The Challenge

Program directors are commonly tasked with the responsibility and challenge of resolving conflicts in their residency programs.1 Potential sources of conflict may be categorized into subtypes such as resident-patient, resident-resident, resident-faculty, and faculty-faculty.2 Although sources of conflict are innumerable, certain recurring themes underline most: deficiencies in communication, lack of trust, and incorrect assumptions.2 Establishing a framework for dealing with conflict in your residency or fellowship program can contribute to developing competency in interpersonal and communication skills and in professionalism. Moreover, by learning to handle conflict, program directors, faculty, and residents improve in their capacity to promote the welfare of the workplace, enhance collegiality, and ensure an optimal environment for patient safety and care.3 Because conflict resolution expertise is an important skill set for all involved in graduate medical education, residents and faculty may benefit from a structured approach to discovering conflict resolution strategies. The purpose of this “Rip Out” is to provide a practical approach to conflict management within residency programs.

What Is Known

A Framework for Approaching Conflict

As a practical framework for approaching conflict situations, the Thomas-Kilmann Conflict Mode Instrument (TKI) presents 5 principal conflict management styles along 2 dimensions: cooperativeness and assertiveness (figure).4 ,Cooperativeness is the extent to which an individual attempts to satisfy another's concerns, whereas assertiveness is the extent to which an individual attempts to satisfy his or her own concerns. The TKI conflict management strategies have also been tailored specifically for individuals working in medicine.5 This framework can be used to chart one's behavior during a situation in which 2 individuals may have incompatible goals or contradictory opinions.

FIGURE

Thomas-Kilmann Conflict Framework

FIGURE

Thomas-Kilmann Conflict Framework

Rip Out action items

Programs should:

  1. Recognize that conflict affects the learning environment, and skill sets align with Accreditation Council for Graduate Medical Education competencies.

  2. Invite residents and faculty to submit conflict situations they have experienced.

  3. Compile lists of several anonymous scenarios provided by the group.

  4. Meet as a group, led by an experienced moderator, to discuss methods of conflict resolution and to gradually build a consensus around appropriate strategies and professional behaviors.

  5. Establish an annual or semiannual conference setting.

Conflict Management Styles

Residents most commonly use collaborate and accommodate management styles. These 2 styles require the most time and energy and may result in feelings of powerlessness or self-devaluation.

In reality, each strategy may have value depending on the conflict context. To illustrate each management style, an example scenario is discussed: An attending tells a junior resident, in an intimidating manner, to give a patient a 1-week course of antibiotics after surgery. The junior resident realizes the patient has a history of Clostridium difficile (C. diff) infection and is concerned that the duration of antibiotics may be excessive.

  1. Competing assumes that only one individual can win, potentially at the expense of team morale or patient concerns. Individuals who aggressively pursue personal concerns or agendas may do so at the expense of others. This approach is often described as a “win-lose” approach. In this scenario, armed with the information about the patient's history of C. diff infection, the resident refuses to write the prescription.

  2. Avoiding involves repeatedly denying the existence of conflict in the health care setting, suppressing feelings in the short term, and ultimately failing to solve the problem. Avoiding conflict may result in dangerous or disrespectful situations and undermine teamwork. In this scenario, the resident does not speak to the attending about her concern and gives the patient the full course of antibiotics, rationalizing to herself that the risk of C. diff is probably low.

  3. Collaborating requires confronting the issue and problem solving in a team-oriented manner. This approach provides the most possibilities for constructive solutions but may require the most energy. In this scenario, the resident asks the attending if the plan should be adjusted given the patient's history of C. diff infection. After a discussion of the patient's history, together, they decide to obtain an infectious disease consultation.

  4. Accommodating occurs when individuals neglect their personal concerns to satisfy the needs or demands of others—a kind of “smoothing over” of the issues—which may require placing the requests of others first. In this scenario, the resident prescribes the antibiotics, after mentioning to the attending that the risk of C. diff is probably low.

  5. Compromising achieves a mutually acceptable solution that partially satisfies both parties (reaching a middle ground). In this scenario, the resident suggests a shorter course of antibiotics and a course of probiotics.

How You Can Start TODAY

  1. Ask residents to provide descriptions of recently encountered scenarios or situations that resulted in conflict.

  2. Compile resident conflict cases in an anonymous fashion and use them to prompt group discussions.

  3. Apply the management model above to promote reflection and resolution of the conflict cases. Through this discussion, participants identify respective merits in each conflict management style.

  4. Use the TKI framework to generate strategies the residents might employ to resolve conflict effectively and appropriately in the future.

  5. Compose an ongoing compendium of cases that can be used to orient junior residents and, perhaps, faculty.

  6. Revisit conflict cases yearly to emphasize that, although new areas are likely to be highlighted, there will also be recurrent themes and new ways to understand conflict within the high-stakes environment of health care.

What You Can Do LONG TERM

  1. Establish a semiannual forum (ie, didactic session or educational conference) in which residents are invited to submit cases that involved conflict anonymously for discussion. A program director or faculty member with training in the field is best suited to guide the discussion.

  2. Emphasize the application of the conflict resolution model. Working with 1 model may help promote professional conflict resolution that is more likely to yield positive outcomes.

  3. Engender the participation of faculty: Determine criteria for conflict from the perspective of the faculty that have potential to be presented to the residents. Morning didactic sessions or journal clubs represent an opportunity in which articles relating to conflict management can be discussed.

  4. Expect evolution of the forum. Accepting change in the needs of residency programs will allow program directors to devise a session that is shaped to fit the needs of their own unique residency program.

Resources

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Author notes

All authors are at the University of Washington. Matthew Mossanen, MD, is Resident, Department of Urology; Susan S. Johnston, EdD, is Director of Education, Graduate Medical Education; Jessica Green, BA, is Program Administrator, Department of Urology; and Byron D. Joyner, MD, MPA, is Professor and Program Director, Department of Urology, and Associate Dean for Graduate Medical Education, School of Medicine.