Annals of Emergency Medicine
Volume 40, Issue 3 , Pages 347-349, September 2002

Conflict resolution in emergency medicine☆

Department of Emergency Medicine, St. Vincent Mercy Medical Center, Toledo, OH.

Article Outline

Abstract 

[Ann Emerg Med. 2002;40:347-349.]

 

Conflict is ubiquitous in medicine. However, features unique to the specialty of emergency medicine make it especially prone to conflict. Emergency physicians serve on the front lines and interact with individuals from all areas of health care. Often, diversity in training, experience, and perspective cause differences of opinion to arise between colleagues of different specialties, regardless of the preexisting quality of the relationships between the physicians.1 In addition, different value systems may lead to physician-patient conflict, and divergent opinions regarding patient disposition, reimbursement, level of care provided, diagnostic tests, and therapies lead to conflicts with managed care organizations.2, 3 Conflict may contribute significantly to stress and difficulty functioning effectively.4, 5, 6 Thus, the ability to achieve conflict resolution is invaluable. In this article, we discuss the factors that contribute to conflict in the emergency department and present strategies to facilitate conflict resolution.

There are numerous reasons why the ED is particularly predisposed to conflict. Differences in professional opinion and differences in value systems among staff and patients are only a few of the contributing factors. Emergency physicians are routinely compelled to multitask and carry heavy patient loads. Consultants also suffer from taxing call schedules and workloads. Fatigue is ubiquitous in medicine, but nowhere more so than in emergency medicine. Sleep deprivation, stress, and perceptions of ineffectual accomplishments may contribute to difficulties in interpersonal skills and communication. Additionally, both patients and ancillary staff frequently do not understand the triage system and the role of the ED. Thus, both patients and colleagues may make unreasonable demands for more rapid treatment and unnecessary tests. It is sometimes difficult to understand patients with different value systems who prioritize certain matters over health care (eg, taking care of pets, social events).

The ED is staffed 24 hours per day, 7 days per week, including holidays. It is a fundamental principle of emergency medicine that patient care be delivered efficiently at all hours. However, some consultants do not believe that diagnostic and therapeutic modalities should be available at all times. Also problematic is a consultant or an emergency medicine colleague who provides an incorrect diagnosis, advises inappropriate treatment, or behaves in a manner that arouses suspicion for professional impairment. Colleagues may behave unprofessionally and publicly denounce others, as well as complain about the workload and equipment. Such complaints may lead to misperceptions regarding the quality of medical care and dissatisfaction among staff.7

The ED environment is replete with obstacles to effective communication that lead to misunderstanding and conflict. Telephone conversations lack the benefits of face-to-face discussions with a consultant at the patient's bedside. Often, the emergency physician contacts a consultant at an inconvenient time with insufficient details pertinent to the case. Despite a difference in opinion, the consultants may expect the emergency physician to assume the liability for following their proposed treatment. Another barrier to effective communication exists for physicians who look younger than their actual age, because patients may incorrectly equate youth with ignorance and inexperience.

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Conflict resolution 

There are several important steps in achieving successful conflict resolution. The development of communication skills by all staff members can be extremely important. Three elements are considered essential to effective communication: listening, speaking, and receiving feedback effectively.8 The following strategies may improve communications: address the patient or staff member using his or her name; maintain eye contact; introduce yourself and other team members; avoid interruptions; be seated while communicating; avoid condescending speech; use easily understood language; and openly discuss findings, diagnoses, treatment options, and disposition.9, 10, 11, 12, 13 Many decisions in emergency medicine must take place without the benefit of ongoing communications. However, ongoing communication may help resolve such issues as differences in professional opinion and end-of-life discussions. One study demonstrated that patients and surrogates agreed more readily with their physician's recommendations after multiple communications over several days.14

Negotiation and compromise may decrease anger and frustration and set the appropriate tone for problem solving. Willingness to negotiate establishes better working relationships.15 If confrontation with a colleague is indicated, it should be conducted in a private setting. “Mediation,” consisting of a planned meeting with a neutral mediator, can help resolve conflict.16, 17 Accepting and respecting different value systems of patients and colleagues is also important, because the recognition of conflict is an integral part of its resolution (Figure).18, 19

Differences of opinion can be legitimate. As long as it is not detrimental to patient care, individual perspectives and opinions can provide innovative ideas. Moreover, conflict resolution may be medicinal to the involved parties and promote reconciliation, communication, and empathy.20, 21

Achieving consensus among colleagues can be an important step toward resolution of conflict.22, 23 For example, simply agreeing on a time at which a decision will be made and formulating treatment-centered decisions can help satisfy both parties and dissipate conflict.24 Rather than resulting from personal differences, conflict frequently results from frustrations about inefficiencies within the system.25 Recognition of this important fact and working together to resolve systems problems may help avoid unnecessary conflict.12

Because there is no formal training in conflict resolution, conducting didactic sessions for residents, faculty, and staff may be helpful. It is important to discuss barriers to teamwork and to establish an effective team approach. The emergency physician will certainly face the following scenarios at one time or another: a patient who wishes to leave against medical advice, a disgruntled consultant who criticizes the ED management of a patient, a nurse who refuses to follow orders, a consultant who refuses to see a patient, a medical resident who is slow to admit an ED patient, colleagues who are disinterested in teaching, a medical student who shows no initiative, and a resident who shows little compassion for patients. Role-playing such challenging situations can help develop problem-solving techniques. Finally, despite any history of conflict or confrontation, an agreeable disposition (including a smile) can be instrumental in fostering an effective working relationship.

Emergency physicians commonly encounter conflicts in clinical and academic settings, including conflict with patients, staff, colleagues, and managed care representatives. Conflict may contribute significantly to stress and difficulty functioning effectively. There are a number of features unique to emergency medicine that promote conflict, including workload, 24-hour coverage, differences in professional opinions or competence, and differences in value systems. Because of the ubiquitous nature of conflict, it is prudent for emergency medicine residents and faculty to be trained in the basic principles of conflict management.

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References 

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☆ Address for reprints: Catherine A. Marco, MD, Emergency Medicine, St. Vincent Mercy Medical Center, 2213 Cherry Street, Toledo, OH 43608-2691; 419-251-4478, fax 419-251-4211; E-mail cmarco2@aol.com

PII: S0196-0644(02)00051-3

doi:10.1067/mem.2002.126567

Annals of Emergency Medicine
Volume 40, Issue 3 , Pages 347-349, September 2002

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