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How well do you manage conflict?
A guide to how to negotiate—and benefit from—conflict

Keywords: A physician compares conflict management and negotiating styles in hospitals


by Ingrid Palmer



Published in the June 2012 issue of Today's Hospitalist

ASK PEOPLE WHAT THEY THINK OF CONFLICT, and chances are they view it in negative terms. But conflict is a constant in both your work and personal life—and the opposite of conflict isn't peace of mind, but stagnation.

That's according to Eric Howell, MD, chief of the hospital medicine division at Baltimore's Johns Hopkins Bayview Medical Center and Howard County General Hospital in Columbia, Md. At a session on negotiating at last fall's management of the hospitalized patient conference at the University of California, San Francisco, Dr. Howell challenged hospitalists to
"The people who win the most are the ones with the data."

–Eric Howell, MD
Johns Hopkins Bayview Medical Center

think about conflict in a different way. Instead of being something to avoid, conflict should be seen as a means to boost productivity, create a more unified group, and improve motivation and trust.

Dr. Howell cast himself as an "introvert who had to learn how to navigate a very political academic system and survive—without being put on some significant antidepressants." The key to successfully handling conflict and turning it into a positive experience, he said, is to arm yourself with basic negotiating skills. "If you negotiate well, you also develop relationships," Dr. Howell said. "If you develop those relationships, then you can move things down the line in the future and get relationship capital and respect."

When approaching negotiations, Dr. Howell said he's found it helpful to think of the five negotiating styles first outlined in the 1970s by Kenneth Thomas and Ralph Kilmann, business consultants who identified basic strategies that people typically use when trying to manage conflict.

The goal, Dr. Howell said, is to understand your natural style and learn to become adept at others. Here's a look at those different styles and how they may play out when negotiating in the hospital.

Avoidance
Avoiders typically walk away from confrontation and simply refuse to engage. Passive-aggressiveness is a common form of conflict avoidance that makes it impossible to solve problems, Dr. Howell said.

But that doesn't mean that avoidance can't sometimes be a good negotiating technique. You want to avoid conflict if it's over something trivial, when there's no chance of winning or when people need to cool down.

Avoidance is also a good interim strategy when you need more resources to effectively negotiate. "If you are walking down the hall and see your CEO who is trying to get you to do more RVUs with less people, then you might appropriately turn down another hallway to avoid him or her," Dr. Howell said. "You have a chair of medicine who you need to help fight that battle with you."

But if you always avoid conflict—and many internists, Dr. Howell said, are avoiders—you kill any chance of being able to cooperate, solve problems or display leadership.

"Rather than dealing with the surgeons, we just do not come out of the office until they are gone," said Dr. Howell. "Avoid that reputation, or it will be very hard for you to be productive later."

Accommodation
Internists tend to fall into another category when negotiating: accommodators. Hospitalists who rely exclusively on this strategy are always opting for appeasement, not assertiveness, or they're trying (too hard) to preserve a relationship by letting other people win.

"Accommodators say things like, 'No, no, that's OK, I'll go ahead and do what you asked. I will see that patient,' " Dr. Howell explained. When you're a chronic accommodator, you're always being used, he added. Plus, "you always lose whatever is being negotiated."

Like avoidance, there are times when accommodation is useful. The tactic allows you to minimize your losses when you know you're wrong, for instance, or to build political capital when the issue isn't that important.

But if you overuse this negotiating style, expect to be targeted as someone who is easy to manipulate. The hospitalist leader who says "yes" to every surgeon who wants to have his or her patients admitted by the hospitalist service but then can't be bothered to put in a good word with the administration to beef up hospitalist resources is effectively "a doormat," Dr. Howell said.

Compromise
Those who lean toward compromise are at least willing to cooperate and assert their own wishes in negotiations. But they are also willing to give up something if the other side does too.

Compromise can be a useful strategy when opponents of equal power are committed to mutually exclusive goals, or to achieve temporary settlements to complex issues. But overuse compromise, and you'll be viewed as someone who can't get things done.

Hospitalists looking to their group leader for a $10,000 raise, for instance, are not going to think that getting $5,000 is a win. "You may see it as a partial win, but they are almost certainly going to see it as a loss because they were expecting something else," Dr. Howell said.

And always opting for compromise makes it very easy to be manipulated. That's because once others realize you're a compromiser, they will start negotiations with high demands, peel away superficial factors they don't really care about, then "use those against you," Dr. Howell said. "If they say 'yes' to you having a call office and a parking space, then they'll beat you up if you expect higher salaries for the hospitalist group. "The key is to use the style judiciously.

Competition
People who approach negotiation as competition assert their own demands, resist cooperation and play to win. And there are times when competition is necessary, Dr. Howell said. Think of being in a training institution when an intern misses the femoral vein while placing a central line during a code, and places it in the artery instead.

That is not the time for a teaching moment, but the time to say, " 'Get out of the way!' " he said. "When the stakes are high and you know you're right, it is very important to be competitive."

Competition is also useful when you need to implement important but unpopular changes, or when negotiating with people who routinely take advantage of others. But if your motto is to win at any cost or if you start competing within your own group, you may be seen as a tyrant and lose support, especially if you are the leader.

And competitive people tend to create an atmosphere where others simply want to compete, not collaborate. Their combative nature causes a lack of trust among colleagues, which can result in a rash of covert politics within your hospital.

Collaboration
Collaboration occurs when both sides get what they want. It isn't possible to reach collaboration 100% of the time, said Dr. Howell, "but if you have a few wins in the collaboration department, your street credit goes way up."

Collaboration is most useful when you need an integrative solution and the issues are too important to compromise, or when you want to merge differing views or gain commitment through consensus.

One drawback to using collaboration is that it takes time to tease out what everyone's position is and what you need to achieve everyone's ends. "You run the risk of being labeled as taking too long to get things done," said Dr. Howell. "To those outside the actual process, you may appear indecisive or look weak on important issues."

But collaboration, he pointed out, is a good way to resolve situations that repeatedly crop up and fester. The example he gave is a chronic standoff between the hospitalists and the ED: The ED insists that hospitalists need to quickly process admissions, while maintaining that the ED staff doesn't have time to ask for medical records from patients' primary care physicians.

By negotiating collaboratively, Dr. Howell explained, hospitalists can help the ED realize that both you and the ED staff want to provide quality care—and avoid being sued over a delayed diagnosis. The hospitalists could offer to write transitional orders to help move the patient out of the ED faster while prevailing on the ED to call the primary care office and track down pertinent records.

Pick and choose
Each of the five styles has its time and place, Dr. Howell said. The most successful negotiators will sample from all of the above depending on the situation, rather than relying on only one or two strategies. The ability to mix up negotiating styles, he added, also keeps the people you're negotiating with off balance in terms of predicting how you'll proceed.

But no matter which style you use, don't negotiate based only on what you want or what you're willing to threaten. Instead, negotiate based on data. Existing criteria are everywhere to support your needs including salary benchmarks, productivity measurements, scope of responsibilities and organizational structure. Even the most skilled negotiator needs figures to back up his or her arguments.

"No matter what you are doing—negotiating for salaries, buying a car, looking at a house—it is out there now in this Google era," Dr. Howell said. "The people who win the most are the ones with the data."

Ingrid Palmer is a freelance health care writer based in Evergreen, Colo.

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