Psychosomatics 49:8-13, January-February
doi: 10.1176/appi.psy.49.1.8
© 2008 Academy of Psychosomatic Medicine
Consultants’ Conflicts: A Case Discussion of Differences and Their Resolution
Jason P. Caplan, M.D.,
Lucy A. Epstein, M.D., and
Theodore A. Stern, M.D.
Received November 3, 2006; revised November 9, 2006; accepted November 20, 2006. From the Dept. of Psychiatry, Univ. of Arizona, Tucson, AZ; the Dept. of Psychiatry, Columbia Univ. Medical Center, New York, NY; and Massachusetts General Hospital and Harvard Univ. Medical School, Boston, MA. Send correspondence and reprint requests to Dr. Jason P. Caplan, Dept. of Psychiatry, Univ. of Arizona, Tucson, AZ. e-mail: jpcaplan{at}gmail.com
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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Conflicts among consultants are frequent in general hospitals. Unfortunately, such disputes are rarely resolved to the satisfaction of all concerned. The authors discuss the conflicts that may arise among consultants and review techniques that can lead to more effective collaboration. Authors review the literature on consultants’ conflicts and discuss strategies for their resolution. They present the case of a man with neuropsychiatric symptoms and discuss how practitioners of psychiatry and neurology often approach differential diagnosis, work-up, and treatment of challenging cases. The consultants were able to find several points of agreement and generated a workable plan that led to improvement in the patient’s symptoms. Conflict among medical consultants is poorly described in the literature. However, an understanding of conflict and strategies for its resolution can lead to improved patient care. Conflict is a common and virtually unavoidable aspect of multidisciplinary care. However, effective tools exist that can help physicians embrace, rather than avoid, conflict, and lead to more effective collaboration. Effective management of interdisciplinary conflict improves communication, assists in medical decision-making, and, most importantly, improves the delivery of patient care.
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INTRODUCTION
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Conflicts among consultants are frequent in general hospitals. Unfortunately, such disputes are rarely resolved to the satisfaction of all concerned. Overlapping territories often trigger such conflicts between practitioners (e.g., psychiatrists and neurologists) who practice at the interface of two disciplines; each may be called to consult on the same patient who manifests neuropsychiatric symptoms, for example, with complex partial seizures (CPS). Differences in the training, history, and philosophy of American psychiatrists and neurologists may underlie such disagreements.1–3
We present the case of a man with neuropsychiatric symptoms suggestive of CPS and discuss how practitioners of psychiatry and neurology often approach the differential diagnosis, the work-up, and the treatment of this clinical syndrome. Also, we discuss the conflicts that may arise among consultants and review techniques that can lead to more effective collaboration and untangle "crossed wires."
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Case Report
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"Mr. A," a 48-year-old man with history of congenital hydrocephalus managed with a ventriculo-peritoneal (VP) shunt placed in infancy, had a long-standing history of tonic–clonic seizures. He had done well and been seizure-free (with the VP shunt and use of anticonvulsants) for 20 years, until 5 years before the current hospital admission, when his neurologist attempted to simplify his antiepileptic regimen. The frequency of his tonic–clonic seizures increased from once per year to five times per year with subsequent medication changes. His neurologist, concerned that the VP shunt might have ceased to function, obtained imaging studies, which confirmed the dysfunctionality of the shunt. Despite therapeutic levels of both levetiracetam and zonisamide, Mr. A continued to have monthly tonic–clonic seizures.
Two months before his admission, Mr. A’s personality had changed, and he began to report both auditory and visual hallucinations. Although, according to his family, he had always been "as sweet as pie," he became increasingly aggressive, and he laced his conversations with profanity. Family members also noted "spells" where he would stare into the distance; his pupils would dilate; and he would respond to neither verbal nor tactile stimuli. His deterioration culminated in an episode in which he became acutely agitated, ran from the house, and struck his sister when she tried to stop him; this prompted his family to call for an ambulance to bring him to the hospital.
Mr. A was admitted to the medical service. The Neurosurgery Service was immediately consulted because of concerns regarding the status of his shunt; they thought that the nonfunctional shunt was an unlikely precipitant for his current presentation. The Psychiatry Department was then consulted regarding his abnormal behavior and perceptions.
On examination, Mr. A was awake and alert; although oriented only to himself; he appeared pleasant and engageable. He described seeing "pictures" and hearing voices that he found terrifying. Each time he had one of these experiences, he felt an uneasy "frightening" sensation in his chest. Unfortunately, he was not capable of describing these sensations further, and he refused to cooperate with much of the cognitive exam.
