction of the relationship. Thomas and Kilmann identify five fundamental modes or approaches to conflict management: competition, avoidance, compromise, accommodation, and collaboration. (4)

1. In competition, the individual competes to overcome opposition and assure that his or her position prevails. The underlying assumption is that conflict is a contest in which one either wins or loses. Competition is an appropriate approach when: (1) the resources in question cannot be divided (salary negotiation, research grant, insurance contract): (2) the issue is compliance with high stakes policy (informed consent, sexual harassment); (3) significant time constraints limit the process; and (4) the other party refuses to take anything other than a competitive approach. Competition does not enhance the relationship of the parties nor build any support for implementation of the decision. Competition may increase the power differential between the parties and, if used frequently by the physician executive, may send an unwanted message about use of power.

2. Individuals who are unwilling to risk the possibility of loss avoid conflict. This is an appropriate strategy when the conflict is trivial or the individual is not a primary party to the conflict. Avoidance may also be the best strategy when winning is impossible. One can use temporary avoidance to get a needed cool-down period before facing the conflict and it can be used to set the stage for later collaboration. One might, for example, suggest deferring until a set time later in the day an escalating hallway dispute over patient management. When conflict is avoided, the opportunity to clarify issues is missed and the unaddressed issues may trigger additional conflict. Edelman and Crain suggest that failure to deal appropriately with conflict at an early stage may be the most important overall source of conflict. (2)

Repeated avoidance may undermine confidence and self-esteem and stimulate others to regard the individual as weak.

3. Like competition, compromise is based on the positions of the parties, with both making some trade-off and getting some of what they want. Compromise is appropriate when both the issues and the relationship of the parties are important or when an expedient resolution that does not undermine implementation is needed. Compromise may be used to achieve a temporary settlement of complex issues that require collaboration for long-term management. For example, practice partners might agree to a strict rotation of weekend call for four to five months while they address the underlying issues of staffing and income expectations. It is the back-up strategy when collaboration fails. Like competition, compromise may not clarify underlying issues and it may miss a systems solution that is far better than the position of any party. In addition, it is often difficult to balance the concessions so that all parties feel they have won and lost equally. (5)

4. With accommodation, the individual engages the conflict but subordinates his or her personal interests for the sake of preserving the relationship. This approach may be most appropriate when you sense that the issue is much more important to the other party. For example, two colleagues on the medical staff, each bolstered by supporters, may be running against each other for medical society office in the state. When Doctor A starts hurling insults, Doctor B might choose to tell A that he plans to defer his candidacy until the next election, since the race seems so much more important to A. He will, of course, expect A's support when he runs. Accommodation is also useful when you discover that you are in error or can't win in a competition. When you anticipate major competition with an individual, accommodation can be a useful proactive strategy. Most physician executives eventually must deny resources to some individuals; the proactive use of accommodation in minor conflicts can signal that the relationship is valued.

5. Collaboration is often termed win-win because it focuses on achieving goals rather than meeting demands. Collaboration is a key strategy for many major conflicts in health care because it builds understanding of complex issues and interdependent systems and, by building consensus for implementation, increases the possibility of sustainable change. Collaboration, however, is time-consuming and requires that all parties be prepared to listen and work together. Knowledge of the issues and facility with idea-generating and consensus-building tools are key skills for those engaged in collaboration.

Kenneth Thomas describes these five approaches in a two-dimensional taxonomy of assertiveness and cooperativeness; competition and avoidance are the least cooperative while collaboration and accommodation are most cooperative. (3) Both competition and collaboration are assertive approaches.

Compromise is intermediate in both dimensions. Each approach has advantages and limitations. No single mode is superior to others in all situations. The physician skilled in conflict management will be a master of all five modes, able to select the approach most likely to give best results in a given situation, and able to alter the approach as conditions change.

Applying the five conflict management strategies

Scenario 1

A radiologist on the staff of a large community hospital was stopped after a staff meeting by a colleague in internal medicine. On Monday of the previous week, the internist referred an elderly man with chronic, productive cough for chest X-ray, with a clinical diagnosis of bronchitis. Thursday morning the internist received the radiologist's written X-ray report with a diagnosis of "probable bronchogenic carcinoma." The internist expressed his dismay that the radiologist had not called him much earlier with a verbal report. Visibly upset, the internist raised his voice but did not use abusive language.

As emphasized in part I of this article series, the first step in managing any conflict situation should be a thoughtful diagnostic assessment of the parties, issues, and dynamics. (6) The radiologist should seek additional Information, acknowledge the internist's feelings, and avoid comments or body language that might escalate the situation, It would be important for both parties to know whether this incident represented a deviation from current practice, a gap in definition of service standards, or a personal preference of the internist. Ideally, the radiologist should approach this situation collaboratively, engaging the internist in discussing requirements for optimal care of patients. Alternately, the radiologist could be accommodating, acknowledging that while policy does not require it, he would be willing to ensure prompt verbal reports on any patients the internist flags for such.

