EP26 - Sharpen the Sword - The Apple of Discord: Decoding 3 Types of Conflict in Medicine

Hello, my peaceful warriors. I wanted to let you know about a new episode feature on the Scalpel and Sword podcast.

It's called Sharpen the Sword.

And one of the things that's great about conflict and conflict resolution is it is unfortunately pervasive, but because it is pervasive, we have lots of different arenas from which we can learn. And I'm really excited to invite guests from different professions to join us on the Scalpel and Sword. to give us an insight into how they manage conflict, and we can learn from how they do it. So look for a new episode, our new feature, and it's coming up soon. So make sure you tune in for that. And as always, peaceful warriors, be at peace.

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Hello, my peaceful warriors. Welcome to the Scalpel and Sword podcast. I am your host, Dr. Lee Sharma, physician and conflict analyst. I am so happy to be with you today. This is kind of a new one for me. I'm going to talk with you today About speaking the language of conflict. And this is a really interesting topic to me because I feel like when people understand what's being spoken and what the conflict is about, we're much more likely to understand it, approach it, be able to work through it, and also on the other side of it, get a better understanding of ourselves, the other people involved, and more likely to get a resolution, which is beneficial for everybody. And especially in medicine. That somebody's always going to be the patient. It's really important to me when we're getting into conflict to be very clear about what that conflict is about. So what we're going to do today is we're going to talk about 3 general different types of conflict in terms of the things that are at issue, and we're going to sort of learn how to listen for cues that let us know what kind of conflict we're in. So You can't really see it, but I have an apple, and we're going to use this apple today to talk about these 3 different types of conflict. First and foremost, we're going to talk about interest-based conflict. Interest-based conflict is when we are talking about things that we can quantify, so we are in conflict about a specific resource or a specific item that we can actually define. So this may be money, This could be time. This could be call schedules. This could be OR start times. There's so many quantifiable things that can be at conflict. But right now, we're going to talk about my little apple right here. So let's say I have another person in the room, and that person's hungry, and I am hungry, and we only have one apple. If we are dealing with a strictly interest-based conflict, The only thing at question is who gets the apple. If this is purely interest-based, the most logical solution would be to split the apple in half. And if we're splitting the apple in half, then conflict resolved, right? Because that person gets half, I get half, we're all happy. But let's just say maybe I haven't eaten today. I've had a long day in clinic and I really want this whole apple. And let's say the other person who's in the room also had a very busy day. They were doing a lot of work. Maybe they were in surgery all day, but they're really hungry too. And half an apple isn't going to work. When you get to the point that the resources are limited, or let's say getting half or having an equitable solution isn't going to work, that conflict escalates. If you are in an interest-based conflict process, let's say you kind of look at this conflict and this is about bonuses and you come up with a really fair solution for everybody involved. And for some reason, one or multiple parties involved say, that's not going to work for me. You're probably not dealing with a purely interest-based conflict. So I'm going to give you an example from my own life. When I was working with my previous practice, And this was back in the late 1990s, early 2000s. I had gone part-time. I had 2 very small children. My husband was a physician. We were basically just on roller skates all the time. And to really feel like I was raising our children, I cut my schedule back. And to do that, I gave up my partnership, which, ladies, if you're listening to this podcast, women physicians, don't do that. Please don't ever do that. But I did. That was the advice that I got, and I followed it. And when I gave up my partnership, that also, of course, gave up a lot of financial stake in the practice. And as a result, I found that my reimbursement really dropped. I mean, dropped more than it probably should have for the hours I was working. So I wanted to be fair to my partners, but I also wanted to make sure that I was getting reimbursed equitably. So what I did is I started looking for pain points. In the practice, so where are places in my work that I can add value? And hopefully, if I'm adding value, then that's going to help with reimbursement, and that's going to allow me to get more fairly reimbursed. And so the pain point in that particular practice was seeing work-in obstetric patients, walk-in OBs. So I went to my practice, and I worked up a plan with schedule and reimbursement, saying I will see the work-in patients. And when I see the work-in patients, then I should get reimbursed this amount. And I looked at everybody's schedules. I looked at the way the workflow was. I mean, it was, I think, a pretty thorough assessment. And so I sat down with the other doctors in the practice and I said, this is what I propose. And I was really happy about the proposal. And as an interest-based solution to my conflict, I felt like this was a good direction. And the answer I got was, when I presented this interest-based solution was no. Not only no, but heck no and never. Okay. And I was actually in my master's program at this point. So this was a really good place for me to be in terms of understanding what was happening. And when I realized what was happening, I realized really quickly that I, like our 2 friends with the apple, were not in a strictly interest-based This had escalated. And when interest-based solutions escalate or aren't really what's happening beneficially with the conflict, you're dealing with identity. So now we're talking about the second type of conflict, which is an identity-based conflict. Identity-based conflict