Resolving conflicts: principles and practice.

The first principle for conflict resolution is that it requires a diagnostic approach.(1) Each source of conflict suggests a different approach, which ranges from avoidance strategies, such as solution, cover-up, resignation, and withdrawal, to engagement through negotiation, arbitration, and compromise. Whatever the character of the conflict, it usually has three primary components: emotions, verbal content, and procedure. The artful problem solver will develop diagnostic and practice skills in each of these interrelated aspects of conflict.

Emotion

Emotions are present in almost every conflict. Rage and anger often reflect an underlying fear or anxiety(2) that becomes manifested in outrage. The source of anger is sometimes clear; often not. In fact, some suggest that, by the time a conflict emerges, many different levels of expectation have been violated.(3) At the surface, an expected but unfulfilled action, such as an unfilled medication order, frequently prompts anger and conflict.

Social norms refer to the implicit and explicit rules that govern our professional relationships. Health care organizations bring together numerous professionals, each imbued with a sense of rules about work and professional conduct. During conflict, norms are often expressed in the negative, e.g., "...but that's not my job." Norms are influenced greatly by professional interaction, such as the opinions of one's peers about "the way things are done at this hospital." Conflict frequently occurs when such norms and expectations are not clarified in advance among the professional team.

A third source of conflict derives from personal attitudes about the way the world ought to be. For example, physicians may perceive that their "covenant" with society(4) in which physicians enjoy social status as the .just reward for years of personal sacrifice during medical training, has been broken. These attitudes often derive from values imbued early in life, from family, school, religion, and other formative experiences. In a transitional era, many of these expectations are violated and irreversibly changed.

Verbal Content

Perhaps the easiest skill for effective conflict resolution is the development of alternative language, so that assertive statements may be used to clarify and defuse passive, aggressive behavior. Even in the face of the most aggressive opponent, assertive language helps define what is and is not acceptable, which in turn facilitates practical problem solving.

Much has been written about passive, aggressive, and assertive language and interaction.(5) Simply stated, the passive problem solver will accept unacceptable solutions, which demean oneself as well as the other party. A common response by others to such passive problem solving is underlying resentment, distrust, and other "meta messages"(6) that overshadow the substance of the interaction. Passivity may be a form of manipulation, to control the other party through projections of being victimized, into unwanted compromise. Passive-aggressive interactions are characterized by a cycle of guilt, resentment, and vengeful retaliation.

Aggressive behavior also exerts its toll--which is usually great!--where one seeks to "win at all costs." The aggressive problem solver usually destroys long-term trust and candor in the unrelenting quest to be fight.

Assertive skills convey both the substantive concerns and accurate emotions associated with such concerns, which helps keep the communication clear of overwhelming emotion or unstated implied messages.

Developing comfortable language skills and phrases is important to enhance conflict resolution. For example, if an immediate solution is sought, one can either submit or compromise, for the sake of an immediate but agreed upon, short-term solution, where no other method seems to work. This early form of collaboration may well serve to build trust and decrease resistance so that relationships are enhanced for future work together. The easiest skill is to acknowledge the other person, i.e., "You're right" or "You may be right and for fight now I agree, so long as we can reexamine this matter at a later date."

Assertive problem solving is an easily learned skill, and effective problem solvers usually have a repertoire of phrases to rely upon. Such phrases may include gentle inquiries or statements, such as "...if I understand you correctly, your concerns are...." "I feel like I'm missing something. Can you help clarify...." "Do I understand correctly?" and "It sounds like .... " Different professionals will be comfortable with different phraseology. It is important to develop assertive phrases compatible with one's overall professional style.

Another approach is to "actively listen," so that the other's concerns are clearly acknowledged. Active listening is the ability to paraphrase in one's own words the substance and concerns of the other person; it is not repetitive parroting, which only heightens frustration. The active listener conveys understanding of issues and emotions in her or his own words.

A third skill is to separate the person from their behavior and, if necessary, to confront the unacceptable behavior while appreciating the person. For example," Doctor, I can see this is extremely important to you. However, I will not participate if you continue to shout."

A supplemental skill is the habit of "speaking for yourself," instead of making statements for others. The most common pattern is the use of the word "you," instead of "I." For example, "You won't be very happy if you do that" presupposes that one actually knows what the other prefers, an unlikely event. It adds presumption to the state of conflict, which often triggers disputational replies and further escalation. An alternative practice is to speak for oneself, such as "I'm very concerned that we both agree to this solution, and I don't think we have fully discussed all the consequences of that option." Or more simply, "I tried that option and did not like it. I don't think you will either." A gentler approach may include the words "perhaps," "suppose," "what if," and "may 1 suggest." This style of interaction gives credence to the viewpoints of other professionals, helps to maintain professional courtesy, and generally helps maintain a calmer atmosphere.