In actuality, the radiologist said nothing but wrote to the hospital's credentials committee, complaining about the internist's "unprofessional" conduct. Several years later, the internist discovered the letter while reviewing his personnel file. The opportunity to clarify issues and preserve a good relationship was lost.

Scenario 2

The family and community medicine division of a large staff model HMO serves a population that is ethnically diverse. The senior management team of the HMO, spurred by repeated complaints from representatives of one racial group, has encouraged the division, all of whose physicians are white, to diversify. Several black and hispanic physicians with strong credentials apply for the open positions but none are hired Weeks later, a young woman family physician learns from several colleagues that the division director has identified her as racist and the obstructionist to recruiting. The comments attributed to her are not only false but are typical of discriminatory statements that she has heard the division chief utter The rumors about her "behavior" have circulated widely in the division.

Avoidance or accommodation in this situation could be disastrous to the physician's reputation and undermine her self-esteem, Two actions are essential: (1) disseminating accurate counter information to colleagues without labeling the division chief and (2) confronting the division chief to request that he set the record straight. She might first approach him in a collaborative mode, acknowledging their common interest in building an effective, harmonious division and state the rumors that have come back to her. She might then identify the personal result she wants and ask how they might work together more effectively. If he refuses to discuss the situation, denies it, or takes an oppositional stance, she must adopt a competitive strategy and be prepared to leave if she loses.

Scenario 3

A manager who reports to the vice president for clinical affairs of a tertiary care hospital hired a young woman to supervise development of a large community outreach program. During the first four months of her employment, several behavioral problems come to the VPCA's attention: (1) complaints from community physicians that the coordinator criticizes other physicians in public; (2) concerns from two community leaders that the coordinator is not truthful; and (3) written reports about the project that label and blame others, sometimes in language that is disrespectful. The VPCA spoke several times to the manager about these problems. The manager reported other dissatisfactions with the coordinator's performance, but he shows no sign of dealing with the behavior Two more complaints come in, one from an influential community leader.

The VPCA should clarify the manager's accountability for the coordinator's performance. If the manager lacks the competency to manage performance, the VPCA could take a compromise approach, agreeing to speak to the coordinator himself but insisting that the manager have skills training as soon as possible. In a collaborative mode, the VPCA and manager might work together to set new performance management practices and ensure that all managers have the requisite skills. Depending on the manager's overall performance, the VPCA might take a competitive approach, telling the manager to fire the person or risk sanction. Avoidance might affect morale if others think managers don't deal with lowperformers.

Scenario 4

The medical school in an academic health center recently implemented a problem-based curriculum, dramatically reducing the number of lectures given and substituting small group learning that focuses on actual patient cases. Both clinical and basic science faculty are feeling stretched in their new roles. In the past, dental students took the basic course in microanatomy with medical students. The core lectures are still given but at different times that do not match with the dental curriculum schedule. The anatomists insist that they don't have time to teach another course specifically for dental students. The dean has informed the chair of the department of anatomy and cell biology that some educational revenues will be redirected to the dental school if the faculty do not meet this need.

The CEO of this medical center should focus on coaching the medical and dental school deans to a resolution and avoid becoming a primary party to the conflict. This is a situation that will require commitment and active participation of many for sustainable resolution. Collaboration is clearly the best approach. The two deans, for example, might jointly charge a faculty taskforce to develop a curriculum and methodology in microanatomy that will meet the needs of medical and dental students and optimize use of faculty and other resources. This taskforce should have a deadline for its work and accountability for the final decision should be determined in advance. This approach will take some months so a compromise for the next academic year might be needed.

Scenario 5

The partners in a group practice are in formed by the clinic manager that one member of the group has been repeatedly upcoding procedures for a specific diagnosis. This issue first came to light six months ago. At that time the partners met with him, clarified the Medicare guidelines and outlined the threat to the practice for non-compliance. He argued with their view but ultimately agreed to code appropriately. There were no infractions for several months but now he has submitted several erroneous codes. One member of the office staff has asked whether Medicare would consider this behavior "fraudulent."

If this dispute was a matter of practice style preference, collaboration or compromise might be most appropriate. Given the import of the federal regulations, however, there is no room for anything other than compliance with the coding guidelines. Having tried to educate the partner without getting compliance, the partners must insist on a competitive approach, terminating the partner if he refuses to comply. The partners should accurately describe the situation in writing and document all efforts toward prompt remediation. It might be prudent to seek expert advice about whether this situation requires alerting Medicare.

General guidelines for conflict conversations

Whether you are dealing with peers, people you supervise, or the person you report to, there are some general guidelines for every conflict conversation:

1. Identify as much of the critical information as possible

2. Deal with the conflict early

3. Treat the other with respect and avoid demeaning language

4. Be aware of your body language and that of the other

5. Use "I" statements and avoid "you" statements, which may be heard as blaming

6. Articulate your needs

7. Acknowledge their needs

8. Focus on the issues or the behavior, not the person

9. LISTEN, LISTEN, LISTEN

More specific guidelines for managing conflict with peers, supervisees, and authority figures are outlined in Figure 3.

Conflict management as process not event

The action-oriented, multi-tasking work mode of physicians is often at variance with effective conflict management, which is a process not an event. Most physicians have had little or no training in the skills of managing conflict and frequently attempt to "deal with it" by avoidance. They may either underestimate their ability to influence the conflict management process or falsely assume that low-to-mid intensity conflicts are not significant.

To increase their ability to manage complex interpersonal conflict, physicians should: (1) take a diagnostic approach to assessing conflict situations, (2) continually hone their listening skills, (3) use tools such as "protocols for balancing inquiry and advocacy," referenced in the Fifth Discipline Fieldbook, (7) to increase clarity, and (4) practice the five modes of conflict management with a trusted partner. Conflict management is a learned skill akin to playing a musical instrument: with repeated practice, one can "play" increasingly more complex 'pieces" but skill falls off quickly without practice.

FIGURE 2 COMMON CONFLICT SITUATIONS

When physicians were asked to identify the types of conflict that they find most troublesome, they cited situations with peers, people they supervise, and people who hold authority over some aspect of their professional lives. Common examples include:

Conflict with peers

Schedules and calendars

Approaches to patient management

Sharing workload

Clinic or laboratory space

Management of budget for a group/unit

Balancing patient care, teaching, and research

Authorship disputes

Failure to deal with their low performers

Conflict with people supervised

Conflict among supervisees that compromises work

Expectations for performance

Dealing with the low performer

Workloads and schedules

Inappropriate personal relationships at work

Volume and quality of work

Interactions with supervisor

Unwillingness to change practice or behavior

Supervision outside the hierarchy

Conflict with authority figures

Disagreement about values

Lack of consistency in their actions

Micromanagement 

Unfair treatment

Discrimination

Salary negotiations

Broken promises

Clinical and other workload

Ethical dilemmas 

--Carol A. Aschenbrener, MD, & Cathie T. Siders, PhD

FIGURE 3

GUIDELINES FOR MANAGING COMMON CONFLICTS

Specific guidelines for managing conflict with peers, supervisees, and authority figures include:

Managing conflict with peers

Focus on shared interests and goals

Emphasize non-competitive strategies

Involve other parties only if an impasse occurs

Establish ground rules for the discussion

Use humor if appropriate

Cultivate the relationship all the time, not just during conflicts

Managing conflict with supervisees

Be congruent in your words and actions

Assume they know more about you than you know about them

Be explicit about performance expectations and consequences

Give feedback privately, in behavioral terms

Deal with low performance early

Coach employees through their conflicts with each other, don't become party to it

Managing conflict with authority figures

Present the relevant data concisely

Tell them what you want them to know about you

Be explicit about what you want

Link your goal to something they value

Bring ideas for resolution

Distinguish style differences from systemic issues

Acknowledge the interests/constraints of their position

Understand the unwritten rules of the group/organization

Don t expect approval or appreciation

Don t cause them to lose face in public

Carol A. Aschenbrener, MD, & Cathie T. Siders, PhD.

References

(1.) When Cooling it Gets Hot. The Physician Executive. 25(4): July/August. 1999.

(2.) Edeiman J. & Crain MB. The Tao of Negotiation. New York. New York: HarperBusiness, 1993.

(3.) Thomas K. Conflict and conflict management: Reflections and update. J Org Behav, 13: 265-274. 1992.

(4.) Kilmann R.H. & Thomas K.W. Developing a forced-choice measure of conflict-handling behavior: The "mode" instrument. Educ & Psychol Develop. 37: 309-325, 1977.

(5.) Kritek P.B. Negotiating at an Uneven Table: Developing Moral Courage in Resolving our Conflicts. San Francisco, California: JosseyBass, 1994.

(6.) Siders C.T. & Aschenbrener C.A. Conflict management checklist: A diagnostic tool for assessing conflict in organizations. The Physician Executive, 25: 33-37, July/August 1999.

(7.) Senge P.M., Roberts C., Ross RB.. Smith B.J. & Kleiner A. The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. New York, New York: Doubleday. 1994.

Carol A. Aschenbrener, MD, is a Clinical Professor of Pathology at George Washington University Medical Center and a Washington. DC based consultant. She serves as Chair of the National Board of Medical Examiners. She can be reached by calling 202/518-6840 or via email at [e-mail].

Cathie T. Siders, PhD, is a psychologist specializing in organizational consulting and executive coaching. She completed mediation certification through the Boston University School of Public Health ("Conflict Resolution Strategies for Health Care" directed by Dr. Leonard Marcus). She can be reached by calling 202/3381407 or via email at [e-mail].

AUTHORS' BOOK PICK

Senge P.M., Roberts C., Ross R.B., Smith B.J. & Kleiner A. The Fifth Discipline Fieldbook: Strategies and Tools for Building a Learning Organization. New York, New York: Doubleday, 1994.

Even though it's not a conflict specific text, it's always on or next to our desks because it is chock full of clear, concise actions that managers can take to increase clarity, build consensus, and enhance alignment.