Navigating Treatment Pathways and Managing Conflict in Medicine

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,