On Becoming a Colleague​

Since members in a practice involved in recruiting may be more likely to tell you their practice conforms to the second example regardless of how the group actually functions, how can you tell if collegiality actually exists? Discussions with practice members in the areas of communication, trust, shared responsibility, interests and how they go about resolving conflicts and making decisions may help.

Communication occurs at many levels within a practice, from the mandatory exchange of patient information to the non-verbal feelings of acceptance or rejection involved in inter-personal relationships. Practice associates who share responsibility for the entirety of practice endeavors should demonstrate their acceptance of the spectrum of practice roles, their understanding of shared responsibilities, the degree to which they foster their associates' strengths and interests, and the manner in which they structure a supportive communication style.

There are many levels of communication which can be fostered through the structure of the communication process within the practice and between the practice associates and other entities. Although not all of these necessarily apply to every practice, understanding and experiencing how the communication need served by each is accomplished can help you assess the functionality of the practice at several levels.

Patient sign-off.

• The sign-out/patient exchange process is the day-to-day paradigm of interpersonal communication among associates.
• It may range from a rudimentary outlining of patients' conditions combined with a list of tasks-awaiting—sometimes over the phone or on paper, through face-to-face discussion away from or at the bedside, with or without other team members, away from or involving the parents.
• Discussion of this process with various members of a group, or even joining the associates as responsibilities are shifted, may give you an insight into practice communication skills. Discussions with nursing staff may allude to communication styles among the neonatologists (although nurses may want you there to solve some of these problems, so they won't tell!).
• Collegial communication is characterized by respect for, deference to, and admiration for one another. When neonatologists go off service, or have another member of the group "cover," it is the trust in the associates' clinical skills and mutual respect that perpetuates confidence in the ongoing care for the patient. For trust to be part of the practice, mutual candor, mutual respect, and mutual acceptance of critiques are needed and should be reflected in the exchange.

Clinical rounds.

• Clinical rounding reflects the manner by which the practice associates share the responsibility for bedside assessment and documentation (progress notes and coding), daily orders, discussion among multidisciplinary colleagues, interaction with parents, and care-planning for their patients.
• Clinical rounds may be associated with teaching responsibilities, but for optimal care to mix with adequate teaching and oversight of trainees, the "rounder" must have an independent understanding of the patients' clinical findings, ancillary tests, inputs from nursing staff, etc. in order to mentor trainees appropriately. If rounds are held at the bedside, are the teaching, patient assessment, and parent communication activities of the rounder combined at this one time? If rounds are conference-room based, how does the practice partner gain his/her independent understanding of the infants' statuses so as to be able to assess and contribute to the discussion?
• How does the rounding process incorporate recommendations from representatives from clinical nutrition, clinical pharmacy, social work, and nursing?
• Although the basic note-writing and orders responsibilities are often designated to an individual practice member, complex patient problems and often day-to-day routine care issues may be served by discussion among practice associates. Is rounding a solo activity? If so, how do the practice associates gain insights from each other in times of clinical complexity?
• Practices regularly have clinical responsibilities at many levels. In addition to the NICU(s) covered by the practice, coverage for step-down units (Level II), consultations, regular nursery (Level I), and various clinics may be needed. How is the practice structured to meet these needs and how is the process of shared responsibility met? This discussion is not just about whether these responsibilities are part of the practice, it includes the degree of participation of individual members of the practice and the anticipated involvement of each practice member, including yourself if you were to join the group.

Patient care conferences

• Generally multidisciplinary, patient care conferences outside of the daily rounds process allow for a structured look at each patient's "big picture."
• How the neonatologists interact in this setting may reflect the degree of team functioning in the clinical setting.
• Although not essential for communication, if such meetings do not occur, determination of the process by which nutritionists, clinical pharmacists, social workers, discharge planners, and parents are able to collaborate should be sought as you assess the practice.

