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Reference: Tjan et al. Conflict in emergency medicine: A systematic review. AEM June 2024

Date: July 5, 2024

Guest Skeptic: Dr. Lauren Westafer an Assistant Professor in the Department of Emergency Medicine at the University of Massachusetts Medical School – Baystate. She co-founded FOAMcast and is a pulmonary embolism and implementation science researcher. Dr. Westafer serves as the Social Media Editor and a research methodology editor for the Annals of Emergency Medicine.

Case: A 71-year-old patient with a history of hypertension and well-controlled diabetes mellitus without organ involvement presents with left lower abdominal pain, afebrile, blood pressure 138/70 mm Hg, heart rate 82 beats per minute, and oxygen saturation on room air 99%. They are afebrile and tolerate oral intake.  The emergency department (ED) evaluation reveals an unremarkable chemistry panel with normal renal function and a white blood cell count of 10,000. An abdominal pelvic CT scan demonstrates uncomplicated left-sided diverticulitis. The patient is feeling well enough to go home and you discharge the patient to home without antibiotics and ask them to follow up with their primary care provider or return if they get worse. In follow-up, the patient’s primary care provider is upset that the patient was not started on antibiotics.

Background: We have discussed agitation in the ED on the SGEM several times. This has included the use of haloperidol for agitation due to psychosis (SGEM#45), droperidol for acute agitation (SGEM#328) and the problem with the term “excited delirium” (SGEM#218 and SGEM Xtra). We have also done an episode on rudeness and its impact on medical team performance (SGEM#227) and the prevalence of inter-physician professional weight bias (SGEM#343). One thing we have not specifically discussed is the conflict between clinicians.

Conflict in the workplace is defined as a process beginning when individuals or groups perceive differences and opposition regarding interests, beliefs, or values. Workplace conflicts typically involve task issues (disparities in procedures, priorities, or resource allocation) and relationship (socioemotional) issues (breakdowns in interpersonal interactions).

In healthcare, conflicts are attributed to factors like incompatible personal motivations, high workload, stress, role ambiguity, and poor leadership. Such conflicts hinder cohesive teamwork and decision-making, potentially compromising patient safety. These conflicts can ultimately lead to moral injury [1,2,3].

Conflicts in the ED often stem from clinical decision-making and actions, leading to potential adverse patient events and exacerbating access block issues. While individual studies have identified various factors contributing to conflict, there has been a lack of comprehensive reviews specific to the ED setting.

Understanding the individual, team-level and systemic factors that contribute to conflict among clinicians in the ED may provide insights on ways to help efforts to reduce conflict.

Clinical Question: What drives conflict in emergency medicine and are there strategies to reduce conflict?

Reference: Tjan et al. Conflict in emergency medicine: A systematic review. AEM June 2024

  • Population: Empirical, peer-reviewed journal articles written in English about conflict in the ED context that answered one of the identified research questions. Participants included ED physicians, ED nurses, internal medicine (IM) physicians, surgeons, health care technicians, managers, and primary care providers.
    • Excluded: Studies that didn’t focus on the ED context, did not address any specified research questions, nonempirical articles such as commentaries, opinion pieces, letters to the editor, non-English papers
  • Intervention: Strategies and approaches to managing and resolving conflicts in the ED. These included communication training, handover standardization protocols, improving admission guidelines, changes in communication systems, and efforts to improve interpersonal and interdepartmental relationships.
  • Comparison: The strategies for managing conflicts were compared to the usual practices and environments where such strategies were not implemented or where traditional methods were used.
  • Outcomes:
    • What constitutes conflict in the ED?
    • What factors contribute to conflict in the ED?
    • What strategies can be employed to address and resolve conflict in the ED?
  • Type of Study – Systematic review

Dr. Lee Wong

This is an SGEMHOP episode, and it is my pleasure to introduce Dr. Lee Wong. He is an emergency physician at the Austin Hospital in Melbourne, Australia. He also just got a PhD from Swinburne University, Melbourne, researching Leader Identity Threat in emergency medicine.

We also have the lead author, Mr. Timmothy Tjan. He is a final-year medical student at Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.

Authors’ Conclusions: “In emergency medicine, conflict is common and occurs at multiple levels, reflecting the complex interface of tasks and relationships within ED.”

Quality Checklist:

  1. The main question being addressed should be clearly stated. Yes
  2. The search for studies was detailed and exhaustive. No
  3. Were the criteria used to select articles for inclusion appropriate? Unsure
  4. Were the included studies sufficiently valid for the type of question asked? Yes
  5. Were the results similar from study to study? Yes
  6. Were there any financial conflicts of Interest? No

Results: They included 29 studies in the review from countries, such as the United States, Australia, Canada, the United Kingdom, Egypt, Hong Kong, India, Iran, Japan, the Netherlands, Portugal, and Thailand.

Key Result: Conflict is common in the ED; it arises from multiple factors and some strategies can manage and reduce conflicts.

1. What Constitutes Conflict in the ED?

Conflict in the ED often revolves around task issues. These arise during handovers, referrals, admissions, and making diagnoses. The conflicts often revolve around disagreements on clinical decisions, patient management, and diagnostic processes.

There can also be relationship issues leading to conflict in the ED. These include breakdowns in interpersonal interactions, miscommunication, and personality clashes among healthcare professionals. Relationship conflicts are often driven by distrust, biases, and differing attitudes and motivations.