is when we bring our self-view or the view of the other party or parties into the conflict. Now, we may not be aware that we're doing it, but anytime you're in an interest-based conflict process and the interest-based solutions don't work, you've probably got an identity-based conflict on your hands. So, what are some tip-offs that you're dealing with an identity-based conflict? Well, so let's go back to our apple. I'm in the room with my other friend who also wants this apple. We're both hungry. We've both had a long day. And then one person says, you know what? I worked a lot harder than you today. I saw more patients. I was up earlier than you. And because of that, I should have this apple. Anytime somebody starts bringing other topics in regarding themselves and who they are into the conflict, you're dealing with identity. You have just changed the subject of that conflict. So if you're in this situation and somebody says, I did this, or I am this, therefore this is how the conflict should resolve, you know you're dealing with identity. If anybody's a fan of the Mission: Impossible movies, which I'm a big fan, I love that whole franchise. In the 3rd Mission: Impossible movie, where Ethan Hunt is at the CIA and he's in a meeting with his superior, who's played by Billy Crudup, and then their superior, who's played by Laurence Fishburne. We'll link that scene in the show notes because it is one of the best examples of how identity plays into conflict I have ever seen in a movie. So basically, Billy Crudup's character and Tom Cruise's character are getting yelled at by Laurence Fishburne for a mission where an operative died. He was Keri Russell. And how much do we love Keri Russell? So Laurence Fishburne's yelling at them and Billy Crudup's character says, As the director of the department. And Laurence Fishburne immediately says, did you throw a title at me? And it's perfect because Billy Crudup's character is using his identity as a way to resolve the conflict. He throws it out there. And without missing a beat, Laurence Fishburne's character calls him out on it. And anytime we're in that situation, And we start to see this conflict go into an identity realm, we see people bringing in parts of themselves, we should be able to recognize that. And if we recognize it, it should change how we approach the conflict. Because if you're approaching that conflict and you start to bring in elements of identity, then if you know that that's what's being talked about, you can actually make sure the conflict stays on track, and you can address that identity issue. Now, of course, it's not always going to be with our boss. And Laurence Fishburne's character being Laurence Fishburne's character, and he's awesome, absolutely was able to call him out. We're not always going to be in that kind of power dynamic. So because of that, if somebody says, I worked harder than you, I have a bigger title than you, I have more importance than you, and therefore I should have the resource, being able to say to that person, Respectfully, I totally hear you and I totally support you, but at issue is the apple. And so while I respect your title and I know you had a hard day, maybe splitting the apple in half isn't the best solution. And if we're able to do that in that conflict situation, if we're able to actually recognize that identity has entered the chat, but at the same time stay on mission with the actual subject of the conflict, whatever that happens to be, If that happens to be a call schedule, I know that you're working really hard, and I know that you're really busy, and I know that you've worked here longer than I have. But we also both deserve a quality of life. Is there a way we can approach this finite topic of call where we actually both respect each other's positions and each other's effort and who we are, and still find an equitable solution? And it may be harder to do. If you have limited resources, I mean, heaven knows in medicine right now we all have limited resources. But if you're able to approach it in such a way that you acknowledge the identity and you're still keeping your eye on the apple, you're more likely to have people buy into the process. And if they're buying into the process, you're more likely to get a resolution and a resolution that keeps relationships intact. Because when people start talking about identity, I mean, that's very personal. And so if we ignore the topic of the identity, if we happen to, or heaven forbid, actually attack the person's identity, which no, we don't want to do that, then we are at risk of not only not getting an equitable, good conflict resolution, we're at risk of endangering the relationship. So one, interest, the apple. 2, looking at the apple With a mirror in front of us, and that mirror is identity-based conflict. We now know 2 types. We talk about interest-based and we talk about identity-based. So I said there was a 3rd one, right? So the 3rd one involves the way that we look at the apple. What does the apple symbolize to you and what does it symbolize to me? So let's say we've got the same 2 people. They're in a room. We're discussing the apple. I'm in here with my friend. We both really want this whole apple. It's been a day. If the apple to me represents nourishment, this is what this apple is. It's a big old piece of lunch right here. But to the person in front of me, it is respect. It is a symbol of spirituality. It is a symbol of respect of their needs. And I don't see that, then my discussion with them is going to be really difficult and the conflict again is going to escalate. So there's a name for this third one, which is called worldview. When we look at things differently in conflict, our worldviews are different from the person that's across from us. So think of looking at this apple with a lens. So the way I look at it through my lens is different than the way that somebody else looks at it through their lens. So what's an example of a worldview conflict? When I was an intern, many, many, many moons ago, I was called to the floor to see a patient who was in her late teens, who was 20 weeks pregnant, who got admitted with pyelonephritis, with kidney infection. And in pregnancy, we admit those patients because they can become septic and very sick. So we always admit them for IV antibiotics. So this particular patient was refusing her IV