Experts disagree on the impact of using direct questions in conflict resolution.(7-9) Among health care professionals, there seems to be greater tolerance for the direct question, probably stemming from the extensive professional training years.(10) However, one's tone of voice can make a legitimate assertive inquiry sound like a mocking rhetorical question. Where direct questions are used, a professional, calm, and direct tone of voice should be used. Phrases that invite response include, "Can you tell me more about .... ""Will you expand on that point, please...," and "Can you help me understand more about...."

Procedural Principles

It is also helpful to clearly understand one's options before proposing or accepting any one solution. This knowledge of alternatives has several beneficial outcomes. First, it provides a context for any specific solution. By maintaining a sense of several options, among which one is clearly better than others, we feel better and are more likely to stay committed to our choice. Options also provide greater psychological comfort by decreasing the feeling of being trapped or forced against our judgment or will to someone else's outcome. Knowledge of alternatives provides a sense of greater flexibility, which may also help the other party relax and be more creative, because we have not become too aggressive.

The effective physician leader will be well served by asking, "What is my desired outcome, and how do I assess the other options?" This extension of alternative development, on behalf of the other party, usually strengthens one's own perception and empathy about the other point of view. It helps prepare for problem solving, through anticipation, and often helps expedite resolution if ideas are exchanged in a respectful manner.

A cautionary note, however: Avoid preaching to the other party. Telling, ordering, preaching, and similar "know-it-all" behaviors simply escalate opposition, if not to the idea then to the arrogance of having all the right answers.(11)

In addition to learning the assessment of the other party, it is valuable to consider timing. Some conflicts demand an immediate, short-term agreement, not unlike an emergency when all parties agree for the greater good. Other issues are longer term, such as group merger and facility planning decisions. Effective problem solvers sort out short-term issues from longer term concerns. Agreement on short-term priorities often builds a basis for future cooperation and trust on longer term concerns.

In general, it is useful to acknowledge the other person's issue, even if the specific details or particular behaviors are objectionable. For example, "I agree that this is a critical issue, and I need more information before I am comfortable with the specifics of your proposal." Even when conflict is mounting and tensions are getting higher, acknowledging the other person's legitimate concern can help defuse anger. For example, "I can see how extremely important this is to you, and I appreciate your effort to resolve this. I hope you will continue working with me to the end." A guiding principle in conflict resolution is to separate the person from the issue, and to be supportive of the individual while confronting the issue.(12)

It is critical to understand the underlying principles and philosophy any given solution will address. Identification of principles, rather than positions, leads to longer term solutions.*12) For example, the principle of professional equity or fairness may be achieved by comparable salary, work hours, benefits, and even participation in important events. Professionals, however, are especially adept at making and taking professional positions on almost any matter within one's professional scope of practice. In fact, many professionals practice this intellectual shadow boxing as if it were the best way to solve conflict. In matters of scientific fact, such positional debates may help identify numerous related considerations. But in the murkier issues of professional judgment, factual arguments often obscure consensus development. Positional debates often degenerate into detailed nitpicking. Principle-centered interactions seek to clarify underlying wants and perceived needs, such as equity, respect, and security.

The effective conflict resolver will inquire about any given position in order to identify the underlying concern for which the specific position is a solution. This requires a repertoire of skills that may range from gentle inquiries to more assertive statements. For example, in the face of a "take it or leave it" pronouncement, which is not a matter of life and death, one might respond more gently: "I can see your concern, but it is not clear to me how this solution will solve all of your issues. Can you tell me more?" Or more assertively, "I appreciate your concern; your position, however, is not acceptable. We will need to work out further modifications." Asking gentle questions may help to clarify underlying principles, such as "what basic need will your proposed solution fulfill?"

Effective problem solvers strive to transform "win-lose" approaches to "win-win" solutions, to achieve the longer term results associated with mutual commitment. "Win-lose" approaches, often the tradition in scientific training, feel like "right-wrong," and few of us enjoy being wrong or being wronged. As a consequence, we often strive to overturn or undermine those situations. in which we feel we have been mistreated or over-ruled. Our courts, for example, are filled with such litigation, so much so that alternative dispute resolution is widely recommended as an alternative to advocacy legal models.(13)

One skill for transforming opposition to collaboration is to creatively identify even more alternatives than the "take it or leave it" option. For example, "I like the idea you have proposed, and I think we can do even better if we try. Let's take a few minutes and try to brainstorm even more ideas than we have right now." It is important to write down all the ideas created, so that the synergy of working together is captured. In addition, writing ideas down exactly as they are stated provides another example of cooperation. Post-It Notes[TM], legal pads, or flip charts make excellent resources when brainstorming.

While the term "brainstorming" is commonly used, many professionals overlook the spirit and letter of the brainstorming approach. As developed by Osborn,(14) brainstorming is a process in which all ideas and suggestions are written before critical comments are permitted. In this fashion, many useful suggestions are captured before the group becomes fixed on any single suggestion. Brainstorming can be both an efficient and a highly effective process for identifying alternatives. It often helps "reframe" an overwhelming concern into a manageable issue.

Today many professionals are adept in the use of Post-It Notes[TM] to capture ideas and then group them into like-minded categories. This practice is widely used in quality improvement teams. It provides an easy method for capturing all ideas among individuals, sorting them into "affinity" groups, or sequencing ideas where appropriate, and providing a visual record of potential alternatives.

Where verbal discussion provides immediate interaction on a few ideas, writing these same ideas on notepads or an easel usually provides a very effective method for recalling the entire repertoire of ideas among the group.

Another important guideline is to determine criteria or standards for selecting the best of many options, before the final decision is made. For example, figure 1, below shows guidelines a new technology assessment committee might use to evaluate several brands of imaging equipment. Its thinking ahead would allow it to apply a standard set of criteria after much of the fact-finding has already been done. The criteria provide an objective, clear, and consistent set of guideposts when two options are clinically equivalent. They are also useful when it is decided to highlight advantages and concerns, which may provide information for future evaluation of a decision. Few decisions today are unanimous for very long, and acknowledging legitimate concerns that will be afforded ongoing review often helps establish a good faith effort. Many decisions will be more a "work in progress" than permanent. unchanging solutions.

Finally. trust and goodwill require that words become deeds. Translating heated discussions into action plans takes more than just good intentions. Physicians are often familiar with action-oriented dictation, and the use of a generic dictation model can also be applied to conflict resolution. Figure 2, page 15, shows a simple format that clarifies discussions and details actionable elements. Using this type of instrument, if only as a checklist, quickly illustrates where matters are unclear. While heated discussion is often recalled, the specific recommendation, action, assigned responsibility, and follow-up deadline may all be overlooked, resulting in a subsequent perception of bad faith as agreements slip away.

Conflict resolution is inherently a personal and professional interaction. Most of us are strongly attached to our positions, and conflict can easily engage strong personalities in chronic battle. Physicians must learn to disengage from a chronic need to be right, hard as it is. Instead, learning skills to recognize, acknowledge, appreciate and build on the suggestions of others can attenuate the chronic pressures of today's practice environment.

Summary

Resolving conflict is a necessary skill, and one that can be improved with practice. Awareness of one's leadership style, conflict resolution style, emotions, language patterns, and procedural alternatives can be helpful. Physician leaders need to augment their excellent clinical judgment, usually based on expertise and experience, with additional skills to solicit the cooperation of peers. Conflicts usually stay resolved when others feel acknowledged, respected, informed, and involved. The principles and practices described above are a starting point. There is a rich literature to expand even these basic guidelines. Like any art, practice makes perfect, and physician leaders will find many resources available to improve their conflict resolution skills.

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References

1. Pareek, U. "Preventing and Resolving Conflicts." In The 1983 Annual for Facilitators, Trainers, and Consultants. Goodstein, L., and Pfeiffer, W., Eds. San Diego, Calif.: University Associates, 1983, pp. 164-9.

2. Gill, S., and Meighan, S. "Five Roadblocks To Effective Partnerships in a Competitive Health Care Environment." Hospital and Health Services Administration 33(4):505-20, Winter 1988.

3. Aggens, Larry. Personal communication, 1987.

4. Gell, J. "The Broken Covenant." In The Physician Exchange. Medford, Ore.: Rogue Valley Medical Center, May 1993, p. 2.

5. Alberti, R., and Emmons, M. Your Perfect Right: A Guide to Assertive Living. San Luis Obispo, Calif.: Impact Publishers, 1989.

