Conflict Resolution in Medical Interviews: Why Most Candidates Answer This Wrong and Don't Realise It

Hi everyone and welcome back to the Alexander Medical Interviews podcast. My name is Alexander. I'm a Wopper Train Communication coach and I coach people for their medical interviews. Today's episode is primarily based and targeted at junior doctors, preparing for specialty training selection interviews, but if you are a medical school applicant or an international medical graduate, there is a lot here that applies directly to you. Today we're covering conflict resolution. I want to start by saying something that might reframe this entire episode for you. Conflict resolution is not a soft skill, it is not a personality trait and it is not something that you either have or you don't. It is a learnable, practical and demonstrable clinical competency. If you don't have good conflict resolution, you can compromise patient safety, which is always the first thing some of these people say in their medical interviews and Australian interview panels treat it in the same way. The reason I'm dedicating a full episode to this conflict resolution question is because it's most commonly asked in specialty training interviews and it's the most commonly answered badly. Not because candidates don't have good examples but because they don't recognise the question and they don't understand exactly what panels are assessing and they don't have a clear understanding or a structure. I hate structures but we might need to talk about a structure in a minute or they don't even know the good elements of conflict resolution and be able to apply them under pressure. By the end of this episode you're going to have some terminology buzz words, some definitions, some data that backs up but we're saying a scaffold structure that you can implement if you cannot think of anything in the moment and the ability to recognise conflict resolution questions. Even when they're hiding inside clinical scenario situations and if you're lucky I might even give an example of what a good answer would sound like so let's get into it. Now before we get into the how let's be clear on the why because if you understand why panels care about this so much then you'll understand the questions better. Conflict in healthcare is ubiquitous. Unfortunately right humans interacting with humans it's going to have conflict let's just accept that okay we need to know how to manage it. Studies consistently show that healthcare professionals experience conflict regularly but not just with colleagues but with seniors and patients and their families and with other disciplines within the hospital. A 2019 systematic review published in the Journal of Interprofessional Care found that workplace conflict in healthcare settings is associated with increased medical errors which lead to compromising patient safety to staff burnout and reduced patient satisfaction and higher staff turnover. The Joint Commission in the United States which is one of the most cited bodies on healthcare safety has identified communication failure as the root cause in over 70% of sentinel events. Unresolved poorly managed conflict is a primary driver of communication breakdown. Let's come back home to Australia in Australia the Australian Commission of Safety and Quality in Healthcare explicitly names communication and teamwork as critical safety domains and the National Safety and Quality Health Service standards include expectations around open communication, escalation and management of clinical deterioration all of which require conflict navigation when team members disagree. When a panel asks you about conflict they're not testing whether you're a nice person they're assessing whether you are a safe clinician. They're assessing whether you're a safe clinician who can maintain patient-centered care and function in a team under interpersonal pressure. That is a significantly higher bar and it's the bar that you need to be preparing for. Now really quickly before we talk about conflict resolution we want to talk about preventative measures. What can we do prophylactically or talk about prophylactically to prevent conflict? We can maintain psychological safety within a team and what does psychological safety mean in a team? That means creating an environment and climate where people feel safe to speak up. That's something that you can say at the beginning of any kind of interdisciplinary or hierarchical issue where you are the leader and you are trying to prevent conflict. So what are panels really listening for when it comes to assessing conflict questions? Let's be really specific. In my opinion there are five things. One, patient safety. The panel wants to know that the patient's safety is your first and non-negotiable priority. Not the hierarchy, not avoiding awkwardness, not being right patient safety first. If you allow a conflict to continue in a way that compromises patient care that's going to be a red flag regardless of how professionally you handle the interpersonal dynamic. Two, a proportional response. Many people go patient safety and escalation that is not managing the conflict that is disproportionate escalation. Did you match the level of your response to the severity of the situation? Did you escalate immediately to the medical director over some little disagreement that could have been managed through communicating with the other people involved? Panels are looking for judgment. The ability to calibrate your response appropriately. Number three, communication skills. How did you actually engage with the other person? And remember specificity comes in, importantly here. Saying I communicated with them and resolved the conflict. That's not enough detail. We need more detail. Did you listen? Did you understand their perspective before you defended your own? Did you use language that opened up the conversation to be more clear and empathetic rather than closing it off? Self awareness and reflection. You can recognize your own contribution to conflict. Not every conflict is entirely somebody else's fault. Think about things like before I went and spoke to this person, I considered the best tone and words to use because I know that sometimes when I'm tired or night shift, I can come across a little bit grumpy and frustrated. So I wanted to make sure I minimized the risk for escalation and