EDUCATIONAL ADVANCE
Conflict Prevention, Conflict Mitigation, and Manifestations of Conflict During Emergency Department Consultations Teresa Chan, MD, Francis Bakewell, MD, Donika Orlich, MD, and Jonathan Sherbino, MD
Abstract Objectives: The objective was to determine the causes of and mitigating factors for conflict between emergency physicians and other colleagues during consultations. Methods: From March to September 2010, a total of 61 physicians (31 residents and 30 attendings from emergency medicine [EM], internal medicine, and general surgery) were interviewed about how junior learners should be taught about emergency department (ED) consultations. During these interviews, they were asked if and how conflict manifests during the ED consultation process. Two investigators reviewed the transcripts independently to generate themes related to conflict until saturation was reached. Disagreements were resolved by consensus. The trustworthiness of the analysis was ensured by generating an audit trail, which was subsequently audited by an investigator not involved with the initial analysis. This analysis was compared to previously proposed models of trust and conflict from the sociology and business literature. Results: All participants recalled some manifestation of conflict. There were 12 negative conflictproducing themes and 10 protective conflict-mitigating themes. When comparing these themes to a previously developed model of the domains of trust, each theme mapped to domains of the model. Conclusions: Conflict affects the ED consultation process. Areas that lead to conflict are identified that map to previous models of trust and conflict. This work extends the current understanding about intradisciplinary conflict in the clinical realm. These new findings may improve the understanding of the nature of conflicts that occur and form the foundation for interventions that may decrease conflict during ED consultations. ACADEMIC EMERGENCY MEDICINE 2014; 21:308–313 © 2014 by the Society for Academic Emergency Medicine
A
pproximately 40% of emergency department (ED) visits result in some sort of consultation, defined as a request for admission or further consulting service management of a patient.1–3 Consultation encounters create scenarios where physicians must collaborate on patient care and balance competing interests. Although collaboration or the ability to work with colleagues is a prominently featured competency in both the Canadian Medical Education Directions for Specialists and the Accreditation Council for Graduate Medical
Education, the real-world milieu of the ED is a challenging environment for consultation, and conflict may arise between specialists when collaborative efforts fail.4–6 Saltman et al.7 have proposed that conflict is “a disagreement within oneself or between people that causes harm or has the potential to cause harm.” Learning how to avoid or manage conflict is particularly important in the ED setting, as human factors research suggests that collaborative and harmonious transitions of care are key to patient safety and error reduction.8,9 The Canadian
From the Division of Emergency Medicine, Department of Medicine, McMaster University (TC, DO, JS), Hamilton, Ontario; and the Department of Emergency Medicine, University of Ottawa (FB), Ottawa, Ontario, Canada. Received June 28, 2013; revisions received August 19 and September 5, 2013; accepted September 26, 2013. Presented at the Canadian Association of Emergency Physicians Conference, Niagara Falls, Ontario, June 2012. This work was supported by a research grant from the Canadian Association of Emergency Physicians. The lead author was also the recipient of the Royal College of Physicians and Surgeons of Canada’s Fellowship for Studies in Medical Education. The authors have no potential conflicts of interest to disclose. Supervising Editor: Lalena M. Yarris, MD, MCR. Address for correspondence and reprints: Teresa Chan, MD; e-mail: [email protected].
308
ISSN 1069-6563 PII ISSN 1069-6563583
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12325
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
Medical Protection Agency, which is a national organization that provides legal assistance and risk-management advice to nearly all Canadian physicians, endorses conflict management as a necessary physician competency, stating that “… [l]earning how to prevent or manage conflict effectively is an important clinical skill for physicians.”6 Although the body of literature surrounding consultations in emergency medicine (EM) is growing, little is known about conflict in EM consultations or intraprofessional conflict management.3,10–19 Much of the published literature on physicians and conflict has focused on conflicts at the physician–patient level.6,20–22 To date, no studies that we found have explored the effects of conflict on the ED consultation process. Our previous research found that trust is a critical part of the consultation process.23 In light of those findings, and other findings from the conflict-resolution literature by Lewicki and Wiethoff,24 we hypothesize that conflict exists in the ED consultation process and that efforts to resolve conflict in the ED consultations are affected by interpersonal trust. Lewicki and Wiethoff propose that conflict is highly tied to interpersonal trust: when trust breaks down conflict arises, and rebuilding trust has a role in conflict resolution.24 The purpose of this study was to describe the manifestations of conflict as recalled by emergency physicians (EPs) and consulting physicians during the ED consultation process. METHODS Study Design This was a qualitative study that used a grounded theory approach to examine transcripts from interviews and focus groups on the topic of EM consultations. We used a deliberate sampling of three specialties (EM, general surgery, and internal medicine), including both attending and resident physicians.25 These three specialties were chosen because they interact most frequently within the EDs of the four study hospitals. The line of questioning was planned a priori and conducted as part of a larger study on ED consultations. We were granted approval by the Faculty of Health Sciences/McMaster University research ethics board. All participants provided written, informed consent. Study Setting and Population We recruited our participants from all four academic hospitals that form the core teaching centers for McMaster University. Recruitment was via e-mail using a modified Dillman approach where program administrators e-mailed their faculty and residents three times, approximately 1 week apart.26 We capped recruitment once the maximum of 10 participants in each of the three groups was reached.25 A clerical error resulted in 11 EM residents participating. Participants were questioned via either individual interviews (attendings) or focus groups (residents). The rationale for this difference in interview techniques was logistics. It was impossible to align the schedules of the attending physicians to create focus groups. All residents had to be in their second year of residency or higher and had to have been actively seeing
309
