Telling It Like It Is: Difficult Peer Conversations in the Outpatient Setting

Many of us have become leaders in our practices, ambulatory surgery centers (ASC’s) and hospitals by choice or circumstance. Leadership often means that difficult conversations with our fellow surgeons are part of our responsibility. Unfortunately, few of us are trained in the art of handling these conversations in a way that ends with the desired outcome, which is usually to correct a situation and move forward in a positive way. These conversations require courage and a few basic skills. The literature has shown that bad behavior by surgeons is associated with an increase in medical errors and lawsuits. All of us have run across colleagues who are disruptive in various ways; they typically don’t get better unless someone intervenes.

I have learned a few things in the course of having many of these conversations during my years running a large group of orthopaedic surgeons. I would like to share a few tips and some resources for honing your own skills. Three important principles:

• Decide the desired outcome of the conversation ahead of time and set up your conversation accordingly. In other words, a conversation to address a correctable problem would be set up differently than one where the person really needs to go somewhere else to work.
• Most people can handle almost any feedback given respectfully. Public humiliation doesn’t work and will rarely be forgiven.
• Many excuses for disruptive behavior can be given. The most frustrating excuses are surgeons blaming their behavior on “quality of care,” since we all know that bad behavior only makes matters worse in the OR setting.

I learned from Dr. Jerry Hickson at the Vanderbilt Center for Patient and Professional Advocacy that there are different levels of peer conversation. The first level is usually what he calls the “cup of coffee chat,” which is a casual conversation to make the person aware of the issue and to give them a chance to give you their side. Sometimes there is a misunderstanding that can be easily resolved. No documentation is required. The next level is an “awareness” intervention which would occur if the behavior persists. This would be set up a bit more formally, and the meeting would be documented. After that, an “authority” intervention could occur if the behavior is not corrected, and the last resort would be a disciplinary intervention. In most organizations there is a template in place for disciplinary proceedings, and legal advice might come into play. You should be sure your organization has your back all along the way but especially at the more formal levels.  Dr. Hickson teaches a two-day course at Vanderbilt on “Discouraging Disruptive Behavior” that I found very helpful in dealing with difficult peer situations.

A book I have found helpful in preparing for these situations is Crucial Conversations: Tools for Talking When the Stakes Are High by Patterson, Grenny, McMillan and Switzler. It is an easy read with a lot of practical information on approaching difficult conversations with the right attitude, preparation and listening skills.

I have sat through a lot of meetings where there is tap-dancing around the message that needs to be delivered and broad policy made to address situations that are really about individuals, especially when high producers are involved. Doing the right thing in a respectful way and having the professional courage to work through difficult situations are extremely important for doctors in leadership roles such as medical director, board member or managing partner. The good news is that the skills learned are very useful in other settings such as home, family and volunteer organizations.