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Dear Director,
I know we’re not always going to agree with each other in the ED, or with the specialists that we call, but there are some physicians in our department who seem to find conflict at every turn. What are some strategies for keeping the peace while still fighting to advocate for our patients?
-Make Medicine, Not War


Doctors are generally a smart, competitive group of people who always think they’re right, so in many regards it doesn’t surprise me that we get in heated arguments like the one you witnessed. Add to that the intense emotions of emergency patients and administrative pressures to lower lengths-of-stay and left-without-being-seen rates and you’ve got a witch’s brew for conflict. But while disagreements are inevitable, how we navigate these conflicts is absolutely critical – to our own careers as well as to patient care.

Conflicts with consultants
As ER docs, we frequently have competing goals with specialists though we both think we’re doing what’s right for the patient. Let’s take an elderly lady who fell, has a tri-malleolar fracture and in the emergency physician’s view, is never going to walk with crutches while in her posterior splint. Our goals might include pain control, length of stay, patient satisfaction, and an admission disposition, because we’ve already mentally moved on to the next patient once we’ve seen the x-ray. We also want her admitted because there’s no way we can go back and tell the family they need to take her home and deal with crutches and carrying her to and from the bathroom because the orthopedist doesn’t want to admit her. Of course, the family thinks the orthopedist should be there to see them, and they hate us for not being brave enough to stand up to him. My ortho friends, however, tell me that the swelling needs to go down over several days so the incision will heal and the patient will be better off in the long run. But they’re not telling the family this if they’re on the phone. That is our job and thus begins our battle, which might only get worse when the ticked off orthopedist walks from the OR to the ER to yell at the doc who called him a name on the phone. Yes, I’ve seen this, and obviously you have to.

As much as I’d like to think of myself as a zen master, it’s not always easy to keep your cool. It starts with understanding the basic tenets that (1) we can de-escalate a situation and (2) we are responsible for our actions. There are no winners in a shouting match and even worse consequences if you lower yourself to a seventh-grade fist fight. Here are my basic rules. Treat the emergency department like it’s your house. Our physician consultants are our guests. They are frequently uncomfortable when they come to the ED so they’re already on edge. They don’t know their way around and they don’t know the staff. Try seeking them out (they’re usually not hard to find), introducing yourself if you don’t know them and then shake their hand. Even if they’re there because your co-worker called them, you can still take a minute and help them out, then find your ED colleague. Welcoming someone, particularly with a handshake, is a calming maneuver for them as well as you. It’s hard to be too ticked off when you’re shaking hands. People mirror the emotions of the person they’re with, so if we’re calm, they’ll calm down. They may need a chart or a nurse for assistance, so I always ask how I can help them. I’m not only welcoming them to my house but I’m showing them that we work as a team. Though we may disagree over the next few minutes, I try to rise above the bad behavior, which sometimes means turning the other cheek. These basic techniques typically lower the temperature enough to prevent screaming. Then we can have a reasonable conversation, working as a team to take care of the patient. Checking our own behavior and mental attitude is work. It definitely takes practice to turn the other check or to not yell at someone, particularly if they deserve it, but there are long term payoffs that outweigh the short term emotional relief. In the long run, you’ll feel 10 feet tall when you later realize you did the right thing in the face of a childish argument.

It can be helpful to take a step back and look at why we get so hot under the collar in our interactions with specialists. The business and psych literature is helpful here, explaining how humans have a tendency to put a negative spin on things if we don’t get the anticipated outcome we were looking for. Look at texting a friend—if they don’t respond immediately, we feel blown off or that we said the wrong thing. We assume the worst but typically the person responds with a reasonable explanation—in line at the MVA, in a meeting, etc… The same is true for the doc who didn’t return our page.  We assume they’re blowing us off because we’re a low priority, they were unreasonably pissed off at us, or they don’t want the added work. While that could be true, maybe they were talking to a family about making a loved one DNR and couldn’t make a phone call for 30 minutes. We need to practice thinking about positive reasons why we’re not getting the response we expect instead of simply assuming the worst. This then helps us maintain the right attitude that we need to go into the conversation, no matter what’s happening behind the scenes.

It’s also crucial to recognize the differing perspectives and vantage points of various consultants. While we sometimes call for consults because we don’t know the answer, I think most of the time we have a pretty good game plan in mind for the patient. Then, when a physician disagrees with our plan (for instance, the hospitalist says the patient doesn’t need to be admitted), we often take that personally, like they’re calling us dumb or that we made a mistake. That’s rarely the case. Usually, it’s just approaching the patient from a different point of view, which differs from ours, and we need to not be so sensitive and paranoid but rather understand that they also think they’re doing what’s best for the patient. Of course, if you have a hospitalist that believes that no patient is ever sick enough to be admitted, that is another problem that needs to be reviewed between the ED director and the hospitalist director.

Improving the relationship between EPs and Hospitalists
I’ve worked with enough hospitalist groups through the years to know that at most hospitals, the relationship between the EP and hospitalist starts as oil and water. They just don’t mix. We completely rely on them to help with flow, trust our judgment, and take our patients. But every time we call them, we’re giving them work that they don’t necessarily want. This is a relationship that could benefit from a professional counselor. While we don’t have that luxury, like any relationship, if you can find common ground and get friendly, it will likely improve. I recommend starting with regular meetings (bi-weekly or monthly) at the medical director level just to establish a dialog and build trust. I do believe that I need to fix my own problems before I can complain about someone else’s so these conversations can be as simple as establishing common goals or discussing your own plans for improvement and asking how they align with the hospitalist group. Find out what we can do to make their job easier. I found that just photocopying the patient’s med list they brought from home and getting it in the chart before the spouse takes it home is a huge help to the hospitalist. You can also find common ground over staffing (they’re always short), being over worked, and scheduling. Emergency medicine has learned a lot over the last several decades on these topics, whereas the hospitalist specialty is still fairly new and going through a variety of growing pains. One of my favorite things to do once you’ve reached common ground with the group leader is to do a happy hour with the two groups. This could be the best $300 you could spend to impact productivity. Whether its radiologists, intensivists, or hospitalists, getting to know them as people and not just having them know you as the ER doc who needs something at 3 am is huge. While we don’t have to be friends with everyone, it does certainly help to be friendly.

There’s always one
There’s always at least one person who yells and screams, or throws things in the OR, and this is the type of physician who needs more than a handshake and a beer. The Joint Commission lists as one of its National Patient Safety Goals to “increase the effectiveness of communication among caregivers,” and disruptive behavior is considered so critical that it’s a review item on everyone’s semi-annual Joint Commission mandated Ongoing Professional Practice Evaluation. Hospitals have developed a variety of ways of dealing with the truly disruptive physician, but one of the most effective ways is called a Citizenship Committee. Chaired and composed of senior, respected physicians from the hospital, they sort through the complaints of “unprofessional behavior.” These complaints can be filed by anyone in the hospital, including nurses (who are the people I most frequently see who report inappropriate behavior). After reviewing the issue, the committee has the power to either ask the department chairman to council the physician, ask the disruptive physician to report to the committee meeting to discuss the behavior, and/or impose improvement methods for the physician, such as counseling or anger management training. The committee also tracks the number and frequency of events, which impacts their judgments and future credentialing.

Conclusion
Disagreements about patient care are inevitable, but with a little workplace wisdom, we can minimize conflict, for the sake of the department and our patients. Remember to keep the patient first, use de-escalation methods like seeking common ground, and rise above other peoples’ bad behavior. Finally, know when enough is enough, and make sure your hospital has a systematic method for dealing with unprofessional behavior.


Michael Silverman, MD, is a partner of Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center.

 

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