patients in the ED within the past 12 months to be eligible. Attending physicians were to have actively practiced in the ED setting within 6 months of the interview, to be eligible for enrollment in our study. Study Protocol The initial interview template was based on input from three local content experts who had been recommended either because of their previous lecturing (JC) or because of research (DW, CKS).18 The survey was piloted on a representative sample of nonparticipating faculty members and residents. The template was revised according to their suggestions. No changes were made to questions pertaining directly to the topic of conflict; however, some clarification questions were added to nonrelated questions on the survey. This piloted interview template served as the basis for a series of semistructured questions for both the interviews and the focus groups. The complete listing of our questions has previously been published.21 The participants were only asked two structured questions directly pertaining to conflict (What are the impediments to a good consultation-referral encounter? How do you cope or compensate for these impediments?). They were free to comment during other lines of questioning on topics related to conflict, and our analysis involved both direct answers, and other mentions of conflict in the remainder of the questions. The same questions were administered during both interviews and focus groups. All responses were recorded regardless of whether they answered the prompting questions. A single interviewer and focus group moderator (TC) conducted all questioning of participants and used unscripted probes to explore areas that required clarification and explanations. This interviewer was a junior EM resident physician at the time and had no power over any participating physicians or surgeons, but had previously worked with a minority of them. Interviews were planned for about 40 minutes and focus groups were planned for 60 minutes, although our protocol allowed participants to speak until the completion of their thoughts. Data Supplement S1 (available as supporting information in the online version of this paper) includes the focus group instructions. Focus groups consisted of specialty-specific groupings of residents. The interviews and focus groups were recorded and then transcribed by the lead interviewer and two hired research assistants (medical students). All transcripts were reviewed by the lead interviewer to ensure consistency of language and syntax. The transcripts were made anonymous prior to analysis. Data Analysis The transcripts of the interviews were analyzed using grounded theory principles.27–29 Transcripts were analyzed holistically and tagged throughout. Transcripts were independently reviewed by two investigators (FB, TC) to create a single registry of codes until a saturation point was reached and no new codes were generated. At the time of analysis, one reviewer was an EM resident (TC) and one was a senior medical student (FB). Each reviewer began with an independent open coding
310
Chan et al. • CONFLICT DURING ED CONSULTATIONS
procedure. The separate codes were compared and merged, by consensus, into a single registry of codes. The two reviewers then separately analyzed the transcripts to identify themes in an axial coding procedure to interlink discovered themes to map them to major themes. Finally, the reviewers merged their analysis, by consensus, into a thematic framework. Using a constructivist approach, the common, final framework was considered in the context of other literature to better understand the results. A third reviewer (DO) examined and audited the analysis and provided investigator triangulation. This reviewer was an EM resident. An audit trail was established between both initial reviewers. Additionally, all notes from the analysis meetings were reviewed. Suggestions highlighted by the third reviewer were appropriately amalgamated by three investigators (FB, TC, DO). There was one single theme (of 21 original themes) that was parsed further into two separate themes.
Table 2 Conflict-causing and Conflict-mitigating Themes
Factors
Historical factors Good reputation Good prior experiences
Attitudes and values displayed Actions taken
Conflict-mitigating Themes The 10 positive, conflict-mitigating themes were on a variety of topics. These themes could be sorted into three major thematic groups by axial coding: 1) historical factors, 2) attitudes and values, and 3) actions. The
Table 1 Demographics Characteristic
Total
Level of training Residents n = 31 Attendings n = 30 Mean (SD) age (yr) Both groups 36 (9.0) Residents 29.5 (3.3) Attendings 42.7 (8.0) Sex 41 M/20 F Residents
19 M/12 F
Attendings
21 M/9 F
Breakdown 11 EM, 10 GS, 10 IM 10 EM, 10 GS, 10 IM 35.2 EM, 38 GS, 35.5 IM 30.5 EM, 39 GS, 29.2 IM 40.2 EM, 47 GS, 41.1 IM 62% M, EM; 70% M, GS; 65% M, IM 64% M, EM; 60% M, GS; 60% M, IM 60% M, EM; 80% M, GS; 70% M, IM
EM = emergency medicine; F = female; GS = general surgery; IM = internal medicine; M = male.
Empathy Engagement Professional behavior Agreeing with plan of care Collaboration Meeting expectations Provision of expert care adjusting expectations
RESULTS From March to September of 2010, a total of 61 physicians (31 resident physicians and 30 attending physicians) were questioned about the ED consultation process. The participant demographics are listed in Table 1. Interviews with attending physicians and surgeons ranged from 20 to 72 minutes in duration. Focus groups with residents ranged in duration from 80 to 96 minutes. We identified some manifestation of conflict in all transcripts. Ultimately there were 12 negative themes and 10 protective themes. Table 2 lists these conflictmitigating (positive) and conflict-producing (negative) themes. Data Supplement S1 shows exemplar quotes for each of these themes.
Conflict-mitigating Themes
Trust Others
Presence
Conflict-producing Themes Bad reputation Unknown reputation Doubt in other party’s competence (based on prior experience) Being disengaged
Poor communication Disagreeing with plan of care Self-serving behaviors Providing inappropriate care Failing to collaborate Failing to meet expectations Absence External stressors
historical factors were good prior experiences and good reputation. Each of these themes was related to how participants recalled that their prior encounters or knowledge contributed to conflict during ED consultation encounters. Attitudes and values displayed by individuals included factors such as empathy, engagement, and professional behavior. These themes all concerned personal attributes that one party outwardly displayed to the other during the encounter. Actions were a grouping of themes that described activities participants felt they needed to perform during the consultation encounter to mitigate conflict. These were “providing expert care” (e.g., stabilizing very sick patients), “agreeing to the plan of care,” “adjusting expectations about the consultation,” “meeting expectations of others,” and “collaborating.” Conflict-Producing Themes The 12 negative, conflict-producing themes were similarly grouped under three major themes: historical factors, attitudes and values, and actions. One other theme was identified during the analysis: external stressors. Some examples of language used to describe maladaptive behaviors and conflict-producing themes were “being avoidant,” “ducking consult,” “getting angry,” “pulling rank.” Curiously, the theme of “external stressors” could not be sorted in to the previous major themes, but was felt to be a separate major theme. An example of an external stressor that was prominently featured was the perceived time stress on the ED. This stressor was noted as a theme in transcripts by all parties (EPs, consulting physicians, attendings, and residents). Of note, we did not note a similar mirroring conflict-mitigating theme. Participants did not recall when external forces positively affected their ED consultation processes.
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
Trust: A Fifth Major Theme In examining our conflict-producing and conflict-mitigating themes, we noted that there was a fifth underlying axial theme (trust) that intersected all the other themes. This was not surprising, as it was the theoretical and conceptual framework that informed our original constructivist approach to analysis. Conflict recollections during our interview and focus group sessions seemed to show that attributes that caused conflict could similarly be seen as a breach of trust, while other trust-building activities might mitigate or resolve conflict.