an emotionally charged conversation in order to reach a solution. Right? You're aware of how you come across. The panel is listening for some insight into your own behaviour and patterns. Not just a polished account of how you were perfectly able to handle somebody else's unprofessional conduct. Five, systems thinking. Did you recognize and address any systemic factors that contributed to the conflict? A conflict between a junior doctor and a nurse about medication or it might actually be a conflict about an unclear handover or documentation process and a strong answer will recognize and mention that. So these are the five things that I've mapped out directly to the CANMED's roles of professional communicator, collaborator and leader. Conflict resolution questions will generally try and test things that cover all five of these. Evidence-based. Now let's talk about something that the research actually says because conflict resolution isn't just some esoteric concept. Having the data may not be something that you want to quote in your answer, but it might be something that just gives you an extra layer that if you are lost and not sure how to answer, you can go, "Oh, I remember that this is an important thing to talk about." And it helps demonstrate that you've been thinking about this more than just the three milliseconds since they ask you the question. So the Thomas Kilman conflict mode instrument, which is one of the most widely used conflict resolution frameworks in organizational psychology identifies five approaches to conflict, competing, collaborating, compromising, avoiding and accommodating. The research consistently shows that collaborating, so seeking a solution that fully addresses the concerns of both parties, produces the best outcomes in interpersonal and team conflicts, whereas competing, asserting your position at the expense of the other, produces the worst long-term outcomes, even when it resolves the immediate issue. Think of this long-term professional collegiate approach. The reason this matters for medicine is that this hierarchical structure of the clinical teams can push junior doctors towards either avoiding conflict entirely or deferring it completely, both of which are accommodating responses that fail the patient when the senior is wrong. Now the Harvard Negotiation Project, which produced the famous "Getting to Yes" framework by Roger Fisher and William Uri, gives us the concept of principled negotiation. The key insight is to separate the people from the problem. The conflict is between two different approaches to a clinical problem and framing it in that way changes the entire dynamic. Again, how do we use this in our interview? So we know from the concept of principled negotiation that framing it as a conflict between ourselves and the problem rather than two professionals helps you integrate this thought process into your answers for your interview. research on psychological safety, this term coming up again by Amy Edmondsson at the Harvard Business School is directly relevant here. Edmonds work showed that teams with high psychological safety, remember where team members feel safe to speak up, to disagree and to raise concerns without fear of punishment, make fewer errors, not more. The common assumption that hierarchy and deference produces safety is wrong. Speaking up, done well is safer. Knowing this gives you confidence and evidence to reference when you talk about raising concerns with seniors. A massive study found that one analysis of malpractice claims in the US healthcare system found that communication failures contributed to 30% of these malpractice claims and of those communication failures a significant proportion involved conflict between team members, between clinicians and patients and between disciplines. This is the clinical cost of conflict handled badly. Name these things if you want, get them succinct and clear but you don't need to quote it. I just want you to understand the importance of this and allow you to integrate your knowledge so it seems like you've been thinking about these kind of things for longer than five seconds. Now the meat and potatoes, the elements of good conflict resolution some buzzwords for you to use. And scaffold your answers around it. Know that naturally you don't have to use them all as a checklist but help them as bridging words or vocabulary to use when you are practicing your answers. Psychological safety. A climate in which people feel safe to speak up. In answers you may want to frame your approach as one that tries to create psychological safety before conflict arises or making it safe for the other person to hear your concern without feeling attacked. Next one, separating the person from the problem like we said conflict is about the clinical decision, the process, the outcome, not about the character of the person you're disagreeing with. This reframe diffuses defensiveness and helps with solution for conflict resolution. Perspective taking. This is an empathetic process, the active effort to understand the other positions before even approaching the conflict, before even communicating with them and before defending your own position. Knowing what do they know that I don't know? What constraints are they working under? What does this situation look like from where they're standing? This is not the same as agreeing with them but it's understanding them and helping understand the behaviour that underpins everything. Principle disagreements. I have a concern about this decision because rather than I think you're wrong because specifically evidence-based respectful disagreement is not in subordination, it is professional obligation. Clarifying intent. Before we go all nightmarish and assume the worst about what the other person intended, you might say something like, "I want to make sure I understand your reasoning here." This is the same as gathering information but it's a little bit more specific. Remember, specificity wins here. This opens up the conversation rather than triggering defensiveness. Appropriate escalation. Remember appropriate escalation, not just escalation. Knowing when the conflict requires higher authority and when it doesn't. Remember escalating is not failure. Escalating when patient safety is at risk is a professional obligation. Maybe you might want to say, "I escalated this not because I couldn't manage the interpersonal dynamic but because patient safety required a clear plan." Close-loop communication. Confirming that your concern has been heard and addressed. Not just raising it and walking away. Following up, checking in that the plan has been implemented. This both feels safe and demonstrates personal accountability or you might want to talk about actively. I listened actively by listening and then relaying what they said back to me in my own words so that they felt validated and knew that I understood and was taking the energy to see their perspective and understand. Document. Don't forget to document, especially for international doctors. If you raise the concern and you've been overruled and you believe the patient's safety is at risk, document your concern. This protects the patient and it protects you but don't forget to mention it. Some in the often gets forgotten is debrief and repair. After the conflict is resolved, acknowledging the tension and seeking to restore the relationship. Hey, I just wanted to check in after yesterday how you feeling. Did you have any more thoughts about that? I know it was a tense moment but I want to make sure we're okay. This is relational intelligence and it separates an excellent colleague from a merely competent one. And what I said before, systemic attribution, recognizing that individual conflicts are often symptoms of systemic problems. In adequate handover, unclear roles, excessive workload, maybe naming that systemic factor alongside the interpersonal response shows leadership thinking. Okay, a structure for you who need structures and want to know and have a parachute that you can pull that cord in case you're not really thinking on the day. It's called class C-L-A-R-R. I've added something at the beginning. I'll talk about it. Here we go. C stands for clarify and stay calm. So before you do anything else, I want you to understand your own state and clarify information. Okay, so this might look like I noticed I was feeling frustrated so I took a moment of mindfulness before responding or I wanted to gather all the information regarding the patient before I have this conversation with such and such staff member to make sure that what I had was accurate, this signs that you have good self-regulation, you have a professional role inside and it's really honest. Then L, listen to understand, listen with active listening, seek the other person's perspective before defending your own. I asked them to help me understand their reasoning because I wanted to understand it fundamentally before I approached the conflict, gave my opinion. This changes the entire dynamic of the conversation and often reveals information that you didn't have. Acknowledge. Finding something in that position that's legitimate, understandable or at least worth acknowledging. I understand that you are managing multiple priorities at that time. I can see from your perspective why what you were thinking seemed straightforward. Acknowledgement is not necessarily agreement, it's respect, it's validation and it creates a psychological safety needed for them to hear your concern. Then the first are raise your concern clearly and specifically using principle disagreement. My concern is the specific thing for this specific region which I believe has this specific implication for patient safety. Don't be vague, don't be personal, be specific, clinically focused on the problem. Then resolve or escalate. Either work towards a collaborative solution, a compromise or a new approach that addresses both concerns or if resolution isn't possible and patient safety is at risk, escalate appropriately through the right channels, document and follow-up. So C-L-A-R-R, clarify and stay calm, listen to understand, acknowledge, raise clearly, resolve or escalate. Don't need to say all these words in an interview but you just need an answer that will demonstrate all of these steps. Use this structure or scaffold in your preparation. So buried conflict resolution questions. They're often not labeled as conflict questions, but they come dressed as clinical scenarios or ethical dilemmas or professional situations and can that it's usually answered the clinical content really well and completely miss the conflict element that the panel is actually assessing. So a good one is there's some sort of issue with the patient that's urgent and they're deteriorating and all these things are going on and a consultant from another team has told you that they need the theatre urgently. So how do you handle that conversation? People get stuck talking about, "Oh, what are all the things I need to do with the patient?" No, it's asked you, "How do you deal with that conversation?" You're reviewing a post-op patient who has signs of sepsis from the nurse. You've spoken to the reg about them earlier and the reg said, "They're fine, don't call me again. I don't worry about that about this." What do you do in this situation? You can talk about obviously the clinical stuff of, "I take history and examination." But the main thing is you need to address the conflict with the reg because you need to escalate it. The conflict is between your clinical assessment and the registrar or the seniors instruction. The panel wants to know that you can respectfully but firmly override that instruction when the patient's safety is calling for it. Can you escalate appropriately and can you communicate the disagreement? Reflex here are going to be escalating immediately without reassessing the patient or attempting to communicate with the registrar first before you do your clinical assessment. Another one is you notice a fellow doctor is consistently making medical errors. What do you do? This is buried as a professionalism question. It's like a difficult conversation, a conflict question. The conflict is between your obligation to patient safety and your collegial relationship with your peer. The panel wants to know, "Can you have a direct, respectful and private conversation with a colleague about your concern? Can you escalate appropriately? Can you support the colleagues well being while maintaining patient safety as the primary priority?" Reflex are going to include going straight to the consultant without speaking to the colleague first. Another one is ignoring it because it's not your place. A strong answer is going to be talking about having a