ADVICE: Managing physician conflict

Malcolm Ogborn, MBBS

 

Conflict is an intrinsic part of human experience. This article explores the distinction between cognitive disagreement and the emotional experience of conflict. It discusses the sensitivity of physicians to the perception of shame and the impact that shame can have on conflict behaviour. It offers a framework for conversations to navigate conflict and a number of simple strategies physician leaders may employ to work through conflict themselves and within their teams. Although some conflicts require the help of a skilled specialist, most can be facilitated with thoughtful and courageous leadership.

 

KEY WORDS: conflict, physician, physician leadership, physician coaching

 

Ogborn M. Managing physician conflict. Can J Physician Leadersh 2022;8(2):58-65.

https:// doi.org/10.37964/cr24750

 

The nature of conflict

 

Conflict is part of the landscape of human experience. However, in my experience, managing conflict among their peers is a major source of anxiety for physician leaders and is often cited as a reason for reluctance to take on a leadership role. Top

 

Conflict is more than disagreement. Disagreement is cognitive; conflict is emotional. Conflict coach, Cinnie Noble, has a useful model that captures the emotional nature of conflict, the (Not So) Merry Go Round of Conflict (Figure 1).1 A precipitating interaction triggers a limbic system response. This perception of threat may be a transgression of a personal value, a physical or emotional need, or an aspect of identity. An internal reaction follows, feeding story-making and  building assumptions. Pressure increases until a boundary is crossed and an external reaction manifests, which might be verbal or behavioural. The consequences of these reactions create new triggers that escalate the cycle.

This pathway resembles Argyris’s Ladder of Inference of how we build beliefs about the world.2 The more cycles of the loop, the more confirmation bias develops and the greater the distance between belief and objective truth. The conflict becomes the lens through which all incoming information is viewed and subconsciously selected. An important implication of this model is that the external reaction, which may be the first sign of conflict the leader sees in their team, is not where the conflict starts. It may have been preceded by many rounds of precipitating interactions that fell just short of crossing the boundary into behaviour. Such interactions may have been shaping thinking and belief for months or years. They may be happening in the head of one person with the other antagonist(s) unaware of the impact of their actions. Not seeing conflict is very different from absence of conflict.

 

Once the boundary has been crossed, bystanders often withdraw in silence, a common behaviour among physicians. Sometimes, those on the sidelines are drawn in and pick a side. They, too, are triggered by the process or by the misinformation that often develops around conflicts. The saying “In war, truth is the first casualty” (Aeschylus 525–456 BC) can be applied here. Bystanders need to belong and not separate from their peers. At a brain level, exclusion generates similar patterns of neural activation as physical pain; thus, consequences of joining the fray may seem less than the perceived pain of exclusion. Top

 

Once the emotions of conflict are established, the “facts” play an exceedingly small role. The experiences of those involved are now in the past. Everyone’s version of them, shaped by their own cognitive filters, is immutable. Managing conflict by arguing about past “facts” is futile, yet it consumes vast amounts of time and energy. Conflict stories are valuable in understanding what triggered a disagreement to become conflict, but they should not be considered objective truth. Conflict management is about managing emotion in the present and designing actions in the future, not rewriting the past.

 

Knowing your own conflict preference

 

As conflict is a ubiquitous part of our experience, we develop preferred approaches to it. A useful model is that of Thomas and Kilmann.3 It classifies conflict style by level of assertiveness and cooperativeness (Figure 2). Avoiding sidesteps conflict and maintains a situation where no one’s needs are met. Accommodating satisfies the other party without regard for your own needs. Competing secures your wants without regard to those of the other party. Collaborating attempts to obtain a result that meets the most needs of all parties. Compromising incompletely meets the wants or needs of all parties. Top

 