Table 3 Comparing Domains of Trust to Conflict-related Themes Domains of Trust Reliability
Shared interests
DISCUSSION Health care has evolved over the years into a teambased endeavor, and as such, conflict may occur during high-stakes, complex interactions. Therefore, it is not surprising that we were able to determine a number of conflict-causing and conflict-mitigating factors. Five major themes (historical factors, displayed attitudes and values, actions, external stressors, and trust) affected the consultation process. This adds a layer of complexity to existing basic models such as the 5Cs and PIQUED models that have been proposed for understanding the anatomy of the ED consultation.20,21 Our findings suggest that effectively performing a consultation may require extensive, more nuanced awareness of social forces at play. Our previous work had shown that trust affects the interpersonal relationships between emergency and consulting physicians.23 In a study of residents in emergency and consulting services, we found that familiarity and trust were key themes that affected the interactions between housestaff.23 These factors aligned with the theory of interpersonal trust described by Giffin.30 By comparing our previous work to the themes found to produce or mitigate conflict, we suggest a link between the themes in this present study and the “domains of trust,” as well as Giffin’s Theory of Interpersonal Trust8 (see Table 3). As originally discussed, we had based our study out of the work of Lewicki and Wiethoff’s model for conflict negotiation.24 In this model, Lewicki and Wiethoff24 describe that, “As relationships are based on differing levels of trust, when that trust breaks down, conflict may arise between the parties involved.” Mayer31 describes five major forces that cause conflict: history, emotion, structure, values, and communication. Our findings align with certain features of Mayer’s model as well. For instance, having any sort of reputation (good, bad, unknown) is consistent with having a history with the other party. An individual’s behavior due to external stressors and professionalism, as well as one’s ability to empathize, will shape the emotional landscape of any encounter. Expertise, being engaged and collaborative with one’s colleagues, or as a corollary, acting in a self-serving manner, may be a reflection of the values of parties involved. These may potentiate or mitigate conflict scenarios. Communication, especially if done poorly as we have identified, is most certainly a factor in causing conflict as well. Conflict management has been frequently described in the medical literature, with translational work coming
311
Personal attributes and conduct (e.g., being likeable or personable) Engagement
Mitigates Conflict
Produces Conflict
Meets expectations Good prior experiences Adjusting expectations Collaborating on patient care Agreeing with the patient care plan Empathy Professional behavior
Failure to meet expectations
Being engaged
Being disengaged Poor communication Bad reputation Unknown reputation Providing inappropriate care to the patient
Reputation
Good reputation
Expertise
Providing expert care to the patient
Self-serving Lack of or failing to collaborate/help Disagreeing regarding patient care issues External stressors Unprofessional behavior
Doubt in the other person’s competence
from the health management and medical education literature.7,32–34 This translational work has focused on management applications for conflict resolution32,33 and providing learners with conflict resolution skills.7,34 Examining high-risk interactions such as consultations or other transitions of care may bring new concepts to light. Using scenarios faced by EPs every day allows for more context specificity and helps translate concepts from other fields. This may be especially imperative for medical learners, as case specificity may be important understanding.35 Physicians are generally known to be conflictaverse,36,37 and when they tackle conflict situations, they often use instinctive techniques.36 Louise Andrew states: “… conflict resolution skills employed by most physicians mirror those that were modeled by parents or significant others … Not surprisingly, the outcomes of our attempts at work-related conflict management based on these models are frequently mediocre and sometimes disastrous.”36 From our transcripts and analysis, we propose some strategies that may assist ED clinicians with consultations by reducing conflict (Table 4). LIMITATIONS As this was a qualitative study, there may be some case specificity relating to the culture of an academic center that are not generalizable to other environments, such as community hospitals. Moreover, as with all qualitative studies, we would caution readers against generalizing the results, although themes may highlight certain occurrences common to other hospitals.
312
Table 4 Applications for the Clinician Based on the analyses from this study, there are numerous immediate applications that clinicians might utilize. We theorize that the following three behaviors or attitudes may assist clinicians in any ED consultation process. Know colleagues: Our study found that being unknown was a negatively impacting factor, similar to having a bad reputation. Remaining anonymous may make discussions more difficult, since the reservoir of trust and experience is not there to mitigate potential conflict. Engage colleagues: Showing interest in a colleague’s work and acknowledging their impact on a patient’s care can go a long way to demonstrate respect, which builds trust and decreases conflict. Display shared interests to colleagues: Try to display interest for common goals and highlight shared interests in helping to stamp out disease or alleviating the suffering for that shared patient.
Moreover, our study was limited to a single academic center for logistical reasons as this was a resident research project and we had funding and resource limitations. We did attempt to sample from four different hospitals within the academic jurisdiction, to mitigate this problem. The focus-group moderator and interviewer for this study was a junior EM resident, and this may have influenced the openness of the participants. The involvement of medical students and EM residents in the analysis may also have altered the analysis by influencing their metaposition from the data. Also, two-thirds of our participants were male, which may affect the forms of conflict that are described and the strategies described to mitigate conflict. CONCLUSIONS Conflict occurs within the ED consultation process. Our research reveals the factors that influence the development of intraprofessional conflict. There is a tie between conflict and trust, since distrust can lead to conflict around a patient care plan. The factors that we identify that increase trust between colleagues may possibly resolve or decrease conflict during ED consultations. The authors thank Gerson Mobo and Sarah Compeau for their assistance with the transcription process. We also thank Drs. John Crossley, Douglas Wright, and Claire Kenny-Scherber for their assistance in determining our study design and survey. We are also indebted to Drs. Michelle Lin, Nikita Joshi, and Brent Thoma for their advice. Finally, we would like to thank Dr. Lalena Yarris and the Academic Emergency Medicine journal reviewers for their coaching and thoughtful suggestions.
References 1. Kessler CS, Asrow A, Beach C, et al. The taxonomy of emergency department consultations–results of an expert consensus panel. Ann Emerg Med 2013;61:161–6. 2. Woods RA, Lee R, Ospina MB, et al. Consultation outcomes in the emergency department: exploring rates and complexity. Can J Emerg Med 2008;10:25– 31.
