Calming the waters in group practice conflicts

Here are ways to get a boatload of dissident docs to pull together.

By Mark Crane
Senior Editor

Put enough humans together and disputes are inevitable. It's critical, then, particularly if you practice in a group setting, to learn how to fight without destroying professional relationships.

Unfortunately, physicians' interpersonal skills tend to run in the opposite direction, say management consultants and psychologists. By their nature and training, doctors are highly independent, and often competitive and even aggressive. It takes a strong ego and a fair amount of self-confidence, after all, to make life-and-death decisions. These traits often get in the way of resolving conflicts. And as confident as most physicians are, they're far from immune to bruised egos, hurt feelings, and vicious personality clashes.

What do doctors fight about? Anything and everything: income division, call coverage, staffing, scheduling, titles, vacation policy—you name it. And since conflicts reduce productivity, waste time, undermine morale, and damage the bottom line, groups are taking the problem very seriously.

Some large practices hire consultants and psychologists to assess the battlefield and serve as peace negotiators. They may take physicians on weekend retreats to iron out differences and learn techniques for working together. A number of clinics even send combative physicians to "charm school," consisting of weeklong courses in improving interpersonal communication skills. "This isn't just psychobabble or a feel-good encounter session," says Karen A. Zupko, a management consultant in Chicago. "It can also involve substantial attitude adjustment.

"Often, a person becomes a doctor because he wants to be his own boss," she explains. "These days, that's difficult. So we take someone with an entrepreneurial mentality and, with the stroke of a pen, turn him into an employee who's expected to put the good of the group ahead of his own interests. For him, that employee mindset has to be learned. Doctors have to work at being team players."

Andrea Molberg, an organizational psychologist in Rochester, MN, agrees. "My toughest clients are physicians, attorneys, and policemen," she says. "They're not accustomed to having their views challenged."

How can you resolve conflicts without splitting your group apart? Here are some examples.

Sleep on your memo

Physicians come from a culture in which there aren't a lot of role models who demonstrate consideration for colleagues' feelings, says Zupko. Residency training, a trial by ordeal, may even imbue the opposite. One-upmanship is more highly rewarded than accommodation.

In practice, that can undermine your career. "A physician I know wrote memos so scathing and mean-spirited that he sabotaged his own work," she explains. "He had reason to be disappointed and critical, but after those memos, the people he was trying to convince just went deaf on him."

So, when you write a memo critical of a colleague, put it away at least overnight. The next morning, you may realize that it was more tart than necessary. "Do your venting at home or with a friend," says Zupko. "It just hurts your own interests to have these outbursts at the office." For the same reason, count to 100—or 1,000—before sending an e-mail message when you're angry.

Learn to think as one

A group of six surgeons in the Midwest wasn't really operating as a group practice. "It was six different practices in the same space," says Cheryl Wergin, a consultant who works with Zupko. "They were actually competing with each other. There was no cohesive management. As a result, the staff was dysfunctional and manipulative. If Dr. Jones said No to something, they'd go to Dr. Smith, who would say Yes. The buck stopped nowhere."

Since each doctor did what he wanted without consulting his colleagues, the group had signed contracts for two different computer systems at the same time. Receivables had crept up to more than 10 months, and occasionally it was difficult to meet the payroll. The group's junior members were thinking about bolting. "These brilliant and successful doctors didn't have a clue about human relations," says Wergin.

On a retreat weekend, she administered a psychological test that measured personality styles. "That helped the doctors understand their partners' motivations, which lowered the level of hostility. We got them to come up with concrete suggestions to clean up the receivables problem. The two doctors who'd ordered the computer systems agreed to put the contracts on hold. Then, in a nonconfrontational way, we pinpointed how such unilateral decisions had contributed to the growth of the receivables, the high staff turnover, ill-advised contracts, and zero economies of scale.

"The purpose of the weekend was to get the doctors to start thinking as a group," Wergin explains. "In addition, each doctor was given an organizational assignment. One would become the coding guru. Another was put in charge of quality assurance. Another took on personnel matters, and so on. The staff was told to bring questions in each area only to the doctor in charge. We set up group standards, and the physicians made a pact to work together."

Retreat weekends that focus on group governance are becoming more and more popular, she says. But even if you don't go away on a retreat, every physician in a practice must come to the realization that working together toward a common goal is essential.

Deal gently with the boss' wife

When a senior doctor's spouse is involved in the practice, usually in the bookkeeping or financial arena, things can get hairy. It takes great diplomatic skill to let your boss know that his wife is wrecking the practice and driving you crazy.

Wergin found just such a situation when she consulted for a group of internists in California. The wife of the senior partner had been running the practice for 20 years. He held the majority of stock and voting power. Another partner had a smaller share, and two junior associates had none.

