Conflict is a natural part of everyday life; disagreements are bound to happen when we interact with others. As physicians, we often work in time-pressured, high-stakes circumstances and engage with teams comprised of people with different backgrounds and perspectives. In the environment of the healthcare workplace, conflict can easily occur, be difficult to manage, and negatively affect patients. However, not all conflict is bad. Learning how to maximize the potential benefits and minimize the potential harms of conflict can help us successfully reach a beneficial outcome for ourselves and for our patients. Understanding how to both identify and manage sources of conflict can make us better professionals, and often, friends.
In a recent NEJM Resident 360 discussion, we addressed how conflict arises in the healthcare environment. We discussed a hypothetical case that described the sequence of events that led to a patient receiving an inappropriate medication. The suboptimal outcome was rooted in conflict between healthcare providers. In this post, we summarize some key points to help you better understand and manage conflict as a resident and avoid similar conflicts that may arise in your professional career.
Types of Conflict
Identifying the source of a conflict is often the first step in managing what can be a difficult situation. Behavioral science research has identified three potential types of conflict:
Task conflict: Disagreement about the content and outcomes of a particular task.
Example: Members of a team disagree about whether or not to obtain a CT scan to rule out infection. In this case the task – obtaining a CT scan – is the source of conflict.
Process conflict: Disagreement related to the logistical issues associated with the execution of a given task.
Example: Members of team agree that a CT scan should be obtained but disagree about whether it should be done before or after the patient is seen by surgery.
Relationship conflict: Conflict between two parties stemming from personal issues that are not directly related to a work task and may be a result of prior interactions.
Example: A medical resident avoids discussing with his attending a problem he is having with an intern because the resident’s past interactions with the attending have been difficult and he thinks that the attending does not like working with residents.
Although most workplace conflict involves components of all three types of conflict, one source tends to dominate. Identifying the primary driver of conflict is important because it helps define the appropriate remedy.
Both task and process conflicts, if dealt with in the moment and objectively, can offer a valuable opportunity to exchange information and ideas that might not occur otherwise. In the examples mentioned above, open discussion within the team about why members of the team want to obtain a CT scan as opposed to a different test (or no test at all) and the reasoning behind the order of testing could help the team develop a shared understanding of the task and why it is being performed. Once the differences have been aired and discussed, a solution can often be identified that is understood by all the parties involved. Task and process conflict are best handled objectively at the time the conflict arises.
Relationship conflict generally arises from assumptions we make about others that are rooted in past, often negative experiences. This type of conflict can be the most difficult to manage and the most damaging to relationships. We create a mental model about another individual that rationalizes or makes assumptions about their behavior that may or may not be true, and can be subject to bias.
Relationship conflict arises most often when we make observations about others, add meaning to these observations based on personal experience, infer assumptions based on these observations, and draw conclusions about the behavior of others based on this model of belief.
Ascending the Ladder of Inference
Ascending the ladder of inference is the cognitive process we use to move from an observation to a decision or action. Each “rung” in the ladder represents a cognitive step in that process, beginning at the bottom at step 1 to “ascend the ladder” through each sequential step:
6) Take actions that reflect the conclusions and updated belief systems
5) Refine belief systems
4) Draw conclusions
3) Make assumptions about the meaning of the data
2) Interpret that data
1) Select the data to pay attention to
One key point about the ladder of inference is the reflex loop inherent in it – each time we ascend and refine our belief systems, those refined beliefs influence what data we choose to pay attention to, and how we interpret, make assumptions, and draw conclusions about the meaning of that data. Being aware of this cognitive process is crucial to understanding how biases and assumptions influence how we interpret the world around us, but also how others may interpret our actions.
In the example of relationship conflict cited above, the medical resident assumes that his attending will not be open to discussion based on previous experiences and characteristics he has assigned to his attending. Perhaps most importantly, when ascending the ladder of inference, we often deem an observed behavior to be a result of a given person’s inherent character or personality (the fundamental attribution error): We explain behavior based on assumptions about factors inherent to the individual and discount the influence of circumstance and unobservable variables.
If left unaddressed or taken to extremes, both task and process conflict can progress to relationship conflict. Once relationship conflict exists, it often affects future interactions and makes it more likely that other task and process conflicts arise. Remedying relationship conflict requires both the time and space to analyze the situation and allow tempers to cool. Importantly, asking questions that are self-reflective (What assumptions have I made about the other individual that have influenced my behavior and how I understand their perspective?) and recognizing external forces at play (What are the circumstances that could have led to the behavior I observed?) can be key to understanding how a relationship conflict developed. Similarly, making your thought processes visible can help prevent others from ascending the ladder of inference about you. Finally, remedy of a relationship conflict often requires open, honest inquiry with the other individual about how the conflict arouse, asking them to explain their perspective and contributing your perspective in an objective manner.
Conflict in the workplace can be challenging, especially when poor decision making in the midst of conflict causes a patient to suffer. However, when conflict is handled properly, it can be a source of improved decision making within teams and a source of personal strength for individuals who can handle it properly. When you observe a trusted peer or advisor handle conflict in a productive way, make note of it and consider asking them for advice the next time you find yourself in conflict.
Dr. Iyasere is a general internist, member of the MGH Core Educator Faulty and the co-Director the MGH Department of Medicine Resident Leadership Program. Her areas of interest are physician leadership, resident education and innovation.
Dr. Baggett is an academic hospitalist at Massachusetts General Hospital, a member of the Core Educator Faculty for the Department of Medicine, and an Assistant Professor of Medicine at Harvard Medical School. She co-directs the Internal Medicine Residency Leadership Program at MGH and serves as an Inpatient Physician Director for two MGH general medical floors. She completed her Internal Medicine residency and served as Chief Medical Resident at the University of Washington before joining the MGH Core Educator Faculty in 2008.