Hospitalists face the potential for conflict every day. They work in highly complex organizations in which in order to be successful they must interact effectively with a wide variety of individuals in what is often a challenging, emotionally charged environment. They must learn to navigate not only the formal organizational bureaucracy of rules, systems, and processes, but also the informal political hierarchy that influences power and decision making. Often, they must do so with little or no formal training in conflict management at an early stage in their medical careers. In addition, they may encounter conflicts between what referring physicians would like them to accomplish during hospitalization and the needs of the hospital to expedite care to the outpatient setting.

Hospital Medicine is also a young, evolving specialty that has enjoyed unprecedented exponential growth by serving the needs of multiple competing stakeholders. Few mentors or seasoned clinicians have specialized in Hospital Medicine, and as such they may not have a complete understanding of the specialty or even have career advancement of hospitalists on their radar screen. The potential exists for the service obligations of hospitalists to overwhelm opportunities for professional development, and this may promote career dissatisfaction, turnover, and symptoms of burnout. Leaders of hospitalist services may find themselves isolated as they advocate for the professional development of members of the service while meeting the service expectations of their employers or supervisors. The professional medical society for hospitalists, the Society of Hospital Medicine (SHM), is rapidly developing flexible support resources for hospitalists relating to business practice, career satisfaction, core competencies and role expectations. Until these standards become widely disseminated and health care services become better designed and hence less prone to error, hospitalists will continue to work in a hospital environment where they will increasingly be expected to perform as change agents at a time when change may not be welcome by others at their institutions.

For the purposes of this chapter, it will be important to distinguish between disagreements and conflicts. Disagreements happen regularly in human interactions, and occur whenever two or more individuals have differing opinions about something. A disagreement need not devolve into a conflict, and many do not. Conflicts arise when a party perceives that another party has negatively affected or will negatively affect agendas that the first party cares about. Conflicts are defined as processes that occur when tensions develop, that is, the emotions associated with a disagreement become so elevated that they impede the ability of the parties to interact with each other effectively.

Almost all conflict is a result of unmet expectations. For hospitalists, this commonly arises when there is a lack of understanding or a difference in expectations about the role of hospitalists. Hospitalists may assume that primary care physicians have explained to patients that someone else will be seeing them in the hospital. Patients and families, however, may not understand why their primary care physician is not present in the hospital and directing their care. Emergency Medicine physicians may expect the hospitalist to respond promptly to take a complicated social admission off their hands whereas hospitalists may feel that it is the role of the emergency room physicians to discharge patients who do not require admission. Emergency Medicine physicians and staff may expect for patients be triaged to hospital floors (to reduce their emergency department length of stay or avoid diversion) before critical information is available, or may expect hospitalists to see patients in the emergency department when no beds are available. Meanwhile, floor nurses may expect hospitalists to be immediately available to address nonurgent requests. Primary care physicians may want patients to remain in the hospital until the workup is complete due to lack of resources in the outpatient setting and/or patient/family demands, whereas hospitalists are under pressure to discharge patients who do not require acute hospitalization. There may be differences of opinion among specialists and generalists regarding diagnosis, workup, and treatment or the role of the hospitalists in management. All physicians expect to be treated professionally, to have some autonomy over clinical decision making, and to have a reasonable work-life balance. Hospital administrators and employers, however, may require hospitalists to do nonphysician tasks or solve problems for other physician groups without taking into account the perspectives of the hospitalists or staffing needs for time-consuming tasks. When such expectations go unmet, people get frustrated or angry. They often respond in ways that then result in frustration or anger on the part of others. Emotions on both sides become elevated, and the stage is set for a conflict.

The most common reasons that expectations go unmet include

• Lack of clarity about what is expected, or about how the expectation will be met. It is easy to assume that because one’s expectations are clearly understood by oneself, they are clear to others as well. Even when expectations are carefully explained, the other party may hear or interpret things differently than the speaker intends. The other party may also react more to the emotional aspect of the presentation or who is doing the talking rather than the content.
  
• Lack of agreement about what is expected or how to achieve it. The high degree of complexity in error prone health care systems, stress and pressure, and the need for rapid change are important sources of potential conflict. Sometimes each party’s expectations are clearly understood by the other party, but they simply disagree with each other about the desired outcome, the method, or both. This can occur if the parties have competing needs or interests that are perceived to be in opposition. For example, although resident work hour restrictions are clearly delineated in the academic setting, stress and pressure develop for hospitalists when the increased service obligations resulting from such restrictions conflict with the need for professional advancement. The emergence of rapid response teams involving hospitalists as first responders may also create conflict if hospitalists do not have the resources to handle their other tasks such as admissions, discharges, and essential communication due to interruptions in their workflow. Changing hospital processes to promote efficiency and recruitment of additional staff to meet challenges takes time and money.