Given the paucity of psychiatric symptoms before his admission, it seemed unlikely that he had developed a functional psychosis. Instead, in the context of new-onset multisensory hallucinations, confusion, and unusual physical sensations, CPS and levetiracetam toxicity were considered. The psychiatric consultant recommended that levetiracetam be discontinued and that an EEG be obtained to evaluate the CPS. A neurological consultation was also recommended and was ordered. An EEG revealed poorly formed and attenuated alpha rhythm over the right posterior quadrant, with periodic theta–delta range slowing; it was interpreted as being inconsistent with epileptiform activity. Nevertheless, the psychiatric consultant believed that the EEG was consistent with a postictal state of CPS of the right temporal lobe—the brain region most commonly linked with complex hallucinations. The neurology consultant disagreed with this interpretation and promptly signed off the case.
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DISCUSSION
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Diagnostic Considerations and Complex Partial Seizures
What could account for Mr. A’s symptoms? Given his history of congenital hydrocephalus, neurosurgical interventions, and new-onset episodic symptoms with perceptual problems, CPS should be strongly considered. CPS is a form of seizure disorder consisting of a partial seizure in which consciousness is also impaired. It often produces neuropsychiatric phenomena and thus may become the focus of clinical attention for both neurologists and psychiatrists.4 CPS may reflect seizure activity in the temporal lobe; when repeated seizures ensue, the term temporal lobe epilepsy (TLE) is applied. The etiology of CPS is unclear and may be multifactorial, including the presence of mesial temporal sclerosis, which may serve as a nidus for abnormal electrical activity.
Symptoms of CPS can vary widely. Abnormal sensory perceptions (such as visual, olfactory, gustatory, auditory, or tactile hallucinations) commonly occur.5 Affective symptoms (such as anxiety, panic, and depression) also arise and may be abrupt in onset.6 Motor symptoms (such as automatisms, picking, and oral/buccal movements), sensory symptoms (such as numbness and paresthesias), and autonomic symptoms (such as nausea and flushing) also arise. Cognitive symptoms include déjà vu, macro- and micropsia, and even dissociative phenomena.6 Some authors suggest that there is an entity of "interictal personality," consisting of hyper-religiosity, hyposexuality, hypergraphia, impulsivity/aggression, and "viscosity,"7–9 although this suggestion remains controversial.10
Many practitioners believe that the diagnosis is made on clinical grounds and does not rely on the EEG findings. Nonetheless, when the EEG is abnormal, the diagnosis is more readily made; however, a normal result does not rule out the presence of CPS, because surface electrodes may not be sensitive enough to detect electrical dysrhythmias located deep within the temporal lobe and in other limbic structures. One study of patients with clinical symptoms of CPS found only 37% with epileptiform patterns derived from scalp EEGs, although the yield increased an additional 15% with a sleep-deprived EEG, and a further 25% when nasopharyngeal leads were used.11 Nonetheless, some neurologists hold that EEG with video monitoring allows seizure activity to be ruled out "with near certainty."12 Single photon-emission computed tomography (SPECT) or positron emission tomography (PET) scans can also be useful for localization of seizures.13
Treatment requires management of the seizure activity, with first-line interventions including use of anticonvulsant mood stabilizers (such as carbamazepine or valproic acid).
Conflict and Its Genesis
What creates conflict? Conflict between medical consultants (such as that seen in the case of Mr. A above), is poorly described in the literature. Indeed, no reports that specifically examined this ubiquitous experience were discovered with an electronic search of the medical literature on PubMed and MEDLINE. Reports of conflict in the medical workplace focus almost entirely on interpersonal (e.g., "dealing with the disruptive physician"),14–17 rather than interprofessional, friction. In contrast, the business literature provided a significantly more thorough examination of how to maximize interdisciplinary collaboration. Avoidance of acknowledging conflict within medicine appears to be the rule until it crosses a certain threshold and leads to fractured care (e.g., dealing with "the disruptive physician.") For several decades, psychiatrists who work in general hospitals have discussed the importance of being able to recognize interpersonal conflicts and reactions;18 unfortunately, specific and practical suggestions for their resolutions have been few and far-between.
In a study of interprofessional differences in a general hospital, Skjorshammer19 identified three principal responses to conflict: avoidance, "forcing," and negotiation. Avoidance of conflict between physicians was deemed common; it even extended to the identification for what constituted "conflict." Physicians were loath to use the word "conflict" in discussions of their work, and reserved it for "war-like" situations. In fact, physicians have a significantly higher threshold for defining a situation as conflicted, even when other professionals (e.g., nurses and ancillary staff) in the same milieu had already done so.