The latter three had brought up several problems, including income distribution, and never gotten satisfaction. "When they did manage to get the senior doctor to agree to something," says Wergin, "his wife would usually veto it. Next day, he'd tell his colleagues that he'd changed his mind.

"However, the two juniors were scheduled to become partners within a year, at which time the unhappy three would have more than 50 percent of the voting power. Then they would simply fire the wife. Of course, the coup would break up the group."

Wergin helped the rebels find a happier solution. Wergin recommends that disgruntled doctors always try to find a gentler way before resorting to confrontation. Claim, for example, that your financial adviser needs the numbers. "It's a lot easier to say, 'My accountant doesn't understand this' than to tell someone, 'You did this wrong.' "

Try to stay focused on the immediate problem, and keep personalities out of it. Once you start saying, "Why are you acting like this?" in a confrontational way, the recipient becomes defensive and you don't get anywhere, says Wergin.

Don't corner a colleague

Several members of a Texas ob/gyn practice called in psychologist Andrea Molberg to help deal with a problem colleague. "He was skilled at managing high-risk pregnancies, but inattentive to his regular patients," she says. "Most of the group's patients were afraid that he would be the partner who'd deliver their babies, and were leaving the practice in waves."

Nobody had been willing to confront this fellow until Molberg was brought in. "Finally, we let him know in a direct but nonthreatening way that his behavior was hurting the practice. He hadn't realized that at all. Courteous but firm feedback from his colleagues was the impetus for him to change."

In a group of internists, one doctor routinely overscheduled, then ran late and kept patients waiting a long time. He resisted staff efforts to help him improve his scheduling. Since no patient had complained directly to him, he thought the staff was exaggerating when they said patients were unhappy.

"Patients rarely complain directly to the doctor about office problems, such as long waits," says Wergin. "The group decided to do a patient-satisfaction survey. Because the patients could respond anonymously, they were much more willing to criticize this doctor. When the staff had confronted him directly, he'd felt cornered and responded defensively. But once he saw the objective data from patients, he was willing to let the staff schedule his patients more efficiently."

Merge with care

Some groups are dysfunctional from the start because they were put together by accountants and attorneys. "It isn't just dollars and cents," says Cheryl Wergin. "You need to ask yourself if you can be partners with these other people for the rest of your career."

Groups work most efficiently when each doctor knows exactly what's expected of him. "How many patients will you see in a day? Is that more or less than you're used to? What does it mean to be a partner?" asks Karen Zupko. "If these and other questions are ironed out in advance, you'll prevent a lot of conflicts."

Don't avoid conflicts

While disputes may be unpleasant, avoiding them can prove costly. "Physicians who aren't afraid to confront anything in the operating room can be so nonconfrontational about personal issues," says Cheryl Wergin. "They avoid dealing with problems that only come back to haunt them."

In a group of eight internists, one junior associate actually refused to take Friday night call—one of many selfish demands that forced his colleagues to work harder. Instead of confronting him about his behavior, the group let the problem slide for two years. By then, the problem doctor was a partner. By the time his colleagues could no longer tolerate his attitude, they could no longer send him packing, either.

"I've consulted with several practices in which the partners knew an associate wasn't going to work out," Wergin says. "But they did nothing. There were many signs of trouble long before the doctor became a partner, but they still refused to act. It's like the difference between marriage counseling and divorce mediation. The first is a lot less unpleasant."

Techniques for conflict resolution

Andrea Molberg, a psychologist in Rochester, MN, conducts workshops with medical groups on conflict resolution and prevention. Here are some of her suggestions for how to conduct yourself when a "battle" is unavoidable.

Be a broken record. Do you want to hold your own without being punitive or threatening? Once you've decided what you want to say and how, keep repeating the same phrase or a variation of it to your adversary. That way, you remain focused on what you're trying to achieve and you avoid becoming hostile, says Molberg.

When others get angry or raise extraneous issues designed to provoke you, you might reiterate, "I'd like to explore more options" or "if you're willing, I'd like to continue looking for alternatives."

Learn to fog. Use this technique to lower the tension and cope with baiting and criticism. Instead of reacting defensively in an argument, find something in what the attacker is saying that you can agree with, and say, "You're right" or "You may be right." It could buy you time to collect your thoughts in a heated argument. "You may have a point there," "Maybe so," and "That's possible" are other useful phrases.

Saying "It could look that way" doesn't mean that you've conceded the argument. It simply acknowledges the possibility of another viewpoint. The fogging technique lets you show respect for the other person, which can lower the heat in a conflict.

 

Mark Crane. Calming the waters in group practice conflicts. Medical Economics 2002;4:31.