Medical staff fights: How to strive for the best outcome when the stakes are high

What do you call a medical staff vote of 99 to 1? A tie! This old joke would be funny if it were not so true. How many medical staff meetings have been less than productive because members spent an inordinate amount of time trying to convince one or two medical staff members that they should vote with the majority? Why is it so difficult for a medical staff to allow a majority vote to stand? Is there a way to help change this culture? Can there be a “good fight” in a medical staff meeting?
 
Culture, which can be defined as “the way we do things here,” is usually a local phenomenon. However, when it comes to medical staff meetings, there is an almost universal decision-making culture. Physicians typically want consensus concerning whatever topic they are discussing; at least, that is the spoken sentiment. This really translates into wanting the entire medical staff to agree. As educated people, physicians would tell you that getting a hundred or more people to agree is next to impossible, but blinders go on as they struggle to convince the inconvincible to join the majority. Physicians tend to do this for two reasons. The first is that one of the profession’s daily activities is to convince patients to do what, in physicians’ opinion, is the right thing to do. Therefore it is easy for physicians to slip into professional mode and try to convince their colleagues to “see the light” and vote for the option that they “know” is the best. The second reason is collegiality. Although physicians often “know” they are right, they want to maintain harmony in the medical staff. If someone is really against the majority, they will do their best to help them see things their way so that the “family” can once again be in harmony. Most physicians realize that harmony in a medical staff is an unobtainable goal, but we’ll expend significant time and energy to try to achieve it anyway.

Neils Bohr, the Danish physicist who made fundamental contributions to understanding atomic structure and quantum mechanics, for which he received the Nobel Prize in physics, once said “The opposite of a fact is falsehood, but the opposite of one profound truth may very well be another profound truth.” Medical staffs often fight over profound truths and therefore spend time trying to convince staff members who hold different profound truths to change them. As you are aware, physicians rarely give up their profound truths. A classic Harvard Business Review article from the July–August 1997 edition provides a framework for having a good fight. Managing conflict is as much of a problem in the world of medicine as it is in the world of business.

This article describes six strategies for having a good fight. These are:
 

• Focus on the facts: Objective data encourages people to focus on the issues at hand and not on an individual’s personality. Without good data, the discussion turns into a debate about opinions.
• Multiply the alternatives: By deliberately developing multiple alternatives, people can diffuse conflict by no longer taking sides but instead focusing on the core issues. The individuals involved in the discussion can tap into their creativity to find an unlimited number of alternatives.
• Create common goals: Creating common goals tends to frame the discussion as a collaborative effort, not a competitive one. When focusing on common goals, there is much less of a winner-loser mentality.
• Use humor: Not only is humor a psychological defense mechanism against stressful, threatening situations, it also increases collaborative efforts by improving mood.
• Balance the power structure: When one group is more powerful, the other group will feel that the process is unfair. This feeling will escalate the conflict and turn the focus towards personalities and not the issue. Balancing the power structure improves the perception of fairness.
• Seek consensus with qualification: If the medical staff is able to reach consensus, great! If not, rather than fighting, the person or group with the most relevant information (the subject matter expert) makes the decision. Because other members of the group know that when the next fight arises, they may have the most relevant information, this process is generally considered fair. If the group views the process as fair, even a decision that is not in their favor, will be acceptable.

Research suggests that healthy conflict leads to better decisions because individuals evaluate more relevant information, discuss alternatives, and better understand the core issues. So as a medical staff leader, what should you do to break the 99-to-1 tie? The answer is to create healthy conflict. Remain vigilant, and do not think that a quiet room is consensus; it may be apathy. To generate the best outcomes, remember to keep the group focused on the issues and not the personalities. Understand the range of possibilities, and just for fun, occasionally toss in and argue for a solution that you do not think is correct. You will be surprised how this can bring the discussion back to the solution that is best for the majority.

William F. Mills, MD,  MMM, CPE, CMSL, FAAFP, is currently the senior vice president of quality and professional affairs for the Upper Allegheny Health System located in western NY. He writes frequently for MedicalStaffLeader.com.