Chan et al. • CONFLICT DURING ED CONSULTATIONS
3. Cortazzo JM, Guertler AT, Rice MM. Consultation and referral patterns from a teaching hospital emergency department. Am J Emerg Med 1993;25:456–60. 4. Royal College of Physicians and Surgeons (Canada). Objectives of Training for Emergency Medicine. Available at: https://www.medicine.mcgill.ca/post grad/accreditation_2013/PSQs/1_Emergency_Medicine /05_OTR_Emergency_Medicine_2008.pdf. Accessed Dec 4, 2013. 5. Beeson MS, Carter WA, Christopher TA, et al. Emergency medicine milestones. J Grad Med Educ 2013;5(1 Suppl 1):5–13. 6. Canadian Medical Protective Association. Dealing With Conflict the Doctor-Patient Relationship. Available at: https://oplfrpd5.cmpa-acpm.ca/safety/-/asset_publisher/ N6oEDMrzRbCC/content/dealing-with-conflict-in-thedoctor-patient-relationship;jsessionid=B57DFAB931D B05ABD5ECC25E835841A4. Accessed February 1, 2014. 7. Saltman DC, O’Dea NA, Kidd MR. Conflict management: a primer for doctors in training. Postgrad Med J 2006;82:9–12. 8. The Joint Commission. Sentinel Event Data: Root Causes by Event Type, 2004-2012. http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_ 04_4Q2012.pdf. Accessed Dec 4, 2013. 9. Institute of Medicine. Executive Summary. In: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001. 10. Kessler C, Woods R, Chan TM, Sherbino J. A call to action in consultation training. Can J Emerg Med 2011;13:361. 11. Kessler CS, Chan T, Loeb JM, Malka ST. I’m clear, you’re clear, we’re all clear: improving consultation communication skills in undergraduate medical education. Acad Med 2013;88:753–8. 12. Lee RS, Woods R, Bullard M, Holroyd BR, Rowe BH. Consultations in the emergency department: a systematic review of the literature. Can J Emerg Med 2008;25:4–9. 13. Wright D, Kenny-Scherber C, Patel A, et al. Defining and optimizing collaboration between emergency medicine and internal medicine physicians. Can J Gen Intern Med 2011;6:28–9. 14. Matthews AL, Harvey CM, Schuster RJ, Durso FT. Emergency physician to admitting physician handovers: an exploratory study. Proc Human Factors Ergonom Soc 46th Ann Meeting. Baltimore, MD, 2002, pp 1511–5. 15. Kessler C, Kutka BM, Badillo C. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med 2012;42:704–11. 16. Chan T, Orlich D, Kulasegaram K, Sherbino J. Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner. Can J Emerg Med 2013;15:42–51. 17. Kessler CS, Afshar Y, Sardar G, Yudkowsky R, Ankel F, Schwartz A. A prospective, randomized, controlled study demonstrating a novel, effective
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
18.
19.
20.
21.
22.
23.
5.
25.
26.
model of transfer of care between physicians: the 5 Cs of consultation. Acad Emerg Med 2012;19:968– 74. Kessler CS, Kalapurayil PS, Yudkowsky R, Schwartz A. Validity evidence for a new checklist evaluating consultations, the 5Cs model. Acad Med 2012;87:1408–12. Iwata M, Yamanaka K, Kitagawa Y. The level of agreement regarding patient disposition between emergency physicians and consultants in the emergency department. Int J Emerg Med 2013;6:22. Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med 2011;26:588–94. Stavropoulou C, Glycopantis D. Conflict in the Doctor-Patient Relation and Non-adherence: A Game Theory Approach. LSE Health working papers. Available at: http://eprints.lse.ac.uk/28830/1/ LSEHWP10.pdf. Accessed Dec 4, 2013. Simpson M, Buckman R, Stewart M, et al. Doctor– patient communication: the Toronto consensus statement. BMJ 1991;303:1385–7. Chan TM, Sabir KR, Sanhan S, Sherbino J. Understanding the impact of residents’ interpersonal relationships during emergency department referrals and consultation. J Grad Med Ed 2013;5(1): 476–581. Lewicki RJ, Wiethoff C. Trust, trust development and trust repair. In: Deutsch M, Coleman P, editors. The Handbook of Conflict Resolution: Theory & Practice. San Francisco, CA: Jossey-Bass, 2000, pp 86–107. Punch KF. Introduction to Research Methods in Education. Thousand Oaks, CA: Sage Publications Inc., 2009, pp 162–7. Dillman DA. Mail and Internet Surveys: The Tailored Design Method 2007 Update With New Internet, Visual, and Mixed-mode Guide. Hoboken, NJ: John Wiley & Sons Inc, 2007.
313
27. Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis, 2nd Ed. Thousand Oaks, CA: Sage Publications, 2006. 28. Bandiera GL, Lee S, Tiberius R. Creating effective learning in today’s emergency departments: how accomplished teachers get it done. Ann Emerg Med 2005;45:253–61. 29. Flick U. An Introduction to Qualitative Research, 2nd ed. Thousand Oaks, CA: Sage, 2002. 30. Giffin K. The contribution of studies of source credibility to a theory of interpersonal trust in the communication process. Psychol Bull 1967;68:104–20. 31. Mayer B. The Dynamics of Conflict Resolution: A Practitioner’s Guide. San Francisco, CA: JosseyBass, 2000. 32. Porter-O’Grady T. Embracing conflict: building healthy a community. Health Care Manage Rev 2004;29:181–7. 33. Harolds J, Wood BP. Conflict management and resolution. J Am Coll Radiol 2006;3:200–6. 34. Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, Part 1: the nature and causes of disrespectful behavior by physicians. Acad Med 2012;87:845–52. 35. Wimmers PF, Fung CC. The impact of case specificity and generalisable skills on clinical performance: a correlated traits-correlated methods approach. Med Educ 2008;42:580–8. 36. Andrew LB. Conflict management, prevention and resolution in medical settings. Physician Exec 1999;25:38–42. 37. Dawson R. Why do physicians have difficulty negotiating? Physician Exec 1999;25:43–4. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Sample focus group orientation script.
Conflict Prevention, Conflict Mitigation, and Manifestations of Conflict During Emergency Department Consultations Teresa Chan, MD, Francis Bakewell, MD, Donika Orlich, MD, and Jonathan Sherbino, MD
Abstract Objectives: The objective was to determine the causes of and mitigating factors for conflict between emergency physicians and other colleagues during consultations. Methods: From March to September 2010, a total of 61 physicians (31 residents and 30 attendings from emergency medicine [EM], internal medicine, and general surgery) were interviewed about how junior learners should be taught about emergency department (ED) consultations. During these interviews, they were asked if and how conflict manifests during the ED consultation process. Two investigators reviewed the transcripts independently to generate themes related to conflict until saturation was reached. Disagreements were resolved by consensus. The trustworthiness of the analysis was ensured by generating an audit trail, which was subsequently audited by an investigator not involved with the initial analysis. This analysis was compared to previously proposed models of trust and conflict from the sociology and business literature. Results: All participants recalled some manifestation of conflict. There were 12 negative conflictproducing themes and 10 protective conflict-mitigating themes. When comparing these themes to a previously developed model of the domains of trust, each theme mapped to domains of the model. Conclusions: Conflict affects the ED consultation process. Areas that lead to conflict are identified that map to previous models of trust and conflict. This work extends the current understanding about intradisciplinary conflict in the clinical realm. These new findings may improve the understanding of the nature of conflicts that occur and form the foundation for interventions that may decrease conflict during ED consultations. ACADEMIC EMERGENCY MEDICINE 2014; 21:308–313 © 2014 by the Society for Academic Emergency Medicine
A
pproximately 40% of emergency department (ED) visits result in some sort of consultation, defined as a request for admission or further consulting service management of a patient.1–3 Consultation encounters create scenarios where physicians must collaborate on patient care and balance competing interests. Although collaboration or the ability to work with colleagues is a prominently featured competency in both the Canadian Medical Education Directions for Specialists and the Accreditation Council for Graduate Medical
Education, the real-world milieu of the ED is a challenging environment for consultation, and conflict may arise between specialists when collaborative efforts fail.4–6 Saltman et al.7 have proposed that conflict is “a disagreement within oneself or between people that causes harm or has the potential to cause harm.” Learning how to avoid or manage conflict is particularly important in the ED setting, as human factors research suggests that collaborative and harmonious transitions of care are key to patient safety and error reduction.8,9 The Canadian
From the Division of Emergency Medicine, Department of Medicine, McMaster University (TC, DO, JS), Hamilton, Ontario; and the Department of Emergency Medicine, University of Ottawa (FB), Ottawa, Ontario, Canada. Received June 28, 2013; revisions received August 19 and September 5, 2013; accepted September 26, 2013. Presented at the Canadian Association of Emergency Physicians Conference, Niagara Falls, Ontario, June 2012. This work was supported by a research grant from the Canadian Association of Emergency Physicians. The lead author was also the recipient of the Royal College of Physicians and Surgeons of Canada’s Fellowship for Studies in Medical Education. The authors have no potential conflicts of interest to disclose. Supervising Editor: Lalena M. Yarris, MD, MCR. Address for correspondence and reprints: Teresa Chan, MD; e-mail: [email protected].
308
ISSN 1069-6563 PII ISSN 1069-6563583
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12325
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
Medical Protection Agency, which is a national organization that provides legal assistance and risk-management advice to nearly all Canadian physicians, endorses conflict management as a necessary physician competency, stating that “… [l]earning how to prevent or manage conflict effectively is an important clinical skill for physicians.”6 Although the body of literature surrounding consultations in emergency medicine (EM) is growing, little is known about conflict in EM consultations or intraprofessional conflict management.3,10–19 Much of the published literature on physicians and conflict has focused on conflicts at the physician–patient level.6,20–22 To date, no studies that we found have explored the effects of conflict on the ED consultation process. Our previous research found that trust is a critical part of the consultation process.23 In light of those findings, and other findings from the conflict-resolution literature by Lewicki and Wiethoff,24 we hypothesize that conflict exists in the ED consultation process and that efforts to resolve conflict in the ED consultations are affected by interpersonal trust. Lewicki and Wiethoff propose that conflict is highly tied to interpersonal trust: when trust breaks down conflict arises, and rebuilding trust has a role in conflict resolution.24 The purpose of this study was to describe the manifestations of conflict as recalled by emergency physicians (EPs) and consulting physicians during the ED consultation process. METHODS Study Design This was a qualitative study that used a grounded theory approach to examine transcripts from interviews and focus groups on the topic of EM consultations. We used a deliberate sampling of three specialties (EM, general surgery, and internal medicine), including both attending and resident physicians.25 These three specialties were chosen because they interact most frequently within the EDs of the four study hospitals. The line of questioning was planned a priori and conducted as part of a larger study on ED consultations. We were granted approval by the Faculty of Health Sciences/McMaster University research ethics board. All participants provided written, informed consent. Study Setting and Population We recruited our participants from all four academic hospitals that form the core teaching centers for McMaster University. Recruitment was via e-mail using a modified Dillman approach where program administrators e-mailed their faculty and residents three times, approximately 1 week apart.26 We capped recruitment once the maximum of 10 participants in each of the three groups was reached.25 A clerical error resulted in 11 EM residents participating. Participants were questioned via either individual interviews (attendings) or focus groups (residents). The rationale for this difference in interview techniques was logistics. It was impossible to align the schedules of the attending physicians to create focus groups. All residents had to be in their second year of residency or higher and had to have been actively seeing
309