The prevalent use of avoidance as a coping strategy may be a product of the personality traits (e.g., compulsivity, perfectionism, and a fervent sense of responsibility) that allow for success in medical training; these attributes are magnified by the social expectations and by the ingrained professional culture of general hospitals. Also, open discussion of conflict is often considered antithetical to a professional’s self-image; Skjorshammer noted that professionals have a strong cultural norm, saying that "when dealing with patients, they [professionals] leave behind whatever disagreements they may have."19 Avoidance can also be viewed as a just and prudent use of time and resources, since time spent addressing conflict is time away from patient care. Group identification and allegiance likely play a significant role in these interactions; if a longstanding disagreement exists between two groups, offering an opinion outside "the party line" is a proposition rife with potential pitfalls, especially for more junior members of the group, whose prospects for career advancement may hinge in no small manner on the approval of their supervisors. Similarly, junior group-members tend to avoid identifying themselves as "troublemakers" by calling attention to conflicts with which they may be involved. Finally, avoidance of discussion of disagreements may seem to be a safer option, since such discussion may result in the need to reformulate a strongly-held belief.
The second identified response to conflict is "forcing." More often used in situations where there is a perceived imbalance of power between the involved parties, forcing occurs when one party (usually the more powerful) pushes his or her own agenda without regard for the position of others. This does not completely represent the "fight" alternative to the "flight" embodied in avoidance, since it is most often done without explicit acknowledgment of the existence of conflict. Forcing often results in ill-will on the part of the "forced," and it can strengthen the rationale for avoiding conflict altogether. For the "forcers," however, this strategy can be quite appealing, since it efficiently accomplishes their immediate goals, and maintains their status at the "top of the food chain." As with avoidance, forcing can become ingrained on a broader cultural level. Skjorshammer noted that departments with the highest status often ignore conflicts with other departments and count on getting their own way.19
The final, and least-utilized, response to conflict is negotiation. Negotiation requires the expenditure of significantly more time and energy by all concerned parties than does either avoidance or forcing. Perhaps most importantly, it requires an explicit acknowledgment that conflict exists, since, without recognition of conflict, there is nothing to negotiate. Acknowledging conflict is difficult in large part because of the prospect of "losing" the negotiation that ensues. Discussion of negotiation in the medical literature is almost entirely limited to situations in which medical managers and administrators can best "referee" negotiations or disputes between their staff; little mention has been made as to how individual physicians can negotiate conflict among themselves without "running it up the ladder."
In the business world, attention is often keenly focused on the concept of conflict (e.g., conflicts of supply and demand are essential forces that drive markets around the world, and analysts and investors scrutinize conflicts between competing companies in a particular industry). In business, discussions on the management of conflict within an organization are commonplace. Recently, Weiss and Hughes, in The Harvard Business Review,20 explored issues related to conflict in the workplace (in the context of attempting to maximize collaboration). They concluded that conflict is neither something to minimize or to avoid. Only by identifying and embracing conflict can an organization hope to maximize collaboration. Since conflict occurs almost entirely at the boundaries between disciplines, it serves as an effective marker for issues where collaboration is most likely to produce the greatest gains. As portrayed in our case (Mr. A), it would have been unlikely for conflict to have occurred between the consultants from Psychiatry and Neurology over the use of psychotherapy for anxiety or the interpretation of an electromyelographic study on a patient with peripheral nervous system disease; each of these content areas is contained entirely within the domain of one specialty. Collaboration, on the other hand, requires "dismantling organizational silos"20 and the useful combination of the expertise found in each. The conflict inherent in effective collaboration, although often uncomfortable, produces significantly more value than does "pussyfooting" around thornier issues, and passively agreeing to "split the difference." Well-intentioned pursuits of team-building and placement of emphasis on common goals may actually serve to inhibit collaboration by stigmatizing the expression and investigation of conflict.
Although collaboration might be necessarily uncomfortable, it need not be either unprofessional or lack civility. Below, we present what we hope can serve as a broad structural outline for confronting conflict and optimizing collaboration.
The Setting for Optimal Communication
Effective examination of conflict should occur in person (i.e., face-to-face). In emotionally-charged situations, the nuance of interpersonal interactions can be all-too-easily lost when discussion takes place over the telephone, via e-mail, or (perhaps worst of all) through the medical record.21 Since avoidance of conflict has, at its core, avoidance of uncomfortable feelings—resorting to methods of communication that allow one to step away from those feelings—merely adds to avoidance. All parties involved in the issue should be present, so that everyone’s concerns can be represented simultaneously.
Identification of Points of Agreement
Perhaps the most important tasks are defining the conflict and locating the initial branch-point of divergence. In the conflict that surrounded the case of Mr. A, all parties could have agreed that Mr. A had a history of a neurological insult (congenital hydrocephalus), a history of seizure disorder, and the recent onset of hallucinations and behavioral changes. Furthermore, all parties could have agreed that hallucinations and behavioral changes might be a manifestation of CPS. The point of divergence was that the consultant from Neurology believed that active auditory hallucinations could not be attributed to epilepsy in the face of a "nonepileptiform EEG," whereas the Psychiatry consultant believed that seizure activity could occur in deep brain structures without inducing epileptiform activity as detected on a surface lead of a non–sleep-deprived EEG, and that hallucinations might also occur as a peri-ictal phenomenon.
Agreement on Definitions
In the jargon-filled world of medicine, definitions are important: two physicians might use the same word to refer to two different conditions or might use two very different terms to describe the same thing. Nowhere is this more pertinent than in the world of neurology. In his text Principles of Behavioral and Cognitive Neurology, M. Marsel Mesulam noted: "one part of the brain can have more than one descriptive name, and cytoarchitectonic (striate cortex), functional (primary visual cortex), topographic (calcarine cortex), and eponymic (Brodmann’s Area 17 [BA] 17) terms can be used interchangeably to designate the same area."22 In this context, it might be easy to imagine that two consultants might believe that they disagree solely based on differences in language that arise from different specialties with training based in different philosophies and histories.
Respectfully Disagreeing
We must remember that collaboration is born of conflict, and conflict is born of disagreement. For collaboration to be realized, disagreement should not be avoided; it should be embraced—but it should be handled in a respectful manner. Examination, discussion, and refutation of opposing views are part of this process; use of sarcasm, patronization, and condescension simply serve as distractions and often represent a more directly aggressive form of avoiding discussion of the issues at hand.23
Autognosis
Although it is important that strong feelings do not spill over into petty name-calling, it is equally vital that parties involved in a collaborative effort be keenly aware of their emotional stake in the process. Autognosis is a term that describes a state of self-awareness, and, more particularly, how that knowledge of the self might affect interactions with others.24 If the other party involved in a conflict generates some antipathy, it is important to be aware of those feelings so as to avoid unconsciously compromising the efficacy of collaboration by "getting one over" a perceived enemy. Once these feelings are identified, it helps to have a safe place in which to explore and air them, since the goal is not to avoid, but to recognize and to confront these emotions.
Addressing Territorial Battles
The initial spark of conflict can often be traced to issues of "turf," or territory. Conflict occurs almost exclusively at the boundaries between territories, frequently around the issue of where the boundary itself should be drawn. A prominent issue of territory in the case of Mr. A centered on the interpretation of his EEG. A less explicitly-stated issue of territory arose later, in the discussion of who should take the lead in the care of the patient. The Neurology consultant voiced concern that if epilepsy were identified as the patient’s primary problem, then Medicine and Psychiatry would retreat from the "front lines" and defer to the opinions of the Neurology staff. Clearly, battles occur around the maintenance of territorial status quo, both in terms of retaining territory that is valued and avoiding what is unwanted.
Case Follow-Up
In order to provide coordinated care, the consultants from the Medical, Neurology, and Psychiatry services met together to generate a plan. They were able to find several points of agreement, including the fact that the patient, Mr. A, had a seizure disorder, that his seizure activity had worsened, and that his psychotic symptoms occurred during the time-frame in which he was having seizures. They set aside the major point of disagreement, which was that his psychotic symptoms could occur as part of his seizure disorder despite ambiguous results of the surface EEG tracing. Once they developed their major points of agreement, they decided to focus on controlling the seizure disorder, and agreed to start him on a combination of valproic acid and mephobarbital (which had controlled his seizures for 20 years). Three days later, Mr. A’s psychotic symptoms had resolved, and he was discharged from the hospital.
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CONCLUSION
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In summary, conflict is a common and virtually unavoidable aspect of multidisciplinary care. However, effective tools exist that can help physicians embrace, rather than avoid, conflict, and lead to more effective collaboration with others. Effective management of interdisciplinary conflict will improve communication, assist in medical decision-making, and, most importantly, improve the delivery of patient care.
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REFERENCES
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ABSTRACT
INTRODUCTION
