How to handle conflict

No, everyone can't always get along, but there are ways to contain disputes and settle differences amicably.

Conflict is natural in an organization, unless you're running the medical group version of The Stepford Wives," says Richard D. Hansen, vice president of the Medical Group Management Association Health Care Consulting Group.

Natural or not, conflict has a way of bringing out people's avoidance instincts. Thomas Benzoni frankly admits that his five-physician emergency medicine group in Sioux City, IA, ignores conflicts until they go away. He doesn't recommend this approach to others, but says that his group is successful nonetheless. That's probably because conflict doesn't always have negative consequences. Sometimes it works as a tension-reducer, Hansen says. And by acting as a catalyst to stimulate change, it can keep an organization from growing stale.

But conflict has its dark side, of course. And while disputes in medical groups rarely reach Shakespearean proportions, they can make coming to work unpleasant, hurt a practice financially, and even compromise patient care. Whether the disagreement involves two physicians, a physician and a staff member, or two staffers, experts recommend taking action before the clash spreads beyond the source and affects the larger group. Here's some advice from consultants and physicians on restoring and keeping the peace in your medical family.

Physician vs physician: problems and solutions

"When physicians are at odds, it's rarely because they disagree about clinical issues," says Will Latham, whose consulting group in Charlotte, provides physician conflict management services. "Rather," he continues, "doctors usually fight about administrative or business-oriented issues. So, paradoxically, I often advise my clients to meet periodically to discuss clinical matters, because by sharing information and ideas in a setting that isn't ripe for conflict, they build the basis for being able to work together when conflict erupts."

ED physician John C. Johnson, regional director of the 140-doctor Unity Physician Group in Valparaiso, IN, maintains that a problem might stem from misperception or miscommunication, so merely talking about it is enough to defuse tensions.

And as long as people are talking, they're likely to determine where their interests converge and reach a compromise. That was the case for GP Liza Shiff in San Jose, CA, who squabbled with her partner about adding new staff members. "The senior doctor was averse to new full-time staff, but after we talked it over he agreed to a part-time student training program of medical technicians who could rotate through our office," Shiff says. "It turns out the temporary help was all we really needed, and much more affordable." On another occasion, Shiff and her partner were jockeying for space in their crowded waiting room. They decided to split office use so that certain times are reserved for one physician or the other. "With some intense talk and a few middle-of-the-road changes, it all worked out," says Shiff.

Sometimes conflict pits one doctor against the rest of the group. One example is the physician who's very productive and generates a lot of income for the group, but is also a maverick who functions independently and treats fellow physicians condescendingly, notes Luellen Essex, a consultant in St. Paul, MN, who has often served as an intermediary for conflicts in physician groups. In such instances, Essex says, the other doctors often tolerate the disrespectful behavior, because they don't want the physician to leave and take his hefty receipts with him. "Confronting the arrogant physician might indeed drive him away," Essex notes, "but if one or two other physicians approach him and explain that his conduct is alienating colleagues, he might rein in his more egregious tendencies."

When physicians clash, Essex favors a "mediating" approach. "The physician leader should meet with each person individually, then talk with both of them together. If, for instance, the doctors feel that work isn't being distributed evenly, the leader can assess the complaint, suggest changes if the complaint is valid, or explain why the complaint is unjustified."

"You should have a resolution process in place before conflicts occur," suggests Frederick J. (Fritz) Wenzel, former executive director of the 775-physician Marshfield Clinic, in Marshfield, WI, and now academic director of the practice management MBA program at the University of St. Thomas College of Business in Minneapolis. "The policy might indicate that disputes should be brought to the attention of the medical director or head physician, who speaks confidentially to everyone involved, then suggests how the conflict might be resolved." Dick Hansen recommends a 10-step resolution protocol that includes engaging the respective parties, striving for impartiality, and setting realistic expectations (see "Conflict resolution protocol").