patients in the ED within the past 12 months to be eligible. Attending physicians were to have actively practiced in the ED setting within 6 months of the interview, to be eligible for enrollment in our study. Study Protocol The initial interview template was based on input from three local content experts who had been recommended either because of their previous lecturing (JC) or because of research (DW, CKS).18 The survey was piloted on a representative sample of nonparticipating faculty members and residents. The template was revised according to their suggestions. No changes were made to questions pertaining directly to the topic of conflict; however, some clarification questions were added to nonrelated questions on the survey. This piloted interview template served as the basis for a series of semistructured questions for both the interviews and the focus groups. The complete listing of our questions has previously been published.21 The participants were only asked two structured questions directly pertaining to conflict (What are the impediments to a good consultation-referral encounter? How do you cope or compensate for these impediments?). They were free to comment during other lines of questioning on topics related to conflict, and our analysis involved both direct answers, and other mentions of conflict in the remainder of the questions. The same questions were administered during both interviews and focus groups. All responses were recorded regardless of whether they answered the prompting questions. A single interviewer and focus group moderator (TC) conducted all questioning of participants and used unscripted probes to explore areas that required clarification and explanations. This interviewer was a junior EM resident physician at the time and had no power over any participating physicians or surgeons, but had previously worked with a minority of them. Interviews were planned for about 40 minutes and focus groups were planned for 60 minutes, although our protocol allowed participants to speak until the completion of their thoughts. Data Supplement S1 (available as supporting information in the online version of this paper) includes the focus group instructions. Focus groups consisted of specialty-specific groupings of residents. The interviews and focus groups were recorded and then transcribed by the lead interviewer and two hired research assistants (medical students). All transcripts were reviewed by the lead interviewer to ensure consistency of language and syntax. The transcripts were made anonymous prior to analysis. Data Analysis The transcripts of the interviews were analyzed using grounded theory principles.27–29 Transcripts were analyzed holistically and tagged throughout. Transcripts were independently reviewed by two investigators (FB, TC) to create a single registry of codes until a saturation point was reached and no new codes were generated. At the time of analysis, one reviewer was an EM resident (TC) and one was a senior medical student (FB). Each reviewer began with an independent open coding
310
Chan et al. • CONFLICT DURING ED CONSULTATIONS
procedure. The separate codes were compared and merged, by consensus, into a single registry of codes. The two reviewers then separately analyzed the transcripts to identify themes in an axial coding procedure to interlink discovered themes to map them to major themes. Finally, the reviewers merged their analysis, by consensus, into a thematic framework. Using a constructivist approach, the common, final framework was considered in the context of other literature to better understand the results. A third reviewer (DO) examined and audited the analysis and provided investigator triangulation. This reviewer was an EM resident. An audit trail was established between both initial reviewers. Additionally, all notes from the analysis meetings were reviewed. Suggestions highlighted by the third reviewer were appropriately amalgamated by three investigators (FB, TC, DO). There was one single theme (of 21 original themes) that was parsed further into two separate themes.
Table 2 Conflict-causing and Conflict-mitigating Themes
Factors
Historical factors Good reputation Good prior experiences
Attitudes and values displayed Actions taken
Conflict-mitigating Themes The 10 positive, conflict-mitigating themes were on a variety of topics. These themes could be sorted into three major thematic groups by axial coding: 1) historical factors, 2) attitudes and values, and 3) actions. The
Table 1 Demographics Characteristic
Total
Level of training Residents n = 31 Attendings n = 30 Mean (SD) age (yr) Both groups 36 (9.0) Residents 29.5 (3.3) Attendings 42.7 (8.0) Sex 41 M/20 F Residents
19 M/12 F
Attendings
21 M/9 F
Breakdown 11 EM, 10 GS, 10 IM 10 EM, 10 GS, 10 IM 35.2 EM, 38 GS, 35.5 IM 30.5 EM, 39 GS, 29.2 IM 40.2 EM, 47 GS, 41.1 IM 62% M, EM; 70% M, GS; 65% M, IM 64% M, EM; 60% M, GS; 60% M, IM 60% M, EM; 80% M, GS; 70% M, IM
EM = emergency medicine; F = female; GS = general surgery; IM = internal medicine; M = male.
Empathy Engagement Professional behavior Agreeing with plan of care Collaboration Meeting expectations Provision of expert care adjusting expectations
RESULTS From March to September of 2010, a total of 61 physicians (31 resident physicians and 30 attending physicians) were questioned about the ED consultation process. The participant demographics are listed in Table 1. Interviews with attending physicians and surgeons ranged from 20 to 72 minutes in duration. Focus groups with residents ranged in duration from 80 to 96 minutes. We identified some manifestation of conflict in all transcripts. Ultimately there were 12 negative themes and 10 protective themes. Table 2 lists these conflictmitigating (positive) and conflict-producing (negative) themes. Data Supplement S1 shows exemplar quotes for each of these themes.
Conflict-mitigating Themes
Trust Others
Presence
Conflict-producing Themes Bad reputation Unknown reputation Doubt in other party’s competence (based on prior experience) Being disengaged
Poor communication Disagreeing with plan of care Self-serving behaviors Providing inappropriate care Failing to collaborate Failing to meet expectations Absence External stressors
historical factors were good prior experiences and good reputation. Each of these themes was related to how participants recalled that their prior encounters or knowledge contributed to conflict during ED consultation encounters. Attitudes and values displayed by individuals included factors such as empathy, engagement, and professional behavior. These themes all concerned personal attributes that one party outwardly displayed to the other during the encounter. Actions were a grouping of themes that described activities participants felt they needed to perform during the consultation encounter to mitigate conflict. These were “providing expert care” (e.g., stabilizing very sick patients), “agreeing to the plan of care,” “adjusting expectations about the consultation,” “meeting expectations of others,” and “collaborating.” Conflict-Producing Themes The 12 negative, conflict-producing themes were similarly grouped under three major themes: historical factors, attitudes and values, and actions. One other theme was identified during the analysis: external stressors. Some examples of language used to describe maladaptive behaviors and conflict-producing themes were “being avoidant,” “ducking consult,” “getting angry,” “pulling rank.” Curiously, the theme of “external stressors” could not be sorted in to the previous major themes, but was felt to be a separate major theme. An example of an external stressor that was prominently featured was the perceived time stress on the ED. This stressor was noted as a theme in transcripts by all parties (EPs, consulting physicians, attendings, and residents). Of note, we did not note a similar mirroring conflict-mitigating theme. Participants did not recall when external forces positively affected their ED consultation processes.
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
Trust: A Fifth Major Theme In examining our conflict-producing and conflict-mitigating themes, we noted that there was a fifth underlying axial theme (trust) that intersected all the other themes. This was not surprising, as it was the theoretical and conceptual framework that informed our original constructivist approach to analysis. Conflict recollections during our interview and focus group sessions seemed to show that attributes that caused conflict could similarly be seen as a breach of trust, while other trust-building activities might mitigate or resolve conflict.