In addition, age, gender, and cultural differences may play a role in the development and management of conflict. A generational gap may result in different work expectations, a paternalistic view of who is actually in charge, or resistance to changing to the new work requirements. Men and women may have different expectations of their work, and often have different ways of responding to stress, emotion, and conflict. In the United States, men often tend to use a competing or forcing style when faced with conflict, whereas women often tend to use compromising, accommodating, and avoiding.

A key aspect of cultural differences is the degree to which a person tends to identify most strongly with the group of which he or she is a part (a “collectivist culture”) as opposed to identifying with the self (an “individualistic culture”). Individualistic cultures, which are the dominant cultures found in North America and Western Europe, value autonomy, creativity, and personal initiative. Most of the rest of the world is composed of collectivist cultures, which instead value conformity and harmony. A meta-analysis of studies on culture and conflict resolution styles found that people in individualistic cultures tend to choose forcing as a conflict style more often and people who come from collectivistic cultures tend to choose withdrawing, compromising, or problem-solving styles instead.

Conflicts are inevitable in human interactions. The increasingly complex and collaborative nature of the work that hospitalists do increases the likelihood that interpersonal conflicts will arise. These conflicts can be destructive if not effectively managed. But a healthy approach to conflict management acknowledges that not all conflict is entirely negative. There are potential benefits that may be derived from conflicts under certain circumstances. DeChurch and Marks (2001) reported that the ways in which groups handle conflict help to determine whether or not benefits were realized, noting that “the relationship between task conflict and group performance was positive when conflict was actively managed and negative when it was passively managed.” This suggests that Hospital Medicine physicians will be well served to develop effective conflict management skills that can help them increase the likelihood that the conflicts they will inevitably face may yield positive results. In order to do so, it will be important for hospitalists to think strategically about how one may extract the maximum benefit from conflicts that do occur. Some of the potential benefits of appropriately-managed conflict include:

• Catalyst for Change. Conflicts can force needed change by surfacing problems that otherwise might not be recognized, and by elevating latent issues to a level that demands attention. This can be especially valuable in tradition-bound, change-resistant organizations.
  
• Improved Outcomes. Similarly, conflicts can ultimately yield improved outcomes, because they can facilitate learning in the search for better solutions and bring to the forefront useful information and emotions that lie below the surface. An individual may learn more about herself, about the other person, and about the situation.
  
• Balance. Healthy conflict helps to ensure that balance is maintained among competing needs and perspectives.
  
• Increased Accountability. Because conflicts involve strong emotions, a healthy conflict resolution usually involves careful articulation of what the parties have agreed to do to resolve it, and a significant degree of accountability to ensure that the agreements are followed through.
  
• Improved Relationships. When people skillfully manage a conflict between them in healthy, respectful ways, it can actually serve to strengthen their relationship going forward. They end up understanding each other better, and building greater trust because they have demonstrated that they can overcome differences.

This chapter offers five key principles that represent a good start for those who wish to build better conflict management skills (Table 25-1). However, more detailed treatments of all of these principles and others are contained in the references at the end of this chapter.

1. 
   

   Commit to Confronting. Most people tend to shy away from conflict. It is tempting to believe that the problem will go away by itself if left alone; that others will soften their positions, forget about the issue, or change their minds, if given enough time. But when pressed, most people will acknowledge this is simply a convenient excuse for avoiding a confrontation that they fear could become uncomfortable or out-and-out unpleasant. In fact, another important reason that people avoid conflict is their fear that openly confronting the situation will make things worse, rather than better. They may worry about handling the confrontation badly and unintentionally cause the situation to deteriorate, or they may fear that the conflict is intractable and that no matter how carefully and skillfully the situation is handled, the outcome will be negative.

In fact, conflicts cannot be resolved if they are not confronted. They may be glossed over or pushed into the background, but not truly resolved. And such conflicts are likely to surface again, often in unanticipated and damaging ways. Thus a willingness to acknowledge the existence of a conflict and to step up and confront it is a precondition to effectively managing the conflict.

In this context, the term “confrontation” is not intended to mean an angry, emotional exchange of verbal attacks. Instead, “confrontation” refers here to an open and honest discussion of the issue, usually face-to-face, with the goal of understanding the root causes (the unmet expectations) that led to the conflict and addressing them. The remaining principles in this section are intended to assist the confronter, once the decision to confront has been made, to carefully plan the confrontation (when time permits), and to handle it successfully.

• 2. Attend to the Conditions1. Patterson, et al (2002) note that there are two components to every successful crucial conversation: the actual content of the conversation, and the conditions under which the conversation occurs. Most people, when planning to confront or actually engage in a confrontation (a “crucial conversation”), think primarily about the content of the conversation: “What is this conflict about? What steps will resolve it? What points do I need to be sure to make? What will I say to get my points across? What will the other person say?”