Managing yourself while managing others.

One of the most difficult aspects of physician leadership is addressing angry colleagues. "It is often the well-established physician who has the most difficulty managing resentments about changes in health care," states John J. Harper, MD. "It's easy to say 'If you don't cooperate with changes in the system, you will lose your privileges.' But this issue is not that simple. These are valued and valuable colleagues; we want to find a way to help them, not censure them. How can this be done?"[1]

Strategies for managing

others' anger

Eight practical communication guidelines are recommended by experts in the field for managing anger in others. They include:

1. Strike while the iron is warm. Perhaps the easiest way to deal with an angry person is to engage him or her before the anger escalates. Respond to subtle signs of anger or irritation in others: their tone of voice, nonverbal reactions, or behaviors. Ask if they are bothered or upset. Offer to help, or to simply listen, or discuss the issue at hand.

2. Match, then lead. If you are to have influence on others, you must "speak their language." This means different things in different contexts. In dealing with an angry colleague, it means initially conveying - through your verbal and nonverbal reactions - a validation of the anger that the other is expressing. Avoid the mistake of showing absolute calm when initially engaging an angry person; doing so may be misinterpreted as an indication that you do not care about the issue that has fueled the a An appropriate matching response might be something like, "It makes absolute sense that you are upset about this. Something has to be done to straighten this out and prevent this from happening again. Can we meet this afternoon to discuss this further?"

3. Stay in your own zone. Matching the other's anger must be accomplished, short of escalating it. This means controlling your own reactions, even when the other person is out of control. As a physician, you have accumulated much experience in maintaining a "therapeutic distance" while treating patients. This can serve you well during highly emotional interchanges. When possible, anticipate the angry interchange and prepare yourself for it. Remind yourself to stay relaxed; dissociate from the other's barrage of anger; use centering self-statements, such as, "I don't have to catch his anger." "I feel anxious myself, but I am not angry." "We have been through this before, and I know that she will soon calm down."

4. De-escalate the other's angry reactions. Here, remember not to discount your influence on others. You can help the other person begin to calm down by being a source of positive emotional contagion. For example, demonstrate a calm approach to the problem solving at hand. You might also offer a new perspective on the problem, using humor (if appropriate). Most effective is to help the other person to simply slow down by subtly slowing down yourself. After matching the person, gradually slow your own speech and breathing. Sit or stand in a relatively still, relaxed posture. Do not interrupt; speak in a calm, steady voice, and avoid using inflammatory words or statements. Avoid arguing back in the midst of the other's angry flurry: Most people are unable to debate rationally during a bout of emotional outpouring. Wait to discuss facts until after the emotion has subsided. Ignore threats or inflammatory statements. Do not mind read; ask for additional information. Calmly and clearly summarize what you think the other is saying. The best way to calm an angry person is to let them know that they are being heard and that you care about them.

5. Do something different. When possible, disrupt the anger escalation by changing venues. Stop what you are doing, and fully attend to the interaction. If you are standing, invite the other to sit. If you are sitting, invite the other to take a walk, have a cup of coffee (decaffeinated!), or move to another room. If need be, simply call time out. This should be done in a manner that conveys respect and concern, both for the issue at hand and for each of you. For example, you might say: "Dr. Jones, this is tremendously important. I would like to make a suggestion: Can we agree to call a time out from this discussion, to let some of this settle. I do not want to respond until I have had a chance to let this sink in. Would it be convenient for you to meet again with me this afternoon at 5:15 to resolve this?"

6. Be assertive, not aggressive. High-powered people often confuse behaving aggressively with being assertive. In fact, the most powerful leaders are seldom aggressive; they are powerfully influential in their ability to clearly assert themselves without doing damage to the other person. See Table 1 on how to develop a model for adaptive expressions of anger.

TABLE 1  CHARACTERISTICS OF ADAPTIVE
         EXPRESSIONS OF ANGER

* Focuses on the problem at hand.

* Involves a clear and genuine expression of personal feelings.

* Avoids expression of opinions that belittle others.

