Fig. 1 The pyramid approach to promoting professionalism. View larger image (PDF).
Courtesy of Vanderbilt Center for Patient and Professional Advocacy


Published 8/1/2016
Kay Kirkpatrick, MD

Difficult Peer Conversations: Getting the Outcome You Want

Are you in a leadership position in your practice, ambulatory surgery center, or hospital? Have you had any formal training in dealing with conflicts among your peers?

As surgeons, we occasionally have to communicate about unpleasant subjects with our patients. As individuals, we may face the same problem at home or in our other roles. But as leaders, we frequently need to address problems with our fellow physicians. Examples of issues that might trigger uncomfortable conversations include the following:

  • being frequently late for surgery or clinic
  • resisting patient safety efforts
  • behaving badly with the operating room (OR) staff

Abundant literature shows that disruptive behavior among surgeons increases the risk of medical errors and lawsuits. All of us have seen colleagues whose behavior has been tolerated or ignored for years, especially if the person is a high-volume surgeon. We know that these behavioral issues usually don't go away without intervention.

Unfortunately, instead of reaching the desired outcome—addressing the problem at hand and moving forward in a positive way—these conversations are often avoided or handled in a way that leads to broken relationships or even legal action.

As entrepreneurs, small business operators, and "owners," physicians don't get regular evaluation and feedback, whether positive or negative, in the same way as employees. This is a real problem in health care and is still not being addressed in medical training as it would be in a business environment. Most high-level executives are in some type of feedback loop and are accountable to their board of directors, but physicians usually are not evaluated on a regular basis. That may be changing with the increase in physician employment, but many times the only feedback given is when something goes wrong.

Recommended readings
Successful management of difficult conversations requires courage and a few basic skills. As the leader of a large orthopaedic group for many years, I have found some resources that can be helpful in these situations. I recommend reading Crucial Conversations: Tools for Talking When the Stakes Are High by Kerry Patterson, Joseph Grenny, Ron McMillan, and Al Switzler. This book lays out an approach and some practical tools that are easy to learn and use.

I was also able to attend a course at the Vanderbilt Center for Patient and Professional Advocacy a few years ago. These courses take place on a regular basis and are well worth the 2-day commitment. I attended "The Why and How of Dealing with 'Special' Colleagues: Discouraging Disruptive Behavior," taught by Gerald B. Hickson, MD, and Charles E. Reiter III, JD. Dr. Hickson has also written on this subject.

Dr. Hickson uses a pyramid approach (Fig. 1), beginning with a "cup of coffee chat." This type of meeting can be held informally and does not have to be documented, but can make the physician aware of the problem and clear up any easily resolvable misunderstanding. The information is presented to the doctor and he or she has an opportunity to give the other side of the story.

If the disruptive behavior persists, the next step on the pyramid would be a more formal "awareness" conversation, which is scheduled in advance and documented. At this point, the person giving the feedback needs to have all the facts and dates together.

The next level would be an "authority" conversation, which might include other involved people. It is important to protect the staff and to let the surgeon know that retaliation won't be tolerated.

Finally, if there is no change in behavior or attitude by the physician, a formal disciplinary process—including due process and frequently requiring legal input—becomes necessary. In addition to the individual professional courage required in stepping up to these conversations, an appropriate infrastructure that protects the messenger is very important. This would include not only support from the organization's senior leadership, but also checking to see if the surgeon delivering the message is covered under the organization's Directors and Officers insurance policy or Employment Practice Liability policy. Professional liability insurance typically does not cover this type of activity.

Important tips to remember

  • It is important to know the desired outcome before the initial meeting is held. Usually the point is to solve the problem and reach an understanding. However, in some situations, the doctor may need to work elsewhere; this type of meeting would be set up in a different way.
  • These conversations need to be held in an environment where both parties feel safe. The dialogue should occur in a respectful way. Public humiliation doesn't work and burns bridges. Role-playing the conversations in advance may be very helpful. A clear understanding of the facts is important and may require some research or talking to other individuals.
  • Many excuses can be given for disruptive behavior, but a common defense is "quality of patient care." However, bad behavior and blaming others rarely improves any situation in the OR.
  • Feedback, whether positive or negative, needs to be timely. As in any training situation, incidents may lose their urgency if significant time passes between the incident and the feedback.

Reluctance to tackle a difficult problem directly with a peer may lead to conflict avoidance and the creation of broad policies in an attempt to address specific problems. However, the person who is the target of the broad policy often completely misses the message. Learning the skills of direct communication is not only helpful to orthopaedic surgeons who want to be leaders in their practices and hospitals, but also beneficial for other roles and relationships.

Most orthopaedic surgeons are trying to do the right thing and provide a great example. As a profession, however, we have been challenged about keeping our own house in order. Becoming skilled at dealing with our disruptive colleagues is a good way to protect our patients and our profession.

Kay Kirkpatrick, MD, is a member of the AAOS Patient Safety Committee.

Bottom Line

  • Physicians in leadership positions may have to confront colleagues about their behavior.
  • A pyramid approach may be useful in dealing with disruptive colleagues.
  • Organizational support and protection is necessary for the "messenger."

Additional Information: