Who would you rather have on your staff: Marcus Welby or Gregory House?

Plenty of doctors, nurses, and support staff certainly are reminiscent of that master healer played by Robert Young in the long-running ’70s TV series. But you probably have a few doctors who think their words are inviolate, their actions justified, and their skills unmatched—like the character Hugh Laurie plays on the popular Fox series.

Conflict in the workplace is inevitable, including personality issues among co-workers and differences of opinion on the proper course of action. But when co-workers in healthcare are afraid to express their concerns openly for fear of reprisal, disaster can result.

The Institute of Medicine estimates the sum of indirect costs of medical errors leading to patient harm are $17 billion to $29 billion annually. Studies from the Joint Commission on Healthcare Accreditation indicate that 60% of medication errors are caused by mistakes in interpersonal communication.

And a joint study from the American Association of Critical-Care Nurses and VitalSmarts shows that although 84% of healthcare professionals have had questions about the competency of a co-worker, fewer than one in 20 voiced their concerns.

It’s no wonder that the joint study, released last year, is called “Silence Kills: The Seven Crucial Conversations for Healthcare.”

Disruptive physicians can exacerbate already tense healthcare situations, and although few doctors fit this category, “They’re a very influential population,” said Joseph Grenny, president of VitalSmarts, the Provo, UT-based provider of training services and consulting research. “Their peers don’t deal with them, their medical directors don’t deal with them, and their administrators don’t deal with them—but they help set the culture in a healthcare setting.”

The study outlines seven conversation categories that are inherently difficult but particularly salient in healthcare, including broken rules, mistakes, lack of support, incompetence, poor teamwork, disrespect, and micromanagement. These issues not only affect the quality of patient care, they also can impact turnover, morale, and productivity, said Grenny, co-author of the best-selling Crucial Conversations: Tools for Talking When Stakes Are High.

“The consequences of avoidance in this setting are more acute,” Grenny said. “It’s not like losing $100,000 in a telecom deal—we’re talking about lives here.”

Dealing with conflict
The Crucial Conversations training from VitalSmarts is creating a better atmosphere during a time of change at University of Colorado Hospital in Denver. The hospital had been using team-building training, but Kelley Williamson, manager of learning and development, said it wasn’t adequately addressing the communications issues the staff were having.

After deciding to give Crucial Conversations a try, Williamson asked hospital vice presidents for the names of 40 managers and directors in key areas who were required to attend the first session. Follow-up evaluations were conducted on 11 members of the initial class who had a total of 15% employee turnover in their departments, above the hospital range of 12% to 14%. The new results showed a total of 9% turnover in those departments, Williamson said.

Since then, more than 200 people have attended the 10-week sessions. Managers, directors, physicians, and residents don’t pay for the training, while nurses and administrative staffers pay $190 for class materials. However, nurses receive 22.4 CEUs for the course.

Positive changes in interactions among nurses, other staffers, and physicians have been dramatic, Williamson said. “New nurses are technically phenomenal, but they’re not very good at dealing with conflict,” she said. “This gives them the right tools to manage their interpersonal relations and improve the quality of patient care.”

A handful of influential doctors have taken the course, as did the executive committee, which requested its own course after seeing the groundswell of support around Crucial Conversations.

Big shots
Cultural changes in any setting are hard to make stick, but the hands-on training that physicians receive can make future changes even more difficult, said Stephen Paskoff, founder and president of Employment Learning Innovation.

“A lot of the behaviors of physicians and surgeons, good and bad, are embedded in the cultural fabric of how people practice,” said Paskoff, an attorney and author of Teaching Big Shots to Behave, which addresses the subject of disruptive doctors. “Doctors are seen as the captains of the ship, and how they’re taught directly and indirectly models what it means to be a physician and how they deal with colleagues, peers, and patients.”

“People who are disruptive often don’t understand how outside the bell curve on behavior they are,” said Richard Clark, vice president at LifeWings Partners. The Memphis-based company uses methodologies and tools honed in the aviation industry by parent company Crew Training International to reduce medical errors and increase patient safety.

The aviation industry keeps track of which crew members others are afraid to fly with, which helps identify those who might need training on interpersonal relationships and effective communication, Clark said.

In a hospital environment, an administrative determination must be made about what’s acceptable behavior and what isn’t. Experts agree that any proposed solution must be supported by hospital leadership before meaningful changes will occur.

And for hospitals that don’t directly employ physicians who practice there, the threat of a disruptive, high-earning doc taking his patients elsewhere causes hospital bean counters and executives to take notice.

Clarks suggests that hospitals look at the big picture when dealing with such physicians. Any bottom-line determination of a physician’s value should include the cost of medical errors, other patient safety issues, support staff turnover, and hospital stress levels.

“Non-employee physicians have a privilege to practice, not a right,” added Paskoff. “The institution controls the environment, and if you’re not willing to hold people accountable, then you tolerate inappropriate behavior.”

Paskoff agrees that any change must come from the top, with leaders expressing clearly what constitutes appropriate behavior. Failure to address the problem drives the issue underground, said VitalSmarts’ Grenny. That’s why the company suggests that top leaders take the Crucial Conversations course first, then train their direct reports, who will train their direct reports in a cascading pattern.

“Ninety-nine percent of these behaviors can be resolved through social control, not economic control,” said Grenny. “The key is to confront bad behavior consistently when it occurs.”

Effective communication, delivered in a consistent manner, is what experts say is required to keep Dr. House on the TV screen and not at your facility.

Grayson Walker, This e-mail address is being protected from spam bots, you need JavaScript enabled to view it , is a freelance writer based in Atlanta.