Imagine a hospitalist, part of a group with 35 hospitalists, is in her second year of practice and is caring for a 55-year-old woman with a history of congestive heart failure and cirrhosis from hepatitis C due to heroin use. The patient was hospitalized with acute back pain and found to have vertebral osteomyelitis confirmed on MRI.
The hospitalist calls a surgeon to get a biopsy so that antibiotic therapy can be chosen. The surgeon says it’s the second time the patient has been hospitalized for this condition, and asks, “Why do you need me to see this patient?” He says the hospitalist should just give IV antibiotics and consult infectious disease.
The hospitalist says, “The patient needs this biopsy. I’ll just call your chair.”
In the course of a busy day, conflicts arise all the time in the hospital – between clinicians, between patients and clinicians, and as internal battles when clinicians face uncertain situations. There are ways to make these conflicts less tense and more in tune with patient care, panelists said recently during a session at SHM Converge, the annual conference of the Society of Hospital Medicine.
In the case of vertebral osteomyelitis, for instance, the hospitalist was using a “position-based” strategy to deal with the conflict with the surgeon – she came in knowing she wanted a biopsy – rather than an “interest-based” strategy, or what is in the patient’s interest, said Patrick Rendon, MD, FHM, assistant professor in the hospital medicine division at the University of New Mexico, Albuquerque.
“What we really need to do is realign the thinking from both the hospitalist as well as the consult perspective,” Dr. Rendon said. “It is not us versus the consultant or the consult versus us. It should be both, together, versus the problem.”
Instead of saying something like, “I need this biopsy,” it might be better to ask for an evaluation, he said.
Handling conflicts better can improve patient care but can also benefit the clinicians themselves. While hospitalists say they routinely experience “pushback” when making a request of a consultant, they also say that they prefer to receive instruction when consulting about a case. Dr. Rendon said that hospitalists also say they want this teaching done “in the right way,” and consultants routinely say that their instruction, when they give it, is often met with resistance.
“The idea here is to open up perspectives,” Dr. Rendon said.
Emily Gottenborg, MD, hospitalist and assistant professor of medicine at the University of Colorado, discussed the case of an intern caring for a patient who says something offensive.
Conflicts, she said, come in all sorts – intimidation, harassment, bias. And they can be based on race, gender, disability, and hierarchy, she said. When on the receiving end of offensive remarks from patients, it’s important for a clinician to set boundaries and quickly move on, with responses such as, “I care about you as a person, but I will not tolerate offensive behavior. Let’s focus on how I can help you today.”
“Practice that behavior so that you have a script in your mind and then use it when needed so that you can nip this behavior in the bud,” Dr. Gottenborg said.
In her hypothetical case, the intern asks for help from her program, and monthly morbidity and mortality workshops on bias and harassment are scheduled. She also receives counseling, and faculty and staff receive discrimination and bias training. Getting help from the institution can help systematically reduce these problems, Dr. Gottenborg said.
Ernie Esquivel, MD, SFHM, hospitalist and assistant professor of clinical medicine at Weill Cornell Medicine, New York, said internal conflicts test physicians routinely – and this has been especially true during the COVID-19 pandemic, in which urgent clinical situations arose with no clear answers.
“In the past year, physicians have experienced an incredible amount of anxiety and stress,” he said. “Tolerating uncertainty is probably one of the most mature skills that we need to learn as a physician.”
The culture of medicine, to a large degree, promotes the opposite tendency: value is placed on nailing down the diagnosis or achieving certainty. Confidence levels of physicians tend not to waver, even in the face of difficult cases full of uncertainty, Dr. Esquivel said.
He urged physicians to practice “deliberate clinical inertia” – to resist a quick response and to think more deeply and systematically about a situation. To show the importance of this, he asks residents to rank diagnoses, using sticky notes, as information about a case is provided. By the fourth round, when much more information is available, the diagnoses have changed dramatically.
Dr. Esquivel suggested physicians switch from thinking in terms of “diagnoses” to thinking in terms of “hypotheses.” That approach can help clinicians tolerate uncertainty, because it reinforces the idea that they are dealing with an “iterative process.”
“There may not be one diagnosis to consider,” he said, “but several in play at once.”
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