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Confrontation has to be planned and timed.

Knowing who to confront, when to confront, what to say, and how to say it is no simple task. Most people dread it. Don't expect that you won't. Even if you polish your technique, you still may procrastinate and have butterflies in your stomach when it comes time to do it. Some people report such extreme physical reactions as diarrhea, nausea, palpitating heart, and sweaty palms.

However, I have met a few physicians who truly seem to crave power, thrive on angry confrontation, and feel the joy of the kill when humiliating others with emotional outbursts. I suspect some of them went into medicine with a desire for power that would allow them to behave badly. Before the health care scene dramatically began to change in the '80s and '90s, they could get by with such behavior for an entire career. With increased competition, some organizations are saying, "You simply cannot behave that way anymore. If you do, you will lose your job."

Physician executives are sometimes called upon to deliver bad news to other physicians. The medical director is usually the one who has to confront physicians about clinical performance or interpersonal behavior problems. Physicians wishing to move into medical management "...should be experts in dealing with other physicians, defining appropriate clinical practices, establishing quality controls, etc....No one expects financial genius, marketing savvy, or computer literacy in physicians. If any of these are part of the physician manager's talent bank, they are frosting on the cake, but they will not adequately ice over a basic inability to monitor professional behavior or deal with an impaired colleague.''1 If a physician is behaving badly toward colleagues, nurses, or patients, there are techniques that can help you confront effectively and stop putting it off.

What makes people finally confront when generally they

do not want to?

Fear--People fear continuing in the present situation more than they fear what might happen if they confront. A medical director fears a patient will die or the organization will be sued for malpractice if an older physician whose skills are declining continues to practice. "Such is the way a man always acquires courage; when one fears a greater danger, it is as though the other did not exist."(2)

Desperation--You have taken it so long, and then one day you say, "No more." Whatever state you are in is so bad you are willing to take a chance. The highest earning physician in your organization has thrown so many tantrums that nurses are quitting and local physicians are beginning not to refer to him because patients come back to them and complain about the physician's rude, abrupt behavior. He has humiliated colleagues to the point that some of them are leaving. As much as you don't want to lose him, the chaos he creates has become intolerable. For me, the courage to confront came because the anger I was afraid to express to adults was erupting against my children. That was unacceptable to me, so I began to confront the people I needed to.

Past success--You have confronted in the past with good results, so you are willing to try again. You confronted a suspected alcoholic physician who went to a treatment program after you told him he must do it or lose his job. He recovered and is now a valuable, contributing member of your organization, and he has told you his personal life is much happier.

The word confrontation usually has a negative connotation for most people. Try to switch your thinking to: "It is important that I learn to ask for what I want. Others should not be able to read my mind."

Neither an angry nor a weak voice is effective in confrontation. Some people propel themselves into a confrontation with the use of anger. They usually meet with open rebellion or subversive behavior that undermines what they are trying to get accomplished. They toll people what to do, but somehow the projects are sabotaged. Example: An anesthesiologist screams, "How many times have I told you this is not the proper set up for someone with cardiac problems?" The technicians get even with the physician by continuing to not set up properly and watching him explode.

Others ask for what they want with such a weak tone of voice and weak words that people do not take them seriously. 'Would you mind not coming late for your shift?" A better way to say it is, "I have to stay late when you don't show up on time for your shift. I need to pick up my children. Please be on time."

Use a calm, firm voice and eye contact. Don't repeat yourself. Sometimes we deliver the message and then, because we are nervous or we think the listener is ignoring us, we say it again and again. If you ramble on and repeat yourself, people discount you and tune you out. Say your major points and then wait for reaction. It is not your job to try to make the other person comfortable by filling the air space with words. Also, you cannot afford the leisure of making yourself comfortable with constant chatter. Let there be silence or let the person blow up and just watch calmly. If the person explodes, so be it. Do not become overly defensive. Stick to your major points.

Also, if you bring up too many issues, you weaken your position. You cannot solve 20 years of irritation in one encounter. Don't bring up what happened in 1975. The more you confront things as they come up, the less you'll need to deal with all past hurts on the few occasions when you get the courage to say something.

You have a fight to ask for what you want. You may not always get it, but in this country you can ask for it. You do not have a fight to yell for what you want and humiliate others with sarcasm in the process. Some of you may be thinking--"Oh, yes I do." If so, I encourage you to sit down and think about your relationships. Are the people who work with and for you cooperative? Are your patients leaving? Do your family members look forward to your coming home at night?

You also have a fight to change how you behave in the relationship if you do not get what you want. Example: If family members will not pick up their own clothes after you have repeatodly asked them to, you can stop washing them.

Try not to use the big emotions of anger and tears in a confrontation. Some people use anger to try to get what they want; other's use tears. Neither is very effective. People feel threatened, frightened, or repulsed by a show of uncontrolled emotion. However, if these emotions occur in others, try to remain calm and strong and not let them throw you off balance.

If you plan to go through with an important confrontation or you have had an interaction that didn't go well, here's a process that may help give you the courage to confront the person.

* Write out what you want to say or wish you had said, and write how angry you are. Let all your emotions spill onto the page. Cuss them. Hold nothing back, but don't show this to anyone.

* Go for a 30-minute walk.

* Write again what you want to say. This time you'll find you don't need to say as many of the nasty things. Come up with three major points you want to make when you actually talk to the person:

1. Explain your view of the situation. I've gotten numerous complaints that you are yelling at co-workers and at times are even rude to patients. I've talked to you about this twice in the past six months. You do better for several weeks and then begin the same old behavior.

2. Tell what you want. This has to stop. I want you to get help to try to alleviate your anger and learn some better ways to communicate.

3. Say what will happen if you do not get it. If this continues, you will lose your job.

You may not always say the third point, but it is important for you to know. It gives you a sense of power, and people can detect it when you have it. When my children were small, and I was feeling exhausted, they would misbehave, because they sensed, and probably feared, weakness in me. Sometimes I went across the street to complain to a neighbor, who would help me come up with a plan. I'd walk back in the house with a strong countenance and a game plan. The children would take one look, see that the power was back, and shape up. Many times, I never had to do a thing. They seemed to be able to sniff the power in the air. The same is true for adults. If you look meek or unnecessarily mean, you probably will get noncooperation or rebellion. Find that middle ground that is firm but reasonable.

As a back-up plan, you need to know ahead of time what you are going to do if the person will not meet you halfway on at least some of the points. You may not use this bargaining chip, but you need to have it in your mental pocket. People can sense power and they can sense weakness. If you have a back-up plan, the room is filled with power.

If you have no bargaining chip and you know the person won't change, don't keep trying to make them. Don't keep whining that you wish they would behave better. Every time you beg, you lose self-esteem and feel more humiliated.

* Decide when you are going to say to the person, "I need to talk to you about something." Then try to quit thinking about the meeting. Keeping yourself churned up by rehashing your anger wastes valuable energy you will need during the confrontation.

* Read your notes just before you start. Don't take them with you. You'll remember what you need to. Or you can do as I did once and hide them. When the emotional heat rises, excuse yourself, and go read your notes. You will be amazed at how similar the encounter will be to what you have written because you stay calm and keep focusing on your major points.

In the '60s and '70s, there was much written about the value of venting when you were angry. The advice was really, "Let the people know who have wronged you." I disagree. Few situations are improved with loud expressions of anger. Usually they just get hotter.

Anger is a physical phenomenon as well as a mental one. You will feel it somewhere in your body--clinched fists, knots in your stomach, gritted teeth, tight neck, somewhere-because adrenaline is rushing through your system. You need to get it out of your body in a physical way, but there are many ways to do it besides screaming at the person who has angered you. Go for a run or a very fast walk. Play golf and pretend the ball is the offending person's head that you are slamming down the fairway. Write quickly without stopping, telling the person how rotten he or she is and what you want to do to him or her. (But don't let anyone see it.) Peter Elbow says, "Garbage in your head can poison you. Garbage on paper can safely be put in the wastepaper basket."(3) You need to get the anger out of your system, but you don't want to dump it on the wrong person or even necessarily on the offending person.

There may be a few times when it is appropriate to get angry and let the person know it, but you need to be careful not to do that often. Don't confront every issue just because you learn how to do it. Pretend you have only a few confrontation bullets. Don't use them up too quickly or use them to kill cockroaches. Save them to shoot bears-- big problems. Spilling juice on the kitchen floor is not a big problem; driving under the influence of alcohol is.

If you feel the occasion warrants an outburst, and you simply must do it, do it once. If you don't get the results you want, next time, confront in a calm, calculated manner with a plan for what you are going to do if the person does not meet your demands. Continuing to hysterically blow your top weakens your position, even though you may experience a temporary sense of power and a release of tension.

Most people communicate quite well from day to day, but, when stress increases, we choose either the fight or flight pattern. When bears were chasing us that was a sensible plan. When we are dealing with people, we need a new plan. We need courage or control.

If you need courage to confront, try a technique employed by the American Indians. They used "...'power chants' as centering devices to keep their hearts open and their minds clear at times of great danger. Each Indian brave repeated a particular affirmation of courage over and over until it became so familiar it was second nature to him. That way, in a crisis he wouldn't have to think about it or try to remember the words of the chant. They would be fight there at the tip of his tongue."

Here are some suggested modern day affirmations:

"I am centered and calm--ready for anything."

"I am composed and serene, able te gracefully handle all that is before me."

"I am filled with great strength, clarity, and courage."5

If you need to calm down and not lose your temper, "call for a time out ('I'm too upset to talk about this anymore-- I'd like to take a break and talk some more later.')" Learning a relaxation technique can also help you gain control. Anger and relaxation cannot exist in the body at the same time. After you have practiced the relaxation techniques for at least three weeks, one or two deep breaths can help you control your reactions.

Take whichever approach will help yon, but don't avoid the interaction too long. We are all different, and we must let each other know our needs in a calm, firm, effective manner.


1. Hartfield, J. "The Costs, Challenges and Rewards of Management." Physician Executive 14(4):3-5, JulyAug. 1988.

2. Kierkegaard, S. The Sickness Unto Death. Princeton, N.J.: Princeton University Press, 1974, p. 145.

3. Elbow, P. Writing Without Teachers. London: Oxford University Press, 1973, p. 8.

4. Arapakis, M. Softpower. New York, N.Y.: Warner Books, 1990, p. 151.

5. Ibid. p. 152.
COPYRIGHT 1992 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
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Title Annotation:Career Management
Author:Linney, Barbara J.
Publication:Physician Executive
Date:Sep 1, 1992
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