Table 3 Comparing Domains of Trust to Conflict-related Themes Domains of Trust Reliability
Shared interests
DISCUSSION Health care has evolved over the years into a teambased endeavor, and as such, conflict may occur during high-stakes, complex interactions. Therefore, it is not surprising that we were able to determine a number of conflict-causing and conflict-mitigating factors. Five major themes (historical factors, displayed attitudes and values, actions, external stressors, and trust) affected the consultation process. This adds a layer of complexity to existing basic models such as the 5Cs and PIQUED models that have been proposed for understanding the anatomy of the ED consultation.20,21 Our findings suggest that effectively performing a consultation may require extensive, more nuanced awareness of social forces at play. Our previous work had shown that trust affects the interpersonal relationships between emergency and consulting physicians.23 In a study of residents in emergency and consulting services, we found that familiarity and trust were key themes that affected the interactions between housestaff.23 These factors aligned with the theory of interpersonal trust described by Giffin.30 By comparing our previous work to the themes found to produce or mitigate conflict, we suggest a link between the themes in this present study and the “domains of trust,” as well as Giffin’s Theory of Interpersonal Trust8 (see Table 3). As originally discussed, we had based our study out of the work of Lewicki and Wiethoff’s model for conflict negotiation.24 In this model, Lewicki and Wiethoff24 describe that, “As relationships are based on differing levels of trust, when that trust breaks down, conflict may arise between the parties involved.” Mayer31 describes five major forces that cause conflict: history, emotion, structure, values, and communication. Our findings align with certain features of Mayer’s model as well. For instance, having any sort of reputation (good, bad, unknown) is consistent with having a history with the other party. An individual’s behavior due to external stressors and professionalism, as well as one’s ability to empathize, will shape the emotional landscape of any encounter. Expertise, being engaged and collaborative with one’s colleagues, or as a corollary, acting in a self-serving manner, may be a reflection of the values of parties involved. These may potentiate or mitigate conflict scenarios. Communication, especially if done poorly as we have identified, is most certainly a factor in causing conflict as well. Conflict management has been frequently described in the medical literature, with translational work coming
311
Personal attributes and conduct (e.g., being likeable or personable) Engagement
Mitigates Conflict
Produces Conflict
Meets expectations Good prior experiences Adjusting expectations Collaborating on patient care Agreeing with the patient care plan Empathy Professional behavior
Failure to meet expectations
Being engaged
Being disengaged Poor communication Bad reputation Unknown reputation Providing inappropriate care to the patient
Reputation
Good reputation
Expertise
Providing expert care to the patient
Self-serving Lack of or failing to collaborate/help Disagreeing regarding patient care issues External stressors Unprofessional behavior
Doubt in the other person’s competence
from the health management and medical education literature.7,32–34 This translational work has focused on management applications for conflict resolution32,33 and providing learners with conflict resolution skills.7,34 Examining high-risk interactions such as consultations or other transitions of care may bring new concepts to light. Using scenarios faced by EPs every day allows for more context specificity and helps translate concepts from other fields. This may be especially imperative for medical learners, as case specificity may be important understanding.35 Physicians are generally known to be conflictaverse,36,37 and when they tackle conflict situations, they often use instinctive techniques.36 Louise Andrew states: “… conflict resolution skills employed by most physicians mirror those that were modeled by parents or significant others … Not surprisingly, the outcomes of our attempts at work-related conflict management based on these models are frequently mediocre and sometimes disastrous.”36 From our transcripts and analysis, we propose some strategies that may assist ED clinicians with consultations by reducing conflict (Table 4). LIMITATIONS As this was a qualitative study, there may be some case specificity relating to the culture of an academic center that are not generalizable to other environments, such as community hospitals. Moreover, as with all qualitative studies, we would caution readers against generalizing the results, although themes may highlight certain occurrences common to other hospitals.
312
Table 4 Applications for the Clinician Based on the analyses from this study, there are numerous immediate applications that clinicians might utilize. We theorize that the following three behaviors or attitudes may assist clinicians in any ED consultation process. Know colleagues: Our study found that being unknown was a negatively impacting factor, similar to having a bad reputation. Remaining anonymous may make discussions more difficult, since the reservoir of trust and experience is not there to mitigate potential conflict. Engage colleagues: Showing interest in a colleague’s work and acknowledging their impact on a patient’s care can go a long way to demonstrate respect, which builds trust and decreases conflict. Display shared interests to colleagues: Try to display interest for common goals and highlight shared interests in helping to stamp out disease or alleviating the suffering for that shared patient.
Moreover, our study was limited to a single academic center for logistical reasons as this was a resident research project and we had funding and resource limitations. We did attempt to sample from four different hospitals within the academic jurisdiction, to mitigate this problem. The focus-group moderator and interviewer for this study was a junior EM resident, and this may have influenced the openness of the participants. The involvement of medical students and EM residents in the analysis may also have altered the analysis by influencing their metaposition from the data. Also, two-thirds of our participants were male, which may affect the forms of conflict that are described and the strategies described to mitigate conflict. CONCLUSIONS Conflict occurs within the ED consultation process. Our research reveals the factors that influence the development of intraprofessional conflict. There is a tie between conflict and trust, since distrust can lead to conflict around a patient care plan. The factors that we identify that increase trust between colleagues may possibly resolve or decrease conflict during ED consultations. The authors thank Gerson Mobo and Sarah Compeau for their assistance with the transcription process. We also thank Drs. John Crossley, Douglas Wright, and Claire Kenny-Scherber for their assistance in determining our study design and survey. We are also indebted to Drs. Michelle Lin, Nikita Joshi, and Brent Thoma for their advice. Finally, we would like to thank Dr. Lalena Yarris and the Academic Emergency Medicine journal reviewers for their coaching and thoughtful suggestions.
References 1. Kessler CS, Asrow A, Beach C, et al. The taxonomy of emergency department consultations–results of an expert consensus panel. Ann Emerg Med 2013;61:161–6. 2. Woods RA, Lee R, Ospina MB, et al. Consultation outcomes in the emergency department: exploring rates and complexity. Can J Emerg Med 2008;10:25– 31.
