All right, fantastic. So these are some of our high level objectives for the talk. So take a breath, conflict happens. Whether we like it or not, it does. Understanding the high conflict personality, and then how to be an effective mediator in this situation. And then we'll kind of bring it home with what we call the fundamental rule, the Kobayashi Maru. The more complex objectives kind of building into all of this is really to delineate the consequences of leaving communication barriers unresolved. Identify sort of the dynamics, and each of this is very unique, that affects interpersonal communication during a lot of high stress situations. And what we really want is to help and kind of employ a framework that is going to increase your ability to mediate, reflect on personal communication strengths and weaknesses, and kind of harness this into resolving issues associated with conflict. So quick introduction. My name is Nikhil Jagan. I'm an assistant professor of medicine. I'm also the associate program director for the Pulmonary Critical Care Fellowship at Creighton University in Omaha, Nebraska. I don't have any disclosures. All right. So as this kind of loads in, so question one, and I'll give everybody a minute or so to answer this. So word according to you is no-win communication. So if somebody's opinion isn't heard, somebody's opinion isn't really understood when that opinion isn't valued, or if somebody is scared, does not really share their opinion, or if there are too many opinions. All right, we got a lot of votes coming in, good, let's move forward, all right, fantastic. That's kind of what we really want to see is a little scatter plot of everybody's sort of thought and opinion, good. So majority of you, 39% feel when somebody's opinion isn't truly valued, all right. Another question, what in your opinion is the biggest impact of no-win communication? Is it low morale, low productivity, wasted time, loss of staff, increased cost, lack of teamwork, or poor clinical outcomes? Good, as you kind of realize, there's really no right or wrong answer to any of this. This is kind of just questions, we just wanted to get a sense of what people's thoughts are, and again, this is a session where we want it to be interactive, so as we move along, if you guys have questions, comments, experiences which you want to share, put your hands up, feel free to come up to the podium and talk. All right, so let's kind of dive into a case. We've got more questions, more sort of interactive stuff coming up as we go along. So as you kind of walk into work, you receive two back-to-back texts. One of those things, 7 a.m. in the morning, bang, bang, your phone goes off. One from the attending in the ICU, one from the on-service fellow. What you figure out is there's been an incident that resulted in a very loud disagreement in a very busy clinical area, and fortunately, a lot of support staff, other trainees present. And then both the texts end with they want to talk. Now, if you were responsible, or you were the one who got this text, and now are responsible mediating this conflict, how would you proceed? Because really, resolve itself, call both people to your office immediately, kind of allow the emotion to dissipate, and then find a mutually convenient time and location over the coming days. Set a date in two weeks, or just deal with it at the fellow's annual eval. You're the director, or the fellowship program director. So you're the individual tasked with mediating this. You were the one who received both texts. Yeah. Or you could be the division chief, or the medical officer. Yeah, yeah. You could be the chief medical officer. You're somebody who's responsible, yeah. You're coming in, whatever time you come in, and those texts came on your phone. He said, she said, they said. Everybody said something. Oh, I like this. Nobody wants to ignore it. It's impossible. Nobody wants to deal with it in two weeks. People might want to ignore it. Yeah. Yes. Some people want to call them both at the office immediately. All right. So this is kind of what happened. As you kind of dive in, we'll give you a little bit more about the case. And this is going to kind of evolve as the talk moves on. So obviously, the attending said, start a new medication. The fellow wants to leave the medications alone. So the thought between this is the attending thinks it's going to prolong stay. The fellow thinks it'll shorten stay. And the attending thinks it'll reduce likelihood of patient readmission. They both think they're acting in the patient's best interest. And they both think they know what they're doing. And they both are not backing down. All right. So whatever be the situation, I think the last three parts is kind of the key, wherein if you talk to both of them immediately, is they both think they're doing the right thing, whatever be the situation. So kind of as somebody who is tasked with mediating this, somebody who is going to mediate whatever be the conflict, is important to remember. Take a breath. Conflict happens. Whether we like it or not, anybody likes it or not, nobody really likes it, but it does happen. It is a normal, inescapable part of life. Periodically occurs in any sort of relationship. But it's also an opportunity to understand opposing preferences and values. And what I kind of learned going through this and in my little experience as my role is it truly is a form of energy. Now, the AMA, the American Medical Association, also defines it. It is not the situation, but the perspective on the situation that really causes anger to fester, leads to a shouting match. And it's really disruptive at the end of the day. Now, if you further dive in a conflict, there are two forms of conflict. Cognitive conflict and effective conflict. Now, cognitive conflict is disagreement about ideas and or approaches. It usually focuses on the issue. It's not very personal. And tension drives communication. And it is really a feature in a lot of high-performing groups. Effective conflict, on the other hand, unfortunately, is there's a lot of personal antagonism. It's fueled by differences in opinion. And it's really not helpful when you think about group dynamics or about group performance or it being cohesive. And we'll kind of dive into both of these as we move along with our case and talk. So we got another question. That's just kind of where you got to make a decision. So who do you think is right? The fellow attending, both, neither, or you guys need more information? Because I gave you some information about what flies through a text when emotions are kind of running high. We got a few more. Poor fellow. Even the fellows are not siding with the fellow? All right. Fantastic. All right. Can I take you through a little bit more? We got my esteemed colleague, Dr. Vachira. Thank you, Nikeil. Yeah, so my name is Kelly Vachira, also known as the greatest Vikings fan. I probably shouldn't take that ownership after a 1 and 4 start, which means my season is over. But I guess I'm a glutton for punishment. I'm glad to be here with you, but even more honored to be sharing the stage with my mentor and role model, Dr. Morrow. So just to recap, like what Nikeil said, conflict is ubiquitous. It's everywhere. Whether you and I like it or not, we're going to encounter it. So the million dollar question becomes, how do we navigate through it? And I happen to be a girl dad of two little girls, which they're awesome and loving. And I can tell you that not only do I deal with conflict at work, I deal with conflict at home. They exhibit what's called a high conflict personality, which is what I've been tasked to go over. So I will tell you what I tell my girls. I tell them, for us to navigate through conflict, there are two things that I think we can apply. One is there's a difference between a reaction and a response. A reaction is an impulsive action that doesn't pause to look at the ramification of the action. A response, on the other hand, pauses first, analyzes the ramification, the consequences of the action, and then it acts. And the other thing that I tell them is there's a difference between a thermometer and a thermostat. A thermometer purely just tells you what the temperature is. A thermostat, on the other hand, sets and regulates the temperature. And so for you and I, as we navigate through these conflict high personality or high conflict personality individuals, we have to kind of shift our lenses and choose to be responders and also choose to be thermostats, where we get to set the tone of the behavior that we want to be displayed. So back to our case. The program director, being the good conflict mediator that he is, meets with both individuals. He allows the temperatures to kind of simmer down a little bit and hears both sides of the story. He encourages introspection. He establishes some ground rules that are based on respect. And then he introduces this aspect that I think is profoundly important, which is considering somebody else's perspective. And I think as we navigate through conflict, it's profoundly important for all of us, before we make a decision about anything, even before we respond, that we consider looking at the issue through the lenses of the other person. Not only is that going to make you a better physician, but it's just going to make you a better human being. So both individuals like these solutions. They feel like they're fair. And they voice that they want to continue to work on their professional relationship. So the plan is to reconvene in a couple of weeks and make sure that things are copacetic. But it doesn't happen. So over the following weeks, unfortunately, the conflict just continues to smolder. The fellow continues to display insubordinate behavior. Basically, it looks like an episode of Scrubs, where he's opening his mouth and talking to everybody that's going to listen. He interjects the attending at all noon conferences and during roundings. He undermines the attending's decision. He doesn't follow through with tasks at hand. He makes unilateral decisions without really consulting the attending. The attending, on the other hand, doubles down on his wrong position and is dismissive of the fellow. He's excessively critical during evaluations. And also, he runs his mouth as well to anybody that is willing to listen. So next question, why do you feel like the solution is not working? All right, all right, move on, so great response, I think I would agree with you. So I would say it's because they both are exhibiting high conflict personality. Now this is not a diagnosis per se, it's essentially a set of dysfunctional behavior where these individuals basically lack conflict dealing skills. An example that I have for you is if a child is born in a war combat zone and is used to violence and chaos, that dysfunction becomes normal to that child. So anytime that they're forced, they're exposed to something different like peace, they will tend to gravitate towards the familiar chaos, then really embrace the different, the unfamiliar peace. And so these individuals live with that kind of framework where really they function best under conflict. So when there's peace, that is uncomfortable to them because they really don't know how to be at peace. So you can imagine when you don't have that introspection and self-awareness, really you can't take accountability, there's absolutely zero responsibility on their end. And anytime you try to correct them, you're essentially infringing upon their identity. And so really it becomes a personal attack and it just makes this problem even more complicated. Other common characteristics include blame speaking, which is basically a preoccupation of finding fault at others, not really at self because they're not really looking within, they're just looking outwards because it's always somebody else's problem. Then they have the all or nothing thinking where basically all people are either all good or they're all bad. And if you cross them, then you're in the all bad category. Then really don't know how to manage my emotions, reminds me of my girls again. They get overwhelmed by emotional states because they really don't know how to respond and this really leads to lashing out in form of extreme behaviors, these swings, emotional swings. So next question. What is your personal experience with high conflict personalities in your work environment? It's getting personal. Okay. So conflict is ubiquitous, clearly. I kind of want to beat the 13%. So as I get to hand off to the next section, really a good summary of these individuals is, like I said, they really lack awareness of their own problem, because it's really not a me problem, it's always a you problem. You know, there's been some research to say that it's a deeper-seated issue where sometimes it's based from how their upbringing and sometimes even a personality disorder, something like narcissism or histrionics. And again, they don't change because they really don't see anything wrong with themselves. It's always somebody else's problem. So as I hand off the note, there's one more poll question. All right, and at that point, I will hand it off to Dr. Marais. Hi, everybody. I am Dr. Gallo. I'm Alice Gallo. I'm one of the Associate Program Directors for the Internal Medicine Residency Program at Mayo Clinic, and I identify as an intensivist. So those of you who identify as intensivists know that there are a lot of conflicts that happen on an hourly basis, I would say, in an ICU. And what the four of us wanted to come together and try to do is to give you a framework that you could take home and practice when things are going well. Why? Because that's one of the ways that we can become less reactive and become more proactive, is one of the ways we can transition from being just a thermometer to becoming an effective thermostat. And I just want to make sure, also, I don't have anything financial to disclose, but I do want to say that I am a strong believer that words really matter. And during conflict, during high-stakes situations, if there's one thing that I can give you to take home with is choose your words and use them. Things that are left unsaid just increase conflict. So very important in high-stakes situations to use words, whole words. So don't forget that conflict resolution is a negotiation. For those of you who work with learners, and for those of you who are part of program leadership, it's also important to remember that giving feedback that includes opportunities for change can be part of conflict resolution. So this can help you also when you need to give feedback to your struggling learners. And also very important that I want to make sure that we talk about is, I'm not perfect, and I've been part of a conflict before. I probably being this fellow at some point in my training years, and I probably being this consultant, I usually don't talk about people behind their backs. I talk to them personally, but just going home and thinking, no, I was right. They were wrong. We've all been there. So again, before going into one of these conversations, before being the mediator, just remember that we've all been there, and that's okay. It's about the behavior. It's not about the human doing the behavior. So negotiations are interactions, and all the parties want something from each other. And at the beginning of conflict resolution, usually no one wants to give up. No one wants to extend the olive branch. It's human nature. Effective negotiation has two parts, which again is information gathering and behavior influencing or becoming the thermostat. The most important thing is remembering also that every story has three sides, mine, yours, and what happened. So as the mediator, it's very important to try to see what were the common grounds so we can get closest to what actually happened to try to mediate. And negotiations are nothing more than communication with results. And as the mediator, we should always try to avoid to be defensive. We should always approach these conversations with curiosity. Embrace the 10-second pause. Embrace using curious questions to understand what was going on at the moment of that conflict. And to resolve a conflict, to be a good mediator, it's crucial that you can engage in those negotiations without inflicting damage on others. So don't add anything. Be curious. Just be there as the sounding board. Most of the times it's best to meet people separately. And another very important thing also, and again, we've all go through conflicts, very important thing to have colleagues that are trusted or friends that are trusted that you know will give you their right opinion. I have two people, one we share a hallway between our offices and he's an amazing intensivist and sometimes I go to him and I'm like, hey, this happened, what do you think? And he always has candy so I've adopted this thing. I always have cookies because when he brings me candy, it makes me happy. So again, develop little things that you can do to also be a good mediator. Lower the volume, lower the temperature and make sure that people are open to talk to you. So make the approach meaningful. Again, leave people with actionable items. Share perspectives. Like I just said, I've been there before, pretty sure I've been that fellow, I'm pretty sure I've been that consultant minus the talking behind people's back. Build understanding. Again, be the person who finds what the true story was, what really happened. Agree on solutions and plan next steps. Give people a plan. Please stop talking behind your attending's back. How are we going to do that? Just saying do it, probably not going to be super effective. How are we going to do it? I have another question for you. Oh, that's awesome. You've received formal training conflict resolution, I love that. Clear chain of command, oh, that's good. Having the security and safety of having a clear chain of command is such a blessing. Say that again. Oh, tell us more about that. Fair, okay, fair. Thank you for the comment. So very important to set the table or the stage, whatever you're used to. So set your table, set your stage. When you are mediating conflict or when you are having these conversations, have an agenda. But an agenda that is reflective on your willingness to solve that conflict, not like what you want to go over, not what you have in your mind that people have to say, not what you're wanting to hear. No, what do you want to go over? What do we want to do? We want to come to a conclusion, we want to come to a closure, we want to have next steps and we want to plan when we're going to get together again. We're going to plan how we move from this. Like I mentioned, it's very important to have a framework, in my opinion, and the Academy of Communication, and again, if you just Google Academy of Communication pearls, they have this algorithm in the way that you can print it and have it, or you can screenshot, have it in your phone again, and very easy to, again, practice and go back to. One way that I think is helpful. For example, you all saw the example we gave today. Whenever you go home, you're like, okay, how would I approach this conflict with the PEARLS framework? Partnership. Again, I know we both want what's best. Our mission is taking good care of this patient. Make it mission driven. Our mission, our common goal is to take good care of this patient. How do we do that? Partnering, finding the common ground, finding your partnership, again, already lowers the tone, lowers the volume in a way that is like, oh, we are in this together, same team, okay. How do we move on? Empathy. Again, I'm pretty sure this was a stressful situation. Pretty sure both the attending and this fellow wanted what was best for the patient. They told us that. Again, very stressful situation. I know this is not ideal. Acknowledge, use your words. This was not ideal. This was stressful. This was concerning. Use your words. Acknowledgement and apology. I'm a big fan of apologizing when apologies are needed. I think that apologizing for the sake of apologizