Conflict Resolution in Emergency Medicine

The problem with conflict is not its existence, but rather its management.¹

Conflict is inevitable. Opportunities for conflict in emergency medicine (EM) are numerous because individuals with different backgrounds and divergent agendas interact over important concerns (e.g., patient care or resource utilization). By nature, these interactions take place under time constraints, which often exacerbates conflict. Many interactions between emergency physicians (EPs) and patients, family members, and staff or consultants occur with limited or no previous working relationship or when previous interactions have been problematic. As a result, the parties involved may be unable to reflect on previous successful interactions, which often decreases the likelihood of intense exchange.²

Controversy exists about the value of conflict. Many believe that at its best, conflict is disruptive. Most agree that at its worst, conflict is destructive to team harmony and patient outcomes. However, conflict also serves as a creative force by providing both initiative and incentive to solve problems.

This online version of the published chapter describes conflict in general and in detail, suggests many of its causes, and identifies contributing factors. Several examples of conflict specific to EM are discussed. The importance of effective communication in conflict resolution is presented, as well as its role in deescalating, minimizing, and preventing conflict. Recommendations for decreasing conflict are offered, and EPs are guided through the challenges of conflict resolution. The ultimate benefits to the patient, staff, and EP of resolving conflict are described, including optimizing patient care, decreasing patient morbidity, and maximizing an individual’s or health care team’s overall satisfaction. Finally, several strategies to facilitate conflict resolution are reviewed.

Communication, in the form of language and interaction, and power, in terms of how conflict is managed (or mismanaged), are tremendously important in the dynamics of groups. EM is very much about group dynamics because physicians, nurses, and other staff members must consistently demonstrate successful teamwork to offer patients the best possible outcomes. Louise B. Andrew, MD, JD, stated that “… conflict is often the result of miscommunication, and may be ‘fueled’ by ineffective communication.”³

Three important sources of conflict have been identified: resources, psychologic needs of individuals or groups, and values. Resource-based conflicts relate to limited resources, common in EM. The premise here resulting in conflict is “I want what you have.” Psychologic needs include power, control, self-esteem, and acceptance. These needs often exist under the conflict’s surface and can be difficult to identify or address. Values (beliefs) are fundamental to conflict. Core values (e.g., religious, ethical, financial) or those involving patient care are difficult to change and therefore generally assume a large role in conflict. Differences in values among people or groups (e.g., health care professionals and physicians with different training) may result in repeated conflicts. The expectations that EPs have of hospital and emergency department (ED) staff regarding work ethic or efficiency, for example, often result in conflict (perceived or real). Under these circumstances, people feel as though their integrity is being questioned, one reason that value-based conflicts are extremely difficult to resolve (Box 1).

Box 1 General Sources of Conflict

Conflict may be broken down into four general types. Intrapersonal conflict occurs when one individual has conflicting values or behavior that causes difficulty for that individual (even though others have similar conflicting values). These are the character traits comprising personality that make conflict more likely. Interpersonal conflicts occur among individuals as a result of differences in opinion or beliefs, communication styles, or goals. These conflicts are the most common in EM and generally occur between EPs and patients, nurses, or consultants. Intragroup and intergroup conflicts occur within or among groups when decision making is necessary (e.g., staff meetings, elections, hiring, scheduling, staffing) (Box 2).

Box 2 General Types of Conflict

Conflict in medicine is relatively easy to understand if you look at physician attributes, such as a tendency toward perfectionism and delayed social development. Physicians in general do not ask others for help and are encouraged not to by their training. These characteristics are highly adaptive to doctoring, reinforced by training, and rewarded by society. However, these traits may be maladaptive when it comes to communicating and interacting with nonphysicians and can result in conflict and poor conflict management. In fact, physicians tend to avoid unpleasant confrontations because they have not typically developed the skills necessary to address them.⁴

To assess interpersonal interactions in the health care environment, the responses of nearly 2100 health care providers were reported by the Institute for Safe Medication Practices in a 2003 survey on intimidating behavior. Despite the inherent biases characteristic of survey research, 88% of the respondents had been exposed to intimidating language or behavior. Condescending language, voice intonation, impatience with questions, and reluctance or refusal to answer questions or phone calls occurred far more frequently than the researchers expected. Nearly half of the respondents stated that they had been subjected to strong verbal abuse or threatening body language. Among the conclusions established by the Institute for Safe Medication Practices were that intimidation clearly affects patients’ safety and that gender made little difference.⁵

However, not all conflict in medicine is the result of intimidation. The ED environment is particularly predisposed to conflict, and conflict occurs for many reasons. Differences in professional opinion and value systems among staff members and patients are only a few of the contributing factors. EPs must interact with individuals from all areas of health care, at all times of the day and night, and during periods of great stress. The result is often tension and conflict. Depending on the size of the hospital or medical staff and the amount of turnover among health care personnel, EPs are not likely to know all the individuals with whom they must interact. This challenges EPs because they are not familiar with each medical staff member’s idiosyncrasies, preferred practice patterns, or communication style. These interactions create even greater difficulties for new EPs lacking a history of a favorable reputation or successful relationship with hospital staff and significantly increase the likelihood of conflict.

Examples of Conflict

Conflict in EM results from a mismatch of expectations between patients, family members, and providers or consultants, as well between nurses, ED staff, and ancillary staff outside the ED. Patients and family members may have unrealistic expectations about their ED experience, not to mention the pain or fear that brought them to the ED. Nurses may have unrealistic expectations of physicians, especially those whom they do not know, and all participants may have widely differing cultural backgrounds. Although gender representation of EPs has become more equal, older EPs tend to be male, whereas nurses are predominantly female. John Grey’s best-selling book Men Are from Mars, Women Are from Venus (HarperCollins, 1992) comments on the frequency of misunderstandings and communication difficulties that exist between genders. Misunderstandings and communication problems exist in the workplace between age groups, known as generational cohorts. Consultants may easily be frustrated with the ED staff, often based on previous unsatisfying experiences. Additionally, each time that consultants are contacted, their practice, social life, or sleep is disrupted. This increase in workload might be enough to ignite conflict.⁶

Numerous additional factors further explain the high likelihood of conflict in EM. Diversity in training, experience, and perspective often results in differences of opinion between EPs and colleagues from other areas of medicine, including nursing. For example, conflict arises simply from the fact that EPs do not want to send someone home who should not go home, whereas hospital-based physicians or specialists may prefer to not admit patients (or be pressured not to) who do not require admission. These two opposing “forces” create conflict.

The responsibility of patient advocacy assumed by EPs and ED staff often creates conflict because it may not coincide with the interests of the patient or family members. If a patient’s decision-making capacity is impaired or their legal advocate is not present, EPs have the duty to act in the best interest of the patient, state, or society regardless of the patient’s wishes. One common challenge occurs when a patient with a history of substance abuse and chemical dependency demands narcotics for “pain.” An EP’s refusal to prescribe narcotics is certain to create conflict.⁷ Conflict also occurs when a patient or family member desires admission to the hospital without medical justification or desires consultation with a specialist that is medically unnecessary or inappropriate at that time. Other times an EP may believe that it is in the patient’s best interest to be admitted to an inpatient medical service even if hospitalization may not influence the ultimate outcome, which creates conflict with the admitting service. Conflict may also develop between two services over which service will admit a patient. The EP must mediate this dispute by keeping the patient’s needs and interests at the forefront of the discussion.

Other aspects of EM that predispose to conflict include issues regarding diagnostic testing. Certain tests may have restricted periods of availability. Conflict is inherent when a necessary test available at one period of the day is no longer available despite the full-service expectation of emergency care. Patients (and EPs) are frustrated by this situation and often take out their frustrations on EPs and the ED. Even specialty consultative services are frustrated at these limitations despite their own limited availability for providing patient care. Many tests may not be indicated or may even be harmful to patients. If patients want these tests, conflict is inevitable if the EP serves in the role of patient advocacy while simultaneously serving society’s needs of managing with limited resources.

Perhaps the area most likely to create conflict is ineffective or incomplete communication between two or more parties. Given the cultural and language differences between patients, families, nurses, staff, and consultants, communication challenges prime the ED for conflict. Frustration, unmet expectations, time constraints, and limited staff, equipment, space, and privacy may be overwhelming if communication is suboptimal or barriers to effective communication exist.

Because the specialty of EM is so complex and has tremendous liability associated with its practice environment, many areas of potential conflict have been addressed at the federal, state, and local levels. Common sources of conflict include the patient care responsibilities of on-call consultants, minimum time standards for patients to be admitted and for hospital-based providers to see admitted patients, patient transfers to or from outside hospitals, telephone treatment of private patients who go to the ED, and use of the ED for directly admitting patients or performing various procedures. Hospitals have established guidelines addressing these issues in an attempt to prevent conflict before it occurs. Despite these policies, conflict still occurs. Frequently, these issues result in troublesome outcomes for patients, staff, and hospitals and thereby generate unwanted public attention. EM organizations are addressing these and other areas of potential conflict based on the needs of emergency patients and professionals. As health policy and the specialty of EM evolve, new challenges will be identified with more issues requiring resolution (Box 3).

As the specialty of EM has gained popularity since the 1980s, hospital administrators and medical staff members have increasingly come to recognize the importance of the role of the ED and EPs in delivery of health care. Multiple factors are responsible, such as mandatory exposure to EM in medical school, greater public awareness of our specialty, well-conducted outcomes research regarding EM, and popular television series that represent our specialty in a positive light. Talented medical students from each class are now entering the specialty, and consequently the new generation of primary care physicians and specialty consultants have relationships with members of our profession. Furthermore, many challenging situations that result from the nature of EM practice are less likely to create conflict than in previous decades because hospital administrators seem more willing to collaborate with ED leadership to prevent conflict before it occurs. Many EM leaders are sharpening their administrative skills to allow them greater success when exchanging ideas with hospital leaders. Opportunities for communication, education, and problem solving in areas prone to conflict, especially during “business hours,” is in the best interest of patients and the entire medical staff.

The Importance of Communication

Effective communication is extremely important to the process of conflict resolution. For effective communication to occur, mutual respect and concern must exist between parties, including respect for an individual’s professional and personal choices. Many physicians have difficulty interacting with individuals who do not share similar values, such as work ethic, practice style, or lifestyle. Physicians have often witnessed and learned attitudes, communication patterns, and styles of interaction with staff from mentors, role models, or other authority figures dating back to medical school or training.⁸

Communication is difficult for various reasons, especially because many physicians are poor listeners. Physicians interrupt patients early and often; these patterns are probably present during communication with colleagues and team members, particularly during stressful situations. In the ED, time constraints make communication challenging, although this style of communication may be necessary in high-acuity situations. Communication is also challenged by the fact that it commonly takes place in a public area. When done by telephone or electronically, visual cues are eliminated, thus making communication even more prone to misunderstanding or conflict. Furthermore, individuals may have unique or different agendas, which makes it even more difficult to communicate efficiently let alone effectively. Past interactions have an impact on future communications—previous negative interactions are far more likely to be remembered than positive ones. The personalities of different specialists often clash, thereby contributing to the likelihood of conflict.

Communication skills of physicians are not always developed with these concepts in mind. The Model of the Clinical Practice of EM, originally published in 2001 and most recently updated in 2009, includes an administrative section on communication and interpersonal issues that lists conflict resolution as one important subheading.⁹ This model was jointly approved by the American Board of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, Emergency Medicine Residents Association, Residency Review Committed for Emergency Medicine, and Society for Academic Emergency Medicine. Another publication by leaders in EM has similarly described the importance of integrating communication and interpersonal skills as defined by the Accreditation Council for Graduate Medical Education core competencies to educate EM residents.¹⁰ These documents guiding the training of future EPs emphasize the importance of acquiring and mastering these essential skills.

A thorough three-part series of articles that focused on physician-patient communication in EM shared many pearls and problems inherent to our practice.^11–13 Other excellent references describe the importance of the physician-patient relationship and EP communication.^14,15 The Association of American Medical Colleges, for instance, included communication in medicine as a central aspect of its Medical Schools Outcomes Project, which is intended to guide curricula in all U.S. medical schools. In 2004 the National Board of Medical Examiners began requiring all U.S. medical students to be evaluated in terms of their communication skills, as well as their clinical skills. The Accreditation Council for Graduate Medical Education now requires all U.S. residency programs to provide instruction in interpersonal and communication skills.¹⁶ Medical licensing bodies have identified the importance of physician communication. As a result, instruction in this area (and that of conflict resolution) is now required in EM training programs.

In clinical practice, physicians characteristically spend much of their time listening and responding to patients’ concerns. Studies have consistently found that clinicians’ interpersonal skills are not always as good as patients or nurses desire. Research has demonstrated that poor communication skills and the lack of team collegiality and trust lead to lower patient satisfaction and worse patient outcomes.¹⁷ Interestingly, when physicians and critical care nurses were surveyed to examine such behavior, nearly all physicians did not consider their collaboration or communication with nurses to be problematic, whereas only 33% of nurse respondents rated the quality of this behavior high or very high.¹⁸

Interacting with consultants is equally challenging in terms of communication and other areas likely to result in conflict. A multicenter survey from London of 171 newly appointed senior house officers demonstrated the frequency and importance of communication problems, especially with reference to consultations in the ED. These authors concluded that senior house officers serving in EDs could benefit from training in consultation skills in which communication skills are taught.¹⁹ It is not clear from this article how much communication training these individuals had before taking on their roles as senior house officers or how much or what type of training they would require. The challenges of interacting with consultants and the difficulty evaluating these interactions are described throughout the EM literature.^20,21

A new era of patient care and physician training has developed. These changes are in part a response to the call by several medical organizations for improved training and competence in the communication skills of physicians. The Patient’s Bill of Rights, resident work hour (duty) restrictions, and the Institute of Medicine’s “Report on Medical Error” released in 1999 all raised awareness of the importance of physician communication, interpersonal skills, and effective team functioning to improve patient safety. Though difficult to study, it will be interesting to see whether patient care outcomes and satisfaction within the medical profession improve over time as a result of these changes.

Many issues challenge communication in EM. Time urgency seems to be ubiquitous to all communication in the ED, yet many physicians and health care professionals are unaccustomed to this challenge. Difficulties with challenging patients and the uncertainty of high-risk situations make simple communication in the ED even more difficult. Multiple distractions, frequent interruptions, background noise, concerns about other patients, and frustrations with the ED or the consultation process often result in fractured communication. This situation is likely to create strain in the relationships of colleagues and consultants over time, if not immediately. Therefore, an established communication style and rules (when possible) for unavoidable consultations are integral to smooth operation of the ED.

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