2. What Factors Contribute to Conflict in the ED?

Conflicts can arise from individual-level factors (e.g., lack of trust, inexperience), team-level factors (e.g., in-group/out-group bias, patient complexity), and systemic factors (e.g., high workload, ambiguous responsibility).

  • Individual Level: Individual-level factors can include a lack of trust. This stems from poor reputations, personality clashes, and unfamiliarity among healthcare professionals. Inexperience and lack of confidence can also lead to conflict. Junior doctors and staff with less experience often face communication challenges and fear of making mistakes.
  • Team Level: One team-level factor is in-group/out-group bias. This is like a form of tribalism. Specialty identities create an “us versus them” mentality, leading to distrust and lack of cooperation. Another team-level factor that can come into play is patient complexity and disposition disagreements. Differing opinions on patient management and the complexity of patient cases can lead to conflicts. Miscommunication during handovers and varying preferences for communication timing can also contribute to conflict. In addition, differences in priorities, perspectives, and expectations. ED and other specialties often have differing goals and approaches, leading to disagreements.
  • Organizational (Systemic) Factors: There are also organizational or system factors that contribute to conflict in the ED. We have a high workload and time pressures. The stress and rushed interactions due to high patient volumes and time constraints can lead to conflict. Some other system factors include ambiguous responsibility after handover, power imbalances on who has the decision-making authority, our shift culture which is often different from other specialties and the physical separation between departments can hinder effective communication and coordination.

3. What Strategies Can Be Employed to Address and Resolve Conflict in the ED?

  • Providing formal communication and conflict resolution training to staff.
  • Implementing standardized communication protocols to improve handover quality and reduce ambiguity.
  • Establishing clear guidelines for referrals and admissions to aid decision-making and reduce disagreements.
  • Granting ED doctors expanded admitting rights to improve patient flow and bed availability.
  • Implementing systems for real-time updates and closed-loop feedback to ensure clear and accurate communication.
  • Use technology (e.g., walkie-talkies, digital translation tools) to enhance communication efficiency.
  • Facilitating shared academic programming, multidisciplinary conferences, and social events to build relationships.
  • Encouraging direct communication and simultaneous bedside evaluations to improve understanding and collaboration.
  • Providing positive feedback and involving all team members, including nurses, in updates and decision-making processes.
  • Remember you are all on Team Patient (was not in the manuscript)

Listen to the podcast to hear Lee and Timmothy answer our five nerdy questions.

  1. Scoping Reviews and Systematic Reviews: These are two ways of synthesizing data. Both study designs use rigorous and transparent methods to comprehensively identify and analyze all the relevant literature about a research question. Scoping reviews present an overview of a potentially large and diverse body of literature about a broad topic whereas systematic reviews collate empirical evidence from a relatively narrower group of studies about a focused research question. How did you decide to do a systematic review versus a scoping review?
  2. Data Synthesis: Data synthesis is a pillar of systematic reviews and it’s important to understand the methods used to synthesize the results. Can you talk more about what methods you used to synthesize and analyze the data?
  3. Certainty: One of the key elements of the PRISMA guidelines for reporting systematic reviews is presenting assessments of certainty or confidence in the body of the evidence. Can you discuss your certainty in the evidence for each outcome?
  4. Quality: Your review involved both quantitative and qualitative studies so what did you use to assess the quality of the included studies and what was the quality?
  5. Single Centre: Most of the included studies were small and from a single centre. Do you think what you identified are common themes in ED conflict and have external validity outside of where the studies were conducted?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions.

SGEM Bottom Line: Conflict in the ED may arise through several different pathways. Bias, burnout, culture, and local protocols for treatment and disposition may help mitigate conflict.

Case Resolution: The emergency physician works with the department, gastroenterology, primary care, and surgery to create buy-in on a diverticulitis protocol that adheres to recent guidelines recommending the select use of antibiotics in uncomplicated diverticulitis.

Dr. Lauren Westafer

Clinical Application: Conflict may arise from personal, team and institutional level factors. Departments could consider ways to create a culture of shared respect, information sharing, and examining where local conflict occurs to create tailored solutions.

What Do I Tell the Patient? Many physicians may disagree with patient care or disposition treatments based on expertise, experience, understanding of the evidence, as well as other operational features. In many cases, there are several reasonable treatment pathways and clinicians may just be more comfortable with one or the other. We are working to address systemic issues.

Keener Kontest: Another win for Dr. Steven Stelts in New Zealand. He knew the ideal location to obtain arterial access for REBOA is the common femoral artery.

Listen to this week’s episode to hear the trivia question. If you think you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will get a shout-out on the next SGEM episode.

SGEMHOP: Now it is your turn SGEMers. What do you think of this study of ED conflict? Tweet your comments using #SGEMHOP. What questions do you have for Lee, Timmothy and their team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

 References:

  1. Physicians are Not Burning out they are Suffering Moral Injury. Stat News 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/  Accessed July 5, 2024
  2. Dean W, Talbot S, Dean A. Reframing Clinician Distress: Moral Injury Not Burnout. Fed Pract. 2019 Sep;36(9):400-402. Erratum in: Fed Pract. 2019 Oct;36(10):447.
  3. Giwa A, Crutchfield D, Fletcher D, Gemmill J, Kindrat J, Smith A, Bayless P. Addressing Moral Injury in Emergency Medicine. J Emerg Med. 2021 Dec;61(6):782-788.
  4. It Is No Wonder. Editors Pick of the Month. AEM June 2024