6. Watzlawick, P., and others. Pragmatics of Human Communication: A Study of Interactional Patterns, Pathologies, and Paradoxes. New York, N.Y.: W.W. Norton and

Co., 1967.

7. Anderson. K. Getting What You Want: How to Reach Agreement and Resolve Conflict Every Time. New York, N.Y.: Penguin Books, 1993.

8. Fisher, R., and Brown, S. Getting Together: Building Relationships That Get to Yes. Boston, Mass.: Houghton-Mifflin Company, 1988.

9. Deep, S.. and Sussman, L. What to Say to Get What You Want: Strong Words.for 44 Challenging Types of Bosses, Employees, Co-workers, and Customers. Reading, Mass.: Addison-Wesley Publishing Co., 1992.

10. Gill, S. "Can Doctors and Administrators Work Together." Physician Executive 13(5):11-6, Sept.-Oct. 1987.

11. Argyris, C. Strategy Change and Defensive Routines. Boston, Mass.: Pitman Publishing, Inc., 1985.

12. Fisher, R., and Ury, W. Getting to Yes, Negotiating Agreement without Giving in. New York, N.Y.: Penguin Books, 1981.

13. Hall, J., and Strong, R. "Alternative Dispute Resolution and the Physician-The Use of Mediation to Resolve Hospital-Medical Staff Conflicts." The Medical Staff Counselor 7(2): 1 - 8, Spring 1993.

14. Osborn, A. Applied Imagination, Third Edition. New York, N.Y.: Scribner, 1957.

Pharmaceutical Companies Selling Outcomes, Not Just Drugs

"Disease management" is becoming a hot topic in the pharmaceutical industry. While pharmaceutical companies are best known for discovering, developing, manufacturing, and selling medicines, they-like many other health care providers and suppliers-are increasingly being held accountable for the outcomes or the clinical consequences of patient populations using their products in managed care plans. This trend has resulted in many pharmaceutical companies' evolving from a traditional sales and marketing approach to an outcomes or "disease management" focus.

While there is no consensus on the definition of the term, it generally refers to a coordinated clinical system for efficiently and appropriately managing patients with identifiable conditions using a variety of resources and tools to provide cost-effective, high-quality care. Some of the tools used in disease management systems include clinical guidelines, care process mapping, case management, physician and patient education and compliance programs, and outcomes measures.

Why the new trend? To further reduce drug utilization and costs, some managed care plans have asked pharmaceutical companies to accept financial risk-sharing arrangements-not unlike physician capitation agreements-in exchange for availability of their products to patients. For example, a managed care plan may request a pharmaceutical company that sells an anti-ulcer agent to provide "outcomes guarantees" based on the performance of its product in reducing complication of.ulcers. The pharmaceutical company would therefore be at financial risk for a portion of the health care costs associated with any patients suffering from an ulcer while taking the product. Conversely, cost savings that accrue to the plan based on fewer ulcers and reduced hospitalizations would be shared with the pharmaceutical company.

If drug companies are to be held accountable for the performance of their products, they need to coordinate other aspects of a patient's care to ensure positive clinical and economic outcomes. In the example above, making sure patients with ulcers take their medicine appropriately is not enough. The pharmaceutical company would need to help reduce other modifiable gastrointestinal risks to the patient, such as dietary factors and smoking, and thus evolve into a disease management partner.

Common chronic conditions primarily managed by pharmacotherapy-asthma, diabetes, cancer, ulcer disease, osteoporosis, AIDS, depression, and cardiovascular conditions, for example-are the best candidates for pharmaceutical industry-sponsored disease management programs. Often these programs are developed in partnership with managed care providers. For example, Group Health Cooperative of Puget Sound, a staff-model HMO in Washington State, has developed a diabetes "road map" or disease management system in conjunction with Eli Lilly and Company and Boehringer Mannheim Company.

Will disease management programs developed by pharmaceutical companies work? First, the pharmaceutical companies must demonstrate to health care organizations and providers that their programs are not simply new promotional programs but collaborative clinical initiatives to enhance the care provided by their managed care partners. Second, they must develop clinical and managerial expertise and provide the necessary financial and personnel resources to establish these programs. Finally, they must prove, through the use of outcomes measures and other objective techniques, that their disease management systems will add real value to the ongoing patient care efforts of their managed care customers.--Stan Bernard MD, MBA, Associate Principal, Health Care Industry, EDS Management Consulting Services, Neshanic Station, N.J.