* Focuses on the speaker's internal reactions, rather than on the
listener's actions.

* Avoids any judgment about the listener's character.

* Inflicts no harm; does not attempt to coerce the listener.

* Suggests constructive remedies to the bothersome situation.

* Conveys a spirit of intention to get beyond the tension at
hand.

* Results in both parties maintaining self-esteem.

- Adapted from Sotile, W. Psychosocial Interventions for
Cardiopulmonary Patients:
A Guide for Health Professionals, Champaign, IL: Human
Kinetics, 1996.

Appropriate assertion involves five steps:

Step 1: Use relaxation to curb urgent behavior and quell escalating emotions.

Step 2: Disrupt catastrophizing, anger-generating frames of reference.

Step 3: Pause and identify what you think, feel, need, or want in the moment.

Step 4: Identify a tangible aspect of the interaction that is upsetting to you.

Step 5: Use the following formula for appropriately asserting yourself: "When you do or say X (fill in with a specific), I feel Y (an undesirable outcome), instead of Z (a desirable outcome). I would appreciate it if you would A (specify exactly what you would like from the other person) instead."

Appropriate assertion is not the same as destructive criticism; it does not leave the other person damaged. Rather, it leaves him or her informed about a tangible way to better get along with you. Extensive guidelines for assertion training are available.[8]

7. Use effective negotiation tactics. Managing angry reactions is about negotiating new outcomes to problem situations. No matter how "right" you are, your point will be lost if you try to negotiate in anger. Effective negotiators employ the six strategies outlined in Table 2.[9]

TABLE 2  GUIDELINES FOR EFFECTIVE NEGOTIATING

1. Stroke the person and demonstrate a leap of faith you will
resolve the problem.

2. Validate the other person's perceptions.

3. Focus on the problem at hand. Don't blame or catastrophize.

4. Emphasize where you agree.

5. Apologize.

6. Listen. Clarify underlying issues and don't lock into
positions.

- Adapted from: Sotile, W. & Sotile, M. The Medical Marriage:
A Couple's Survival Guide. New York, NY:
Birch Lane Press, 1996.

These strategies are taken from the work of professional negotiators, Fisher and Ury,[9] who remind us that the most effective way to negotiate is to separate the person from the problem being addressed, and, while holding to your own most important issues, calm the person. This means letting the other person know that you value him or her, that you consider your relationship to be more enduring than the impact of the problem, and that you regret that this problem exists. In this later regard, the three most powerful words for effective negotiating may well be "I am sorry." Here, apologizing is not done in the vein of accepting blame or responsibility for the problem at hand; it is a statement of regret that the issue at hand is upsetting the other person and/or your relationship.

The point of effective negotiation is to solve the problem at hand. To do so, you must avoid displays of impatience and blaming. Rather, express openmindedness, even toward irrational ideas. During negotiations, always protect self-esteem: your own, and the other person's. In clear, non-inflammatory language, clarify your position and reflect an awareness of the other person's position. Ask what is important to the other person, and solicit his or her ideas about what can be done to resolve the situation. Agree to a solution only if you can implement it. if you cannot agree, or if you must, as a physician leader, implement sanctions against the other person, do so in a manner that conveys respect.

8. Operationalize the Problem. It has been recommended that the problem of dealing with angry physicians be managed on an institutional level. Pfifferling called for conceptualizing angry physicians as suffering from behavioral handicaps, and recommended various institutional safeguards against potential liabilities encountered by such behavior: "The easiest way to deal with behavioral handicaps is to incorporate written descriptions of expected professional behavior into a .. Principles of Practice... document that spells out mechanisms for dealing with an emotionally-disturbed, unruly, or generally disturbing individual."

Change begins with feedback. The effectiveness of any anger management intervention is enhanced if it is paired with input from those who work (or live) with the physician. The exercise in Table 3 an be used to help physicians see themselves as others experience them.

[TABULAR DATA OMITTED]

Change your organization

Managing anger needs to also be addressed on a broader level, one that targets prevention, rather than after-the-fact interventions. Today's physician leaders must chart the way through the new stress-filled territory that faces their colleagues.

Wise administrators implement institutional changes that improve productivity, quality of life, and longevity for physicians. For example, sanctions controlling the number of hours medical residents can work are being implemented, and British hospitals are limiting the number of contract hours for physicians to 72 hours per week.[11] Additionally, such changes might include enforced periods during which physicians are not available for clinical activities; compulsory use of entire vacation allotments; and rotating unpleasant administrative chores in academic medical departments.

To promote stress hardiness for physicians, we would be wise to heed the warning issued long ago by Jack McCue, MD: It is time to put an end to the "conspiracy of silence, that physicians and their loved ones tend to perpetuate with their lack of open support of each other in the struggles that they encounter as individuals, couples, and families. Physician leaders can help in many ways. Training in more effective methods for dealing with emotions and relationships can be incorporated into the curricula of grand rounds and other continuing education events.[13]

During such meetings, we must go beyond the antiquated notion that physicians' significant others mainly want to be entertained, patronized, or ignored. Rather, such meetings should incorporate concurrent sessions that provide training on how loved ones can manage themselves and the teamwork within their family in order to preserve stress hardiness for all concerned.

Finally, we need to destigmatize the physician who seeks help in learning to cope more adaptively. Contrary to popular mythology, approximately one-third of physicians polled indicate that they participate in counseling or psychotherapy for personal or family problems.[14] Physician leaders would serve their colleagues well by making it easy to seek such help. Formal affiliation with consultants who have demonstrated expertise in helping physicians and their loved ones cope can greatly ease the process of getting the help that physicians often need.

Conclusion

Anger management and communication skills are essential tools for physician leaders. These tools help in dealing with problematic interactions, but they do not necessarily resolve the sources of distress that generates angry physicians. Both quality of life and quality of practice are drastically effected by physicians, able to better manage themselves. It is perhaps here, more than in any other area, that physician leaders can make a difference by modeling and teaching ways to control anger, even during the often uncontrollable times that prevail in our health care system.

References

[1.] John J. Harper, Medical Director, Forbes Health System, Pittsburgh, PA. Personal communication. [2.] Sotile, W.M. and Sotile, M.O. "The Temper-Tantruming Physician. Physician Executive 22(8):30-35, August, 1996. [3.] Sotile, W.M. and Sotile, M.O. The Medical Marriage. A Couples Survival Guide. New York, NY: Birch Lane Press, 1996. [4.] Sotile, W.M. Psychosocial Interventions for Cardiopulmonary Patients: A Guide for Health Professionals. Champaign, IL: Human Kinetics, 1996. [5.] Weisinger, H. Anger at Work. New York, NY: William Morrow and Co, 1995, p. 54. [6.] McKay, M., Rogers, P., and McKay, J. When Anger Hurts. San Francisco, CA: New Harbinger Publications, 1989. [7.] Williams, R. and Williams, V. Anger Kills. New York, NY: Harper Perennial, 1993. [8.] Alberti, R. and Emmons, M. A Guide to Assertive Living: Your Perfect Right. San Luis Obispo, CA: Impact Publishers, 1982. [9.] Fisher, R., and Ury, W. Getting to Yes: Negotiating Agreement Without Giving In. 2nd ed. New York, NY: Penguin Books, 1991. [10.] Pfifferling, J.H. "Ounces of Malpractice Prevention." Physician Executive. 20(2):36-38, February, 1994. [11.] Dalamothe, T. Ministerial Group Reports on Juniors' Hours. BMJ 1990;302:819. [12.] McCue, J.D. Doctors and Stress: Is There Really a Problem? Hospital Practice. 1986; March 30, p. 7-16. [13.] Fabri, P.J., McDaniel, M.D., Gaskill, H.V., Garison, R.N., et al. Great expectations: Stress and the Medical Family. Journal of Surgical Research 1989;47(5):379-382. [14.] Segraves, K. & Segraves, R.T. When the Physician's Marriage is in Trouble. Medical Aspects of Human Sexuality 1987; June: 148-159.