private conversation always. from the clinical setting, specific and non-judgmental explores whether there's an underlying cause, any personal issues, burnout, any knowledge gaps, and escalates with appropriate support framing. Another one is going to be something around a patient refusing treatment like a blood transfusion or a surgery that you think is clinically necessary. How do you handle this? So this is buried as an ethics question and a consent question, but it's also a conflict resolution question. The panel wants to know, can you hold tension between your clinical judgment and the patient's right to self-determination? Can you communicate it without coercing? And can you explore the patient's reasoning without dismissing it? Red flags is trying to talk them into it or involving the family to override it. Another red flag is just simply documenting refusal and piecing out without any genuine engagement. Along answers practice perspective taking empathy, clarifying understanding, exploring the barriers to consent involving appropriate support, a chaplain, cultural liaison, an interpreter, getting a second opinion while ultimately respecting the patient's right to refuse. Okay, more red flags for this whole topic. Don't make yourself the hero who solved everything while everybody else is a pain. The panels read this as lack of self awareness and you're likely to be genuinely difficult to work with. Escalating immediately, again, without attempting direct communication first, I've said this before, but I'm only repeating this because so many people come to me and do this in practice questions. You need to actually have the conflict to resolve the conflict. Again, avoiding the conflict altogether, using vague language, like I said before, oh, so I spoke to them in a private room and I communicated effectively and I resolved the situation while remaining calm and professional. No, no, no, no, no, these are tells, not shows. Okay, remember, I need you to be specific panels want to know what you actually did. Specific behavior is what gets you the points. Okay, let's put it all together. I'm going to give you a model answer. So the situation is going to be a nurse asks you to review a patient when you are on a busy night shift and because you were delayed in getting there, she has approached you in the ward and is really frustrated and accusing you of not caring. How do you deal with this situation? First I would prioritize patient safety and do an assessment of the patient and assess if something clinically urgent needed to happen. That notwithstanding I want to address the conflict. So as I engage with this situation, I would probably sense myself having stressful physiology I don't like when people speak an unprofessional way to me or when they may be shout or be rude to me. So I would just take a moment of mindfulness, perhaps step away if I needed to and then re-engage with this situation at a little bit of a later date, not too long. Try and get as much information from the perspective of that nurse as much as possible. So I know nurses have a really busy time. The ratios might be quite out of balance and being a night shift potentially this could fatigue lead to issues of feeling excessively stressed or potentially burnt out. I would then talk to the nurse and ask her open any questions like, "I'm really sorry that I can see that you're a little bit frustrated, which completely makes sense. You probably have been stuck here waiting for me for so long. Can you tell me a little bit more about what it is that you're feeling?" I would explore that as long as she needed. I would definitely use my active listening and re-word what she said to me to help her feel understood that I'm listening and validating her by saying that would really suck. I can understand from that point of view. In this specific situation that I'm using, it turned out that the nurse was actually looking after a family friend who was deteriorating but not in a way that needed an urgent medical review and she felt an additional responsibility because of the relationship with the patient and this led to her reacting in a way that was unprofessional. Let her know that that patient is lucky to have her as a nurse being such a strong advocate for her and I really appreciate her letting me know how she felt about the situation. I then asked if she wanted to hear my point of view and she said she was and I explained to her the list of things I had to do and the triage system that we used and she was then understanding. Later I had a cup of tea with her and I learnt that she had some financial issues and she was only working night shifts in order to help get her son through university. Through that we built a strong working relationship and was able to remain friends until this day and I ended up tutoring her son for university for organic chemistry which was really glad that I could have that ongoing relationship with her. Throughout this process I learnt that it's really difficult to manage your emotions when you are stressed and when someone is acting unprofessional so it's important to take a step away if you need to. It's important to consider everybody's emotions and practice active listening, prioritise building a strong psychological safety net so people are comfortable to come to you with these things and that concludes my response. So I wanted to do a hybrid thing there where it's like responding to a situation and kind of a star question because I wanted to show you how I'm able to integrate those things. So in conclusion, conflict resolution is one of the highest yield preparation topics for specialty training interviews. It comes up directly, it comes up indirectly buried inside clinical scenarios and it comes up in questions about leadership, teamwork and professional behaviour. Know the scaffold, clar, know the buzzwords, psychological safety is important separating the person from the problem, practising perspective, taking active listening, principled disagreement, appropriate escalation, documentation, debrief and follow up and repair and identifying the systemic problems that are attributing to it. And practice your answers out loud, please do not do it in your head, out loud, record yourself and watch yourself back. The difference between knowing this content and performing it under pressure is practice. See you next week.