Consult Process Fine Points: Conflict Management

I had been trying to brainstorm with the residents last week about what to talk about for our Clinical Problems in Consultation Psychiatry (CPCP) conference and I wanted to learn more about conflict management in the psychiatric consultation process. I bemoaned my inability to ever find anything in the  medical literature about this issue.

And then an article about it magically appeared in the most recent issue of Psychosomatics [1]. I always enjoy reading just about anything from Dr. Theodore Stern, MD. And of all things, it was a case report so it described a dispute that the authors experienced with a hospitalist.

Conflicts are not uncommon in my business and I’m always looking for ways to improve communication between me and my colleagues. As the authors point out, conflict can occur at any stage of the consultation process and can often be divided into 3 main types:

  • Task conflict, which is a dispute about what’s to be done for the patient and what the goal or outcome should be.
  • Relationship conflict, which is a disagreement about interpersonal issues and values.
  • Process conflict, which is a dispute over the logistics of how to do the task.

All of these are usually in play in hospitals where many consultations are being performed. Remarkably, there is very little written about the dynamics of physician teams, even though a lot of lip service is paid to the desirability of and need for collaboration amongst health care team members.

Often different consultants will see a given patient through different lenses and the physician who is the primary care provider may even have a third, entirely different perspective. Business leaders talk more about the need for a negotiated approach than doctors do. Stephen Covey’s well-known principle, “Begin with the end in mind” fits the situation in hospitals where the goal is to help patients get well and recover.

ten_commandmentsHowever, it often seems hard for doctors to walk a mile in their colleagues’ shoes and collaborate. The authors mention something I had not seen, which was a paper about the “Ten Commandments for Effective Consultations” [2]. They have not changed much since the early 1980s:

  1. Determine the Question
  2. Establish Urgency
  3. Look For Yourself
  4. Be as Brief As Appropriate
  5. Be Specific
  6. Provide Contingency Plans
  7. Honor Thy Turf (Or Thou Shalt Not Covet Thy Neighbor’s Patient)
  8. Teach…With Tact
  9. Talk Is Cheap…And Effective
  10. Follow-Up

Determining the question and answering it seems to be a tall order most of the time. Tactfully helping the physician asking for consultation to formulate a clear question is an art, Difficult Psychiatry Consult Questions: Go Ask Alice? – The Practical Psychosomaticist. Now these commandments were intended for internal medicine consultants, but they could easily be applied to psychiatric consultants as well.

Prevention is the best medicine for conflicts on consultation. One that the authors suggest works is the seniority of the consultant. In other words, white hair gets more respect.

How come that never works for me?

When conflicts arise, it’s best to acknowledge them. Otherwise we can’t settle them. Resolving them generally places two major issues at odds: concern for the task and concern for relationships. See this post for illustrations, The
Difficult Conversation and How to Stay Aware – The Practical Psychosomaticist
.

Reflection, especially when it’s systematic self-reflection, can help consultants and consultees become more aware of what’s bugging them about the consultation process. Providing constructive feedback is not something doctors are systematically taught in medical school, and I have not encountered a remedial seminar for it. Dr. Stern has a special term for  self-reflection–autognosis. He has written about it elsewhere, teaches it to trainees, and has an interesting analogy to explain what it is and what it’s for [3]:

“Auto means self or car, and gnosis means knowledge or awareness. So, autognosis means knowing yourself, or your car. Imagine what would happen if all you did while driving was to look straight ahead [the analog for only looking at the patient’s lab data]. You might get sideswiped. However, if you only used the rear view or side view mirrors [as analogs for being aware of your own feelings and those of your patients] you might get into a head-on collision. The secret to safe driving, or to good patient care, is being able to use all areas of information [windshield/data, mirrors/feelings].The safest method of driving is to scan the mirrors [feelings] at brief intervals while concentrating on the road ahead [data on a patient]. The more you know about your car [yourself] the better prepared you will be to operate safely and be able to change gears, speed, or direction. Driving conditions often change and become hazardous. Therefore, knowledge of conditions that require special care will facilitate safer travel [patient care]. The professional can usually avoid catastrophe by knowing his or her own limits. Unfortunately, accidents do happen, and collisions occur. In such situations, it is helpful to know a good mechanic [consultant] to whom one can turn.”

Dr. Stern is just as funny in person and at the podium.

It’s not surprising that the authors recommend there be a curriculum in medical school for teaching conflict management to young doctors in training. There is a role for mentors in this endeavor and I have a post about that too (surprise!), My Top Ten List of Mentor Health – The Practical Psychosomaticist. Although the post is somewhat dated now because the “extremely talented” doctor has moved on, there is another newcomer who, though not a new graduate, is a welcome addition to the consultation service.

References:

1. Taylor, J. B. and T. A. Stern (2013). “Conflicts Between Consultants and Consultees: Causes, Consequences, and Corrective Actions.” Psychosomatics 54(5): 479-483.

2. Goldman, L., et al. (1983). “Ten commandments for effective consultations.” Archives of Internal Medicine 143(9): 1753-1755.
• If Internists are not explicitly instructed in how to perform consultations, the outcome of their consultative efforts may be suboptimal. We suggest that consultations will be more helpful if the following principles are followed: the consultant should determine the question that is being asked, establish the urgency of the consultation, gather primary data, communicate as briefly as appropriate, make specific recommendations, provide contingency plans, understand his own role in the process, offer educational information, communicate recommendations directly to the requesting physician, and provide appropriate follow-up. If these ten “commandments” are followed, the consultation is more likely to be effective and satisfactory for all the participants.(Arch Intern Med 1983;143:1753-1755)

3. Stern, T. A., L. M. Prager, et al. (1993). “Autognosis rounds for medical house staff.” Psychosomatics 34(1): 1-7.

The authors describe the autognosis countertransference rounds for medical house staff at the Massachusetts General Hospital. At these rounds, which have been held weekly for more than a decade in the intensive care unit, countertransference phenomena and their relationship to medical practice are discussed. Methods that have facilitated the autognostic process are provided and highlighted by brief case examples. Participants at these rounds report that their self-awareness increases and the clinical care they provide often improves.

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