antibiotics. And so the nurses called me because she was refusing the meds and they didn't know what to do. So I go up there to see the patient and I, like most interns, I think was stupid. And only thing I could think of at that point was how to cover my butt. I was worried about getting yelled at by my superiors for letting this patient go off her antibiotics. So I went in there with a couple of nurses. It's like, look, if you don't want to take them, I don't know what else I can do for you. Do I need to have you sign AMA papers? Like I said, I was stupid. And she stood up and she got really angry with me and started yelling. And I didn't know what to do. And I had to walk out of the room. Later on, I found out from one of my upper-level residents that she had had an older sister who also had pyelonephritis during a pregnancy, who unfortunately did die of sepsis. And in this patient's mind, The reason why her sister died was because she was given IV antibiotics. Now, if I had taken the time to understand her worldview about what those antibiotics meant to her— to me, as the person providing the antibiotics, what it meant to me was I was going to keep her from getting septic, get her well, be able to get her go home so she could have a good, healthy pregnancy. But because of her sister, And because of that experience, her worldview of the antibiotics was completely different. And if I had taken the time to actually understand what her worldview was, then I would have been able to walk in there and say, look, I get it. I understand what happened to your sister. I know it's terrifying, but let's talk about sepsis and let's talk about what may have happened to her and why I'm so worried if we don't give you these antibiotics, same thing might happen to you. And if I'd walked in there actually trying to understand the lens with which she viewed the antibiotics, at that point, you start working towards a resolution. Now, I still may not have been the person who would have gotten that resolution, right? I still may have been a part of the story. It may have taken the second or third or fourth person or someone much, much more groany than I was at that point to come in and talk with her. For her to hopefully see that this was going to be the right course of action. But at that point in time, I didn't know. I didn't understand how to talk to people, and I certainly didn't understand how to approach a worldview. And it's really interesting when you look at really good clinicians, like people who do this all the time, they're kind of doing worldview analysis on the fly. Like every time they walk in to see a patient, as they're taking that history and talking to the patient, they're already sort of getting a feel for Where this patient's coming from, what their medical history has been like, what their experiences are with other healthcare providers, and how that's colored their worldview of what you're talking about. And when doctors, nurses, nurse practitioners, advanced care people do this, it is so cool because what you get out of that interaction, what the patient experiences, is that they feel heard. And if you start hearing patients say, or people that you're in conflict with saying, I really feel like I was heard, or I feel like I was seen. When people start using those words, whatever situation it was, and it may not have even been a conflict, but it may have been a conversation where you were interacting about a topic. If somebody walks away from that saying, I felt heard, or I felt seen, you were actually on that patient's worldview. They felt like you understood where they were coming from and their perspective. And anytime you get that feedback, Number one, pat yourself on the back because that's really cool that you were able to do it. Number two, especially if you were doing this in a situation that was either a conflict or potential for a conflict, you've helped that person buy in that much more to their relationship with you and their relationship with the healthcare system or how they process that conflict. So just to Look at it again. Number 1, interest-based conflict, which is just the apple, dealing strictly with resources, finite, definable things. Number 2, identity conflict, where we're talking about the way we see ourselves and how that enters into that conflict situation. So think about a mirror that you're holding up to yourself and actually using that self-image in the conflict situation. Being able to recognize that you've brought it in or somebody else has brought that in. And if you're able to recognize that, to acknowledge it and then reframe the conflict back to the interest in question. And the third one is worldview. So we're now looking at the apple with a lens. It's how we look at our situation. It's how we look at this topic. And understanding that worldview is going to be shaped by So many different things: our life experiences, our educational experiences, our family experiences. All of those things go into our worldview, and understanding that each of us is walking around with this lens—it is how we see the world. And if you can understand somebody else's worldview, take the time to really sit and listen and get a handle on that. If you are ever in a conflict situation. You are much more likely to have the other person in front of you understand where you're coming from, and the person in front of you to feel seen and heard. So this is a new episode type for me. I hope that you got something out of it, and I hope in context with the other episodes on scalpel and sword, it starts to increase your conflict resolution vocabulary. And. As we all learn to speak conflict well, because it is inevitable, the better we are at speaking the language, the more likely we are to have the resolution. I hope this episode helps. I hope you enjoy it. And until next time, my peaceful warriors, be at peace.

Every episode is an invitation to speak To negotiate, to choose. I'm Dr. Lee Sharma. Join the dialogue by subscribing to Scalpel and Sword. Until next time, peaceful warriors, may your choices be sharp and your voice be even sharper. This podcast is a reflection of lived experience and research in conflict resolution. The Scalpel and Sword. The content of this episode is not intended as medical or legal guidance. For personal matters, please consult a qualified professional.