Chan et al. • CONFLICT DURING ED CONSULTATIONS
3. Cortazzo JM, Guertler AT, Rice MM. Consultation and referral patterns from a teaching hospital emergency department. Am J Emerg Med 1993;25:456–60. 4. Royal College of Physicians and Surgeons (Canada). Objectives of Training for Emergency Medicine. Available at: https://www.medicine.mcgill.ca/post grad/accreditation_2013/PSQs/1_Emergency_Medicine /05_OTR_Emergency_Medicine_2008.pdf. Accessed Dec 4, 2013. 5. Beeson MS, Carter WA, Christopher TA, et al. Emergency medicine milestones. J Grad Med Educ 2013;5(1 Suppl 1):5–13. 6. Canadian Medical Protective Association. Dealing With Conflict the Doctor-Patient Relationship. Available at: https://oplfrpd5.cmpa-acpm.ca/safety/-/asset_publisher/ N6oEDMrzRbCC/content/dealing-with-conflict-in-thedoctor-patient-relationship;jsessionid=B57DFAB931D B05ABD5ECC25E835841A4. Accessed February 1, 2014. 7. Saltman DC, O’Dea NA, Kidd MR. Conflict management: a primer for doctors in training. Postgrad Med J 2006;82:9–12. 8. The Joint Commission. Sentinel Event Data: Root Causes by Event Type, 2004-2012. http://www.jointcommission.org/assets/1/18/Root_Causes_Event_Type_ 04_4Q2012.pdf. Accessed Dec 4, 2013. 9. Institute of Medicine. Executive Summary. In: Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press, 2001. 10. Kessler C, Woods R, Chan TM, Sherbino J. A call to action in consultation training. Can J Emerg Med 2011;13:361. 11. Kessler CS, Chan T, Loeb JM, Malka ST. I’m clear, you’re clear, we’re all clear: improving consultation communication skills in undergraduate medical education. Acad Med 2013;88:753–8. 12. Lee RS, Woods R, Bullard M, Holroyd BR, Rowe BH. Consultations in the emergency department: a systematic review of the literature. Can J Emerg Med 2008;25:4–9. 13. Wright D, Kenny-Scherber C, Patel A, et al. Defining and optimizing collaboration between emergency medicine and internal medicine physicians. Can J Gen Intern Med 2011;6:28–9. 14. Matthews AL, Harvey CM, Schuster RJ, Durso FT. Emergency physician to admitting physician handovers: an exploratory study. Proc Human Factors Ergonom Soc 46th Ann Meeting. Baltimore, MD, 2002, pp 1511–5. 15. Kessler C, Kutka BM, Badillo C. Consultation in the emergency department: a qualitative analysis and review. J Emerg Med 2012;42:704–11. 16. Chan T, Orlich D, Kulasegaram K, Sherbino J. Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner. Can J Emerg Med 2013;15:42–51. 17. Kessler CS, Afshar Y, Sardar G, Yudkowsky R, Ankel F, Schwartz A. A prospective, randomized, controlled study demonstrating a novel, effective
ACADEMIC EMERGENCY MEDICINE • March 2014, Vol. 21, No. 3 • www.aemj.org
18.
19.
20.
21.
22.
23.
5.
25.
26.
model of transfer of care between physicians: the 5 Cs of consultation. Acad Emerg Med 2012;19:968– 74. Kessler CS, Kalapurayil PS, Yudkowsky R, Schwartz A. Validity evidence for a new checklist evaluating consultations, the 5Cs model. Acad Med 2012;87:1408–12. Iwata M, Yamanaka K, Kitagawa Y. The level of agreement regarding patient disposition between emergency physicians and consultants in the emergency department. Int J Emerg Med 2013;6:22. Hinchey SA, Jackson JL. A cohort study assessing difficult patient encounters in a walk-in primary care clinic, predictors and outcomes. J Gen Intern Med 2011;26:588–94. Stavropoulou C, Glycopantis D. Conflict in the Doctor-Patient Relation and Non-adherence: A Game Theory Approach. LSE Health working papers. Available at: http://eprints.lse.ac.uk/28830/1/ LSEHWP10.pdf. Accessed Dec 4, 2013. Simpson M, Buckman R, Stewart M, et al. Doctor– patient communication: the Toronto consensus statement. BMJ 1991;303:1385–7. Chan TM, Sabir KR, Sanhan S, Sherbino J. Understanding the impact of residents’ interpersonal relationships during emergency department referrals and consultation. J Grad Med Ed 2013;5(1): 476–581. Lewicki RJ, Wiethoff C. Trust, trust development and trust repair. In: Deutsch M, Coleman P, editors. The Handbook of Conflict Resolution: Theory & Practice. San Francisco, CA: Jossey-Bass, 2000, pp 86–107. Punch KF. Introduction to Research Methods in Education. Thousand Oaks, CA: Sage Publications Inc., 2009, pp 162–7. Dillman DA. Mail and Internet Surveys: The Tailored Design Method 2007 Update With New Internet, Visual, and Mixed-mode Guide. Hoboken, NJ: John Wiley & Sons Inc, 2007.
313
27. Charmaz K. Constructing Grounded Theory: A Practical Guide through Qualitative Analysis, 2nd Ed. Thousand Oaks, CA: Sage Publications, 2006. 28. Bandiera GL, Lee S, Tiberius R. Creating effective learning in today’s emergency departments: how accomplished teachers get it done. Ann Emerg Med 2005;45:253–61. 29. Flick U. An Introduction to Qualitative Research, 2nd ed. Thousand Oaks, CA: Sage, 2002. 30. Giffin K. The contribution of studies of source credibility to a theory of interpersonal trust in the communication process. Psychol Bull 1967;68:104–20. 31. Mayer B. The Dynamics of Conflict Resolution: A Practitioner’s Guide. San Francisco, CA: JosseyBass, 2000. 32. Porter-O’Grady T. Embracing conflict: building healthy a community. Health Care Manage Rev 2004;29:181–7. 33. Harolds J, Wood BP. Conflict management and resolution. J Am Coll Radiol 2006;3:200–6. 34. Leape LL, Shore MF, Dienstag JL, et al. A culture of respect, Part 1: the nature and causes of disrespectful behavior by physicians. Acad Med 2012;87:845–52. 35. Wimmers PF, Fung CC. The impact of case specificity and generalisable skills on clinical performance: a correlated traits-correlated methods approach. Med Educ 2008;42:580–8. 36. Andrew LB. Conflict management, prevention and resolution in medical settings. Physician Exec 1999;25:38–42. 37. Dawson R. Why do physicians have difficulty negotiating? Physician Exec 1999;25:43–4. Supporting Information The following supporting information is available in the online version of this paper: Data Supplement S1. Sample focus group orientation script.