Monthly meetings provide a forum where doctors can iron out their differences. In FP Robert Hughes' seven-physician practice in Murray, KY, if a conflict between partners can't be resolved informally, it's taken up at the practice's monthly meeting. To avoid a rift, the group doesn't vote on controversial issues until a consensus develops. "Rushing to reach a quick resolution can cause long-term problems," Hughes says. "Frequently the delay adds clarity and direction to the situation."

If doctor and employee are at odds

Disputes involving a doctor and a staff member are dicey because of the inherent power difference. The staffer might need to equalize the battle by getting another physician to intervene on her behalf.

Dick Hansen offers an example: "An office manager at a 10-physician practice told me that one of the doctors was openly criticizing her for not always being at her desk. Because her job often required her to be up and about—supervising the office staff, conferring with the doctors, checking things at the front desk, talking to people in the community—she was unable to comply with the doctor's demand. I suggested that she ask the president of the group and a physician friend of the complaining doctor to act as mediators, because it wasn't her responsibility to resolve this. Behavior on the part of a physician has to be addressed by the physician leader or an administrator."

To keep misunderstandings from developing into full-scale battles, tell employees when they're doing something that's getting under your skin—and urge them to do the same with you. "In the best practices I've worked with, staffers are encouraged to raise issues with physicians," says Luellen Essex. (See "Practice Pointers: How to give and receive employee feedback," May 21, 2004.)

Not everything is repairable, of course. When Fritz Wenzel was executive director of the Marshfield Clinic, a physician and medical assistant with whom the doctor had worked for several years had a falling out, and their brawl was rippling through the larger group. "I wanted to fix it," Wenzel says, "because she was a very good medical assistant and he was a topnotch doctor. I met with them three times, listened to them, and asked them to try to work out their differences. Finally they concluded that one of them had to leave, and the assistant voluntarily submitted her resignation. In essence, she sacrificed her job for the good of the group."

It's important to pick your battles. "Not every conflict requires intervention," says Hansen. "You don't want to get involved in a dispute over trivialities, such as what color to paint the exam room walls. But benign neglect can cause a bad situation to worsen. Give the people involved a specific amount of time to work things out, and tell them you'll step in once the deadline passes."

Maintaining détente among the staff

When your employees lock horns, you or your office manager will likely have to intervene. Austin FP John K. Frederick recently had to referee a squabble between two clinical employees. "Both are wonderful, productive people who just couldn't get along," he says. "I met with them individually, then insisted that the three of us meet to talk out the problem. When we met, I said that they had to at least agree to co-exist, because the anger and resentment were eroding office morale. Both promised to act professionally—no backbiting or bickering. Both also offered resignations, but it hasn't been necessary to act on them."

When should you jump into the fray? "As soon as your gut tells you 'this is a problem,' " says Hansen. "Most people don't want their boss to intervene, and if your practice is large enough you might be able to get the office manager or a longtime employee to mediate, but as the head of the practice most people will look to you to effect a resolution."

To avoid conflict among employees, Latham suggests that you have regular meetings with staff so you can specify how you want things done. Doing so reduces the possibility that employees will clash because each thinks the other is doing the job wrong. If a conflict arises, Latham recommends the same procedure you'd use if the participants were doctors: talk to one staffer, then the other, then both together.

What shouldn't you do when handling disputes? Three no-no's, according to Wenzel, are:

• Avoidance. Don't push the issue aside in the hope that it will go away. Acknowledge it, and do your best to understand it.

• Taking sides. If you indicate that you favor one party or the other, you look like you're not impartial. Even if you ultimately have to impose a solution, point out that you're acting on the issues—not the people—involved.

• Lack of follow-up. You can't say, "We've talked to everyone involved, identified the problem, and decided how we're going to resolve it," and leave it at that. You have to say to the parties, "We're going to get together in a month and see how we're doing." If at that meeting the parties who were in conflict seem to be getting along and the matter seems to be resolved, schedule another follow-up meeting three months hence.

When to bring in outside help

If a dispute is getting polarized and attempts to reach a solution have been unsuccessful, you have three choices: Live with the tension, encourage one of the disputants to leave, or call in a third party.

"The longer you wait, the more the situation gets dramatized, the behaviors that are causing the problem intensify, and people get increasingly stuck in their positions," says Luellen Essex. "So it's a good idea to bring in a third party after two or three efforts to mediate the disagreement on your own."

Conflict resolution specialists usually guide disputants through a process. Will Latham asks each person to indicate, in writing, which aspects of the other person's behavior he doesn't like. "Then I bring them together and have them discuss these behaviors. The exchanges are usually enlightening for both parties. For example, during one session Dr. A complained that Dr. B yelled at him whenever they had a disagreement. 'What I'd like,' he said during our discussion, 'is for no one to raise their voice when we have conversations.' "

Latham's resolution system ends with a "role negotiation agreement," in which the doctors write down how they've agreed to modify their behavior, sign and date the paper, and give a copy to Latham. "I recommend that they review the agreements periodically. It's a way for them to keep each other honest and on track."

When internist Jeffrey M. Kagan's two-physician practice in Newington, CT, experienced administrative and labor conflicts last fall, the doctors called in a facilitator who led the 12 people in the office through team-building exercises. "Each person listed the issues that were on his mind," Kagan recalls. "This eased much of the tension that had accumulated during the preceding months, and helped us resolve our differences amicably."

Because a medical partnership can be like a marriage, FP Gil Solomon of West Hills, CA, and his former partner did the logical thing after having one disagreement too many: They talked with a marriage counselor, who helped them coexist by coaxing them off the "look at all I've done for you lately" treadmill. "If, for instance, I phoned my partner and asked him to admit a patient in the morning when I was on call," Solomon notes, "I would say, 'Remember when I admitted that patient for you last week? Now you can return the favor.' Instead, we learned to ask for a favor and then say thank you without feeling we had to belabor the fairness of it. We also agreed to talk regularly, to keep new misunderstandings from erupting."

Intractable problems might call for heavy-duty intervention, such as binding arbitration. (See "Got a beef? Try arbitration," Nov. 21, 2003.) In most practices, however, the do-it-yourself approach works, although the process can be a long and arduous. "You can't measure a resolution in weeks," says Latham. "You measure it in months. Although people can't change their underlying personality, they can—and will—change their behavior if the relationship is important to them."

Conflict resolution protocol

Richard D. Hansen, vice president of the Medical Group Management Association Health Care Consulting Group, offers the following 10 steps that you can use as a foundation for office-based conflict resolution.

1. Focus on the big picture. Always begin conflict management by discussing the basic mission, vision, values, and goals of the organization. Use these as the foundation for finding a resolution.

2. Identify the conflict. Don't rely on hearsay; get the facts about what has occurred. Be clear about who was involved and what effect the conflict has had on those individuals and the organization.

3. Engage the respective parties. Talk with those involved to find out if, in their opinion, a conflict exists, then enlist their cooperation in resolving it.

4. Create an environment of impartiality. Identify at least two people in the practice who can work together to serve as mediators. They may be existing leaders or respected senior employees.

5. Listen and validate. Take the time to hear out each party and acknowledge what you have heard.

6. Seek commonalities. After listening to all those concerned, find and promote areas of agreement to create a basis for resolution.

7. Set realistic expectations. Don't expect to achieve complete agreement. If the combatants can at least agree to disagree, that's a starting point. Then move on to more important issues.

8. Strive for compromise. Don't characterize compromise as failure. Instead, let everyone involved know that your goal is to find a middle ground that they can all accept.

9. Don't drag out the process. Do your best within a defined period of time. Realistic time frames often nudge parties along to resolution.

10. Periodically check on those involved. Once you achieve a resolution, revisit the issue after a specified period of time to see if the resolution is still effective.

 

Gail Weiss. How to handle conflict. Medical Economics Aug. 6, 2004;81:58.