Practice group meetings

• Meetings of practice associates can be very helpful in maintaining shared understanding of the practice's activities and the mutual expectations of practice members. (Note the frequency of these group meetings; are there too many or too few? Also, does the practice provide for a periodic retreat where associates can spend both formal and informal time with one another as they conduct strategic planning for the future? Knowing one another personally as well as professionally supports greater understanding and diminishes stereotyping around issues or personalities.)
• Regularly-scheduled, and generally mandatory gatherings of practice associates reflect the group's interest in melding individual and group priorities in as fair and equitable a manner as possible.
• How is the agenda for each meeting determined, and how is the meeting led? If the leadership of the practice assures that the time taken for meetings is effectively applied to important practice concerns, these meetings can be an efficient problem-solving tool. Individuals within the practice should have opportunity to add items to the agenda, either in advance of or during meetings. Advance planning of the agenda has the advantage of balanced time allocation and preparation of materials. The agenda should include discussion of non-clinical practice activities.
• Practices may have meetings that combine clinical issues with practice management concerns, but due to the relative comfort in discussing patients' needs and the relative discomfort when discussing interpersonal issues, it may be preferable for clinical discussions to be held in the multidisciplinary, patient care conference setting and for practice management meetings only to include practice associates. (Does the practice have an articulated process for discussion of group and individual issues and or conflicts. For the latter is there a mediation clause in everyone's contract, or is the practice open to such a procedure?)
• Does the practice include a process of peer and self-review? Although probably valuable for practices of all sizes, the formal periodic elucidation of mutual expectations of the practice and of the individual provides a process through which the short and long term goals of the practice are discussed, and it also creates opportunities for individual expectations and adaptations to be explored.
• Members within a practice will inevitably have disagreements. Practices that have incorporated a process for identification and resolution of interpersonal conflicts develop a culture of mutual understanding and support. Although this expectation may seem utopian, practices that claim interest in resolving the small issues will more likely weather conflicts over larger issues as well.

Journal clubs and educational meetings

• Although many practices share their review of current literature and new ideas from meetings and seminars at their regular practice meetings, others may include formal journal club or educational gatherings for this purpose.
• In many cases, these exchanges are held outside of "duty-time" and away from the institutional setting to foster informality and openness.
• Practices may use this type of gathering to formally assess and discuss implementation of new care approaches before introducing them at the bedside.

Quality review

• How does the practice evaluate its own performance?
• In the current world, outcomes analysis using comprehensive databases and benchmarking is the norm and likely will become essential requirements of renewal of privileges and in maintenance of certification.
• How do individual members of the practice interact within the quality-review process?
• The interest in and ability of the practice to use systems analysis in the QA world reflects a shift in problem solving from blame-casting to problem prevention.

Collegial practices believe in open communication and transparency in the decision making processes. In your discussion with members of a potential practice, evaluation of how the associates interact at the above levels may be helpful. If you conclude that the medical playground metaphor best applies, it probably does, since most recruiting groups are at least trying to give the impression that they get along! If members embrace conflict resolution as the essential for growth and have a structure to foster it, chances are reasonable that your new ideas and unique contributions will have a chance of success in the new setting. ​

Challenges to Collegiality

Famous words: "Why can't we all get along?" It is not that we desire destructive conflict, rather we must recognize that conflict is more normal and common place than we admit. When we begin constructing the list of all the ways we are different from one another it is no stretch to accept how difficult it may seem for us to connect with our similarities and let them guide us to remembering how to work together towards solution. As suggested earlier, some conflict can be converted to growth by having a safe environment for resolution. Indeed, the creation of a safe neutral space in which to resolve conflicts is essential for us all. But, there are situations that may arise within a practice that may be out of the direct control of the practice group which may erode the relationships among practice members and/or between the practice and the community. (In those cases, having a structure in place where facilitators in whom all group associates have trust and confidence may be accessed will be a serious option to consider. This discussion may not be of particular use in the recruiting process, but is included for use by those who are in the process of practice analysis and who may have confronted one or more of these problems in the past or are currently doing so. The following provides an outline of common areas where conflict and distress may arise in a practice.)

Financial 

"Money is the root of all evil." Although medicine is to a certain degree a "calling," it is a calling with considerable compensation, and most individuals ultimately will expect compensation commensurate with their contribution. As discussed in the section on contracting, the initial employment contract will delineate expected duties (contribution) and the compensation and benefits provided. At that initial stage of the relationship, newly hired associates should realize that their share of the total practice income will not be the same as that of established members of the practice, even though the work load for the new associate will equal, or in some cases, exceed that of some of the group's members, although some of the apparent disparity results from established members of the group assumption of tasks outside the clinical realm. It is important that the financial rules of the practice be understood. In some cases, progressive income (and even continued employment) will depend on seniority, academic ranking, tenure, individual contribution to income (eg, grants received), and prestige. This may be more prevalent in the "academic" practice model, but may exist elsewhere as well. In the private practice setting, understanding of the steps in the progression toward partnership in the practice and equal sharing of income is important. Although initial discussions rarely disclose dollar amounts, exploration of topics such as the availability of eventual partnership, the time to establish parity, and the overall package of benefits of practice shareholder status is possible. Although money won't necessarily make you happy, feeling that you receive inadequate compensation for your contributions to a practice likely will make you unhappy and erode the relationship with the practice associates. Feelings that other associate(s) is/are not carrying his/her load will create similar dissatisfaction. Because of the significant time commitment to all of the practice activities, a feeling of equitable work distribution and fair compensation requires full disclosure of and commitment to the entire spectrum of duties.

Financial catastrophe could accompany disease, disability, or injury. Some practices support members through disability insurance in addition to health coverage. All practices should advocate for protection against disability.

Although the books of the practice will not be given for your perusal in the recruiting process, gaining an awareness and understanding of the practice's cash flow, expenses, and compensation determinations is important as one gains shareholder status. Especially in the private setting, transparency and secure accounting practices are essential to avoid financial pitfalls that could accompany embezzlement or misappropriation of practice funds. Assurance that these procedures are in place is helpful.

As discussed above, compensation and contribution need to be in balance. In some practices, a new associate is sought because a senior member of the practice wants to "cut back" or retire. If cutting back means getting less pay, the balance is maintained. If cutting back means more work for the associates getting lower incomes and no pay-back from the senior member, imbalance yields to dissatisfaction in relatively short order. With the average age of clinical neonatologists now in the early 50s, the process by which practices are preparing for and dealing with issues relating to the more senior associates of the practice may include part-time work (cutting back), shifting responsibilities, and retirement. On the other hand, remember that many of the "citizenship" activities come from long-term experience, tenure, and prestige, and require greater time from more senior colleagues. Any of these will impact newly-hired associates quite quickly. As the potential new associate with the longest potential future tenure in the practice, your stake in this preparedness exceeds that of many members of the practice.

Marital 

It used to be said "Medicine is a cruel mistress," implying that wives (yes, doctors were nearly all male then) needed to endure the priorities on time and stresses on family and put up with them. Times have changed, and physicians, male and female, expect practices to support family life. Colleagues from generation X work to live, not live to work as was the mantra for the elder generations! Family stress often is associated with stress at work—challenging the interpersonal relationships within the practice. The divorce rate among physicians continues to be high, and marital problems of practice associates places considerable stress within the practice. Practices open to strategies supporting the family interests of their associates at least provide a foundation for marital success. An attitude of openness to and normalization of these issues with support for group members in addressing these issues will be a positive marker. Again, this issue is difficult to directly assess in the recruiting process, but the attitude of the practice toward vacations, family leave, pregnancy benefits, and mental health of its members will be telling.

Substance Abuse

Alcoholism and abuse of licit and illicit drugs is a challenge to medical practices. Should signs of substance abuse be seen at work, the potential for having a serious problem with alcohol is high, because professionals try very hard to hide an addiction from their co-workers. Fortunately, medical societies and hospitals have responded by developing programs combining protection of patients from impaired physicians with support for their rehabilitation. Early detection of such problems, ideally before it becomes an issue with risk management, can avert the problems of patient injury and loss of licensure that could result. Again, this topic is less relevant to the recruiting issue, but important to the overall function of the medical practice. Remember, work is usually the last casualty for the substance dependent practitioner, after they have already lost their families and their health. It is extremely important for the practice to support a prevention and wellness approach to this issue.

Sexual harassment

To complete the list of challenges to collegiality, the potential for real or perceived sexual impropriety is high in the environment of the hospital. Although inappropriately tolerated in the past, unwelcome sexual advances are no longer swept under the rug. Practice policies need to assert the practice's intolerance of such behavior. Most hospitals, universities, and practice groups have adopted such policies.

Conflict Resolution

Some practice behaviors suggest a commitment to conflict management, so as to allow differences to be resolved and to allow less painful change.

• Prevention through communication. Enduring conflict can be prevented through communication. One practice group begins its practice management meetings with "Did any of you have any issues with other member(s) of the practice and how did you resolve them? The group doesn't expect ubiquitous harmony; it expects commitment to collegiality.
• Prevention through performance expectations. As discussed above, mutually-agreed-to duties and performance expectations, reviewed personally and by practice peers, can maintain balance.

Modalities of conflict resolution. Having a commitment toward conflict resolution is a good first step, but having an understanding of the formal conflict resolution process in place can be helpful, because all issues will not be solved by early communication.

Step one is realization that a conflict exists. It is unusual for both sides in a conflict to be unaware—but, less unusual for one party not to realize a significant issue affecting another. The term "clueless" comes to mind—we all at times are clueless as to why someone else is upset, and sometimes the why is us. Once conflict arises, means to approach it vary as noted in the table.

The relationship between the results and the impact on personal relationships can result in a number of commonly-sought outcomes, as noted in the figure below.

Exploration of the goals of the conflict resolution process can elucidate the relative importance of achieving desired outcomes and maintaining interpersonal relationships. As reflected in the picture, with the exception of collaboration, all solutions are associated with some degree of loss of goal or loss of relationship. Although not always achievable, having a culture of collaboration most values both aspects.

How can this be assessed? A discussion of the styles for problem-solving applied to recent decisions can give some insight into the relative value of getting what (someone) wants and getting along.

Managing conflict

Mediators of conflict have a number of approaches that can be applied. The first strategy is to stop the problem from escalating, and the way to accomplish this is to accept the reality of the discord and to believe that inaction generally yields unacceptable outcomes. Optimally the mediator of a conflict will be knowledgeable of the issues and have credibility with the parties. Credibility and hence the authority to resolve the conflict do not automatically come with some title or authoritative position, but arise from recognition by both parties of the potential mediator's fairness and understanding. Having this position, the mediator can get the parties to elicit the root causes and underlying issues by relying on his/her credibility with each party, and then they are able to identify competing interests. The next step involves working with the parties in prioritization of their interests, determination of available trade-offs, and formulating a collaborative solution. The key ingredient to this process involves the mediator's insistence that the parties deal directly with one another.

Practices that can describe the approach to their most-challenging issues have gone a long way toward allowing conflict to be directed into innovation, creativity, and growth. Vignettes for potential use in discussions on collegiality and for ongoing maintenance of collegiality in a practice are presented in the following pages. ​

Vignettes

This section includes a series of events. The stories are true, the names have been changed to protect the innocent. As physicians, our natural response to each of these may be to jump to the solution, and that is ok. But, for each of these situations, try to address it from a systematic viewpoint with the following questions in mind:

1. What is the most appropriate immediate response?

2. What is the underlying cause of the problem?

3. How is the problem-at-hand best approached?

4. What resources best apply to solving this problem?

5. Is there a way to prevent more of the same in the future?

1. Summary: Your group is in the habit of dictating discharge summaries the day before discharge, to help catch any issues that might impede a smooth transition for the baby to the outside world. One morning, one of your partners signs out a child who needs a discharge summary. You:

2. Lasix: One of your partners signs out a BPD baby to you, saying that a two-day trial of Lasix is starting. You think Lasix in this child is a waste of time, maybe even harmful. You:

3. Tiny Tiny: At the end of morning sign-out your partner says, "By the way, I accepted a baby for you to admit. He should be here in 5 minutes." The child is 385 grams, 22 weeks, and 30 minutes old. He's coming from a rural hospital by ambulance, bypassing two other neonatal units that have refused the case. You know the case, because yesterday you told the rural OB that your hospital would also refuse the case. You:

4. Chronic Code: A very ill 24-week child is progressively worsening and seems destined to expire in an hour. One of your partners signs this child out to you, saying that she's done her best to make sure that no child dies on her shift. She doesn't know the parents' state of mind. You:

5. Pain: You are cornered in a small room of the NICU with six RNs confronting you. They have just returned from a conference on neonatal pain. They demand to know, right now, why your senior partner has refused to give a morphine drip to every baby under 32 weeks. You:

6. Negatives: One of your partners takes you aside and suggests that you "tone-down" the negatives. Several nurses have come to him about your intense and detailed counseling of parents for procedures, always mentioning "death" and "crippling CP" as possibilities, even for a circumcision. They claim you often leave parents crying at the bedside. You:

7. Supreme Court: The Supreme Court publishes an important decision on abortion. You work in a Catholic hospital. You are rounding with two of your partners, one an advisor to Right-to-Life, the other an advisor to Planned Parenthood. They offer their opinions on the Court decision, publicly, during rounds. They then turn to you. You:

8. Slowing Down: Your group splits day-call, night-call, and company income equally. Your senior partner, a spry 59-year-old, admits to some recent slowing down. She asks the group for a reduced schedule, some more relaxing administrative duties, and less night-call. Of course, she wants as little a decrease in pay as possible. You:

9. Risk Management: The Risk Manager of your hospital comes to you in confidence with reports of alcohol-on-the-breath of one of your partners, including during several resuscitations. You:

10. Weekend X: The quarterly call-schedule needs to be drawn up. Unfortunately, everyone wants Weekend X off, each with heart-wrenching justification. You:

11. Novel Approach: The day after learning a new ventilator technique at a national meeting, you apply it to a newborn. The next day at sign-out you discuss the novel approach enthusiastically. Later that day you stop in and find that the child's care has reverted to your associate's (and your former) usual approach to care. You:

12. Too early: You are asked by an OB to speak with a 35 year-old G4 P0 at 20-weeks gestation. Membranes are ruptured, the uterus is contracting and the cervix is dilating. Your group has no consensus over how to manage the pre-viable child, beyond agreeing that intensive care would not be appropriate. One colleague openly refuses to attend deliveries unless admission to intensive care is to follow. You tell the patient:

13. Solo: A member of your group refuses to come to the fortnightly group meetings, saying, "I'll leave that [colorful expletive] to you guys." Recently, her clinical decisions have been diverging from the rest of the group's. The group tasks you with drawing up an answer. Your recommended plan is to:

14. Dose:Your associate signs out to you a 500-gram one day old on gentamicin. Double the usual loading dose had been ordered and given, and now the child has a urine output that's slim to none. Further doses are on hold and a level is pending. "Do the parents know?" "No." You:

15. Wee hours: Your group takes call from home. One morning, the Charge tells you that one of your partners came in to admit a premie at one am, but had alcohol on the breath. The nurses felt there were no problems with balance, motor control, decision making, or communication. You reply:

16. Charm: Your charming associate traces a high pCO2 back to an RT's mistake. Then and there he adjusts the vent and endearingly mutters, "I guess I have to do everything around here." He hunts down the RT and unleashes a vitriolic tirade: "If the hospital hires incompetents like you, how in the hell can anyone expect our babies to survive?" As he publicly waxes even more poetic, the Nurse Manager seeks your aid. You:

Interpersonal conflict is better prevented than having to be resolved. Nevertheless, incidents do arrive that challenge every practice and practices must rise to the challenges. The authors welcome examples (names not necessary) for potential inclusion among these examples.

Shared Principles in Practice »​