A few years ago a physician partner retired from our emergency medicine practice. At the age of 65 he was ready to hang his medical hat, put on his fisherman’s cap, and fish his way into the sunset. What I remember most about working alongside him was his calm, level headed, and consistent approach to all of his encounters in the emergency department. During his almost 40 year practice in the ED, he certainly experienced all the same scenarios that we see today, and many more. His recollection of bizarre encounters, difficult cases, and malignant consultants never ceased to entertain, and scare me. But it did not change his behavior. He was a rock, calm and collected, always.
My time with him taught me the importance of maintaining that demeanor. The emergency department is a pressure cooker. Nights, weekends, intoxicated patients, violent outbursts, death, critical patients, and a constant flow of interruptions, make the environment ripe for confrontation. But as emergency physicians it is very important that we maintain composure because more is at stake than is obvious.
Many physicians avoid confrontation, fearful of how it might reflect on their reputation. Though there is truth to that fear, even more important is the patient’s care that will suffer as a result. Here are some examples that will walk you through the predictable cascade resulting form bad interactions :
- As I attempt to persuade a consultant that a certain course of action is necessary, maintaining composure keeps the focus on the medicine. Once I become angry, loud, or confrontational, the conversation has become personal. The focus is no longer on the patient and what they need, but on me and our conversation and the appropriateness (or lack of) of my approach to the conversation. The consulting physician has just become distracted by my behavior and tone, and the patient is the one left ultimately suffering.
- Disruptive, rude, or confrontational behavior also pushes the consultant into a defensive posture. If I am trying to persuade them of a course of action they recommend against, they are certainly less willing to yield after an argument. In fact, they are more likely to give additional weight to their position based solely on my behavior. That leads them to “anchor” or maintain their bias in what they believe is “really going on” and be more dismissive of what I am proposing. I’ve seen this result in the common conclusion “…see, I know this consult was a waste of time, the patient clearly has what I thought he did and nothing else…”.
- Now that the consultant has proven to themselves that I, the ED physician, am the problem and my medicine isn’t sound, their response to the ED the next time I am working will be slower. Those delays don’t hurt me, they hurt my patient.
The extent of the effect does not stop at consultants. As I have more confrontations with physicians, interactions with staff suffer as well. They over hear arguments, develop impressions, and begin to hesitate when approaching me. This results in a breakdown in the open communication necessary between physicians and nurses. They stop reporting changes in a patient’s conditions unless they feel they are critical, and that leads to the me missing pieces of information that may be key to making a diagnosis. For example, a nurse might not share that the patient just told her they saw another doctor yesterday and were given a certain medication. The assumption being that I already have the information and the nurse isn’t going to risk a negative encounter to be sure. That can result in a medication interaction if I don’t know what the patient is taking. The entire function of the team depends on that communication and so does the patient’s care.
So, the next time a conflict arises, take a deep breath, maintain composure, and remember that you are advocating for a patient, not your opinion or reputation. If you are not able to come to a conclusion, utilize what is at your disposal. Ask the consultant to come examine the patient, consider a compromise like a period of observation and a call back, offer to involve a third party intermediary like a chief medical officer or department chief, and always bring the conversation back to the patient at hand. Your patient’s will thank you.