This type preference can be measured with a validated instrument, the Thomas-Kilmann Conflict Mode Instrument.3 Knowing your preference tells you where your natural inclination in responding to conflict lies. It does not tell you of which approaches you are capable. We can use a style other than our preference; it just takes more effort. Neither does the instrument tell you which approaches are correct. Sometimes, conflicts are “not the hill to die on!” In these cases, avoiding or accommodating may be wise strategies. A decision to sidestep the conflict or merely cave in to the wishes of another party should be made carefully, however. Davey4 has a useful concept to consider in these situations, the notion of conflict debt. This is “the sum of all contentious issues that need to be addressed to move forward but instead remain undiscussed and unresolved.” Any avoided, accommodated, compromised, or competed conflict will generate debt. Sometimes an absolute standard must be upheld. For example, a conflict with a surgeon who refuses to use the pre-operative checklist is a situation for competing. Collaborating is the best approach where there is hope that all interests can be met and compromising where some sharing of pain is inevitable. No one has all these style preferences but knowing your preference will inform the level of effort and support required to use the best approach.

 

Conflict and shame

 

Shame happens when we confront an undesirable image of ourselves. Physicians are really good at creating shame. A vision of excellence to which one aspires and against which one measures career progress can be very helpful. However, the study of physician burnout has emphasized that physicians often develop an unachievable self-image of unfailing perfection.5 They do this in part by themselves, but are often aided by well-meaning teachers and family. Anything that casts a negative light on a physician’s performance or behaviour may be interpreted as a failure to be this imagined paragon. If this happens, shame is triggered. Top

 

Sadly, many physicians are also trained in systems that use shaming as a pedagogical tool.6 Even if a dispute did not start with shaming, or shaming was completely unintentional, shame may be weaponized as the dispute escalates. Antagonists search for examples of their colleagues’ or organization’s failings to shame opponents. Physicians’ responses in conflict situations often align with predicted patterns of shame defense.

 

Author and researcher Brené Brown7 identifies a long list of workplace behaviours that are associated with shame. A number that are commonly seen in the landscape of physician leaders, particularly in conflict, include perfectionism, gossiping, back channeling, power over (a particularly noxious behaviour around trainees), withdrawal, blaming, and weaponized humour. All these behaviours make excellent “precipitating Interactions” in driving a cycle of conflict. A physician leader dealing with conflict needs to recognize them and call them out. Top

 

Every effort should be made to keep shame off the agenda. Where there is contention, framing the topic by focusing on the issue and not the person is vital. Encourage, or perhaps require, that people restrict their comments to their own experience. This prohibits hearsay, speculation about other people’s thoughts and motives, and commentary on actions, events, or behaviours that were not witnessed. Almost all that is inflammatory is removed by these sanctions.

 

Personal experiences may still be reported that generate guilt in the listening party. Guilt is a negative emotional response to something we have done, as distinct from shame, which is a negative emotional response to who we perceive we are. Recognition of harmful actions moves toward accepting vulnerability, a necessary precursor to developing trust in any relationship. Admitting responsibility and making amends are important trust-building exercises in the passage through conflict. Top

 

Conflict management techniques

 

The availability of conflict professionals has certainly increased in recent years. However, as conflict is ubiquitous, outsourcing its management in all or most cases would be time consuming and expensive. Few conflicts require external intervention. Many of those only reach that point because the opportunity for thoughtful people to use simple and early interventions was missed.

 

The simple act of not ignoring a conflict is a highly effective step. Using effective conversation techniques to engage individuals or groups that are in conflict, have them civilly describe how things are landing for them, and express their desires will probably allow forward movement on most conflicts. The (Not So) Merry Go Round of Conflict1 is used by conflict coaches to create insight about the experience of conflict. It is also useful to help parties in the conflict to imagine how the other party or parties are experiencing the situation. Exploring what precipitated a conflict, the responses that were generated, and questioning the mental models formed creates a space to explore alternative assumptions that may inform new approaches. Conflict management requires being curious in a search for understanding, rather than just trying see to who is right. Top

 

Awareness of a trigger for conflict, however small, creates the opportunity for early intervention. In 1972, Sherwood and Glidewell8 observed that, over time, we experience triggers or “pinches” in a relationship that build to conflict (Figure 3). We tend to ignore these small provocations. At some point, the pressure to react becomes too much. We then have a “crunch” where the conflict surfaces in our behaviour. Common but ineffective organization behaviours that may arise include withdrawing, triangulating by expressing our frustrations to others, or entering a challenging negotiation to try to restore the relationship. The alternative strategy is to have a collaborative discussion as soon as there is a pinch, to “nip it in the bud.” Dealing with pinches as soon as they occur is a significant and effective personal or organizational cultural shift.

 

Davey4 has also proposed “conflict strategies for nice people.” Three strategies — two truths, question the impact, and common criteria — can be particularly effectively applied by physician leaders. Two truths has parties to the conflict validate each other’s perspective. They repeat the other’s position, asking clarifying questions as needed. They may find ways to strengthen the other’s case. The conversation assumes that both proposals are meritorious. The challenge is now a shared one of finding the best solution. This approach is a good prelude to using integrative thinking to build novel options out of the best components of each position.9 Top

 

Question the impact is a good approach when one side has serious concerns about what is being presented by the other side. These concerns are too commonly expressed as attacks on competence or character. A neutral and inviting response is: “I think I understand what you are saying. I have some concerns. How would you see this working with…” or “What would the effect on X be...?” “How” or “what” questions are asked until either the fears are allayed or the other party finds a way to adjust their idea to fit the new dimensions. This approach invites the other party to problem-solve rather than defend.

 

Common criteria is a good approach for complex and nuanced situations. The parties list all the issues that need to be addressed and then discuss priorities. This creates a situation where all parties see what has brought them into conflict. This can also work into an integrative thinking approach to novel solutions as you drill down into the thinking behind each listed issue.8 This process is helpful at teasing out mutual or complementary interests around which negotiation can occur. Top

 

External intervention for conflict

 

External intervention for conflict can take the form of conflict coaching, negotiation, mediation, or arbitration. Conflict coaching uses inquiry techniques to develop insight and new perspectives on conflict and supports the choice and design of action to move through conflict. It can take the form of coaching a leader to manage conflict in their team, a useful pre-emptive strategy. It can also support one, some or all parties in a conflict. Conflict coaching does not presume a specific solution; that is for the parties being coached to decide. This is the strategy of choice where emotional issues are the dominant feature of the conflict.

 

Negotiation, and its specialized partners, mediation and arbitration, are particularly good at dealing with specific issues rather than the emotional landscape. Before choosing an issues-based strategy, careful exploration of the timeline of the conflict is valuable in discriminating between an issue that has led to conflict and a conflict that has adopted an issue as a justification. If the latter case, a coaching approach may be more productive. Top

 

Arguably, the most popular reference on negotiation is Getting to Yes.10 Among its many practical tips on negotiation, a couple are worth highlighting. The first is to focus on interests, not people, as described in the section on shame. Another important concept is best alternative to a negotiated agreement or BATNA. This means having a plan for what to do if you are unable to negotiate a solution. At an emotional level, having at least one other option reduces the flight or flight response.

 

Mediation is a term that comes up often. Mediators are skilled people who work with individual parties to understand their experience, then work between the parties to lay the groundwork for options, and finally work with all parties present. Complex situations may benefit from conflict coaching to support constructive engagement in mediation. Physician leaders often need to be part coach, part mediator. Top

 

Arbitration is where a third party will decide the outcome based on what the parties to a conflict submit to the process. This can be a reasonable approach for a leader, for example, on a time-sensitive issue that is stuck between parties. Before choosing arbitration as a solution, thought must be given to balancing the benefit of a clear result against the risk of creating a win–lose dynamic that may foster ongoing resentment between the parties. The leader must also weigh the impact on future relations and the impact of taking autonomy from their followers.

 

Neither mediation nor arbitration is a strategy for well-meaning amateurs; both require specific skills and the ability to maintain trust in challenging situations. Leaders should be circumspect about taking on these roles themselves.

 

Conflict and psychological safety

 

A full discussion of psychological safety, conflict, and the work environment is beyond the scope of this article, but parties in conflict now commonly raise concerns about psychological safety. Psychological safety is most emphatically not the absence of conflict; environments where conflict is kept invisible may be among the most psychologically dysfunctional. Rather, psychologically safe environments are ones in which people can be open about their vulnerabilities and expect reasonable support; expectations, processes, and policies are clear and open to civil discourse. They proscribe malicious and hurtful behaviour. They are not, however, democracies or zones where people can fail to meet their work and behavioural obligations without consequence. If these are issues in your workplace, they may have to be addressed in parallel or before conflict intervention if protracted litigation is to be avoided. Useful concepts in this area can be found in recent publications by Clark.11,12 Top

 

Key learning points for physician leaders approaching conflict

 

• Recognize that conflict is a normal part of human relationships.
• Be aware of your own preferred conflict style; practice or find support to work in other styles where they are more appropriate.
• Understand your shame triggers and those of the people with whom you work. Be sensitive to shame behaviours as a source of conflict.
• Act sooner in conflict rather than later; do not let small issues become large ones.
• Use good conversation techniques to share and understand individual experiences in a conflict; this is often enough to resolve most interpersonal conflicts.
• If you cannot work through a conflict that is affecting you or your work, seek skilled help rather than giving up.
• Where conflict involves a specific issue external to people’s feelings about each other, consider mediation or arbitration.
• Do not try to create psychological safety by avoiding or suppressing conflict; instead, work to reveal conflict and work through it constructively. Top

 

References

1.Noble C. Conflict management coaching: the CINERGY Model. Toronto: CINERGY Coaching; 2012.

2.Argyris C. Interventions for improving leadership-effectiveness. J Manage Dev 1985;4(5):30-51. https://doi.org/10.1108/eb051596

3.Thomas KW, Kilmann RH. The Thomas-Kilmann conflict mode instrument. Kilmann Diagnostics; 2021. Available: https://tinyurl.com/3zp8nr3n

4.Davey L. The good fight: use productive conflict to get your team and organization back on track. Vancouver: Raincoast Books; 2019. https://www.lianedavey.com/goodfight/

5.Drummond D. Stop physician burnout. What to do when working harder isn’t working. New York: Heritage Press; 2014.

6.Robertson JJ, Long B. Medicine’s shame problem. J Emerg Med 2019;57:329-38. https://doi.org/10.1016/j.jemermed.2019.06.034

7.Brown B. Dare to lead: brave work, tough conversations, whole hearts. New York: Random House; 2018.

8.Sherwood JJ, Glidewell JC. Planned renegotiation: a norm-setting OD intervention. In WW Burke (ed.). Contemporary organization development. Bethel, Me: NTL Institute; 1972:35-46.

9.Riel J, Martin RL. Creating great choices: a leader’s guide to integrative thinking. Boston: Harvard Business Publishing; 2017.

10.Fisher R, Ury W, Patton B. Getting to yes: negotiating agreement without giving in. London: Penguin; 2011.

11.Clark TR. The 4 stages of psychological safety: defining the path to inclusion and innovation. Oakland, Calif.: Berrett-Koehler; 2021.

12.Clark TR. The hazards of a ‘nice’ company culture. Harv Bus Rev 2021;25 June. Available: https://tinyurl.com/3dp4kubs

 

Author

Malcolm Ogborn, MBBS, FRCPC, COC, PCC, is a retired pediatric nephrologist and senior physician leader, who now focuses on physician coaching and leadership development. He holds certifications in organizational emotional intelligence and conflict coaching, is a member of the CSPL coaches group, and is vice chair of the Canadian Physician Coaches Network.

 

Correspondence to:

coach@optimisticdoc.com

 

This article is a condensed chapter from Dr. Ogborn’s recently published book Sudden Leadership — A Survival Guide for Physicians. Information on the book and suppliers can be found at https://tinyurl.com/bdfcnsa4. The book explores practical, field-tested approaches for physician leaders to common conundrums through episodes in the experience of two new physician leaders.

 

This article has been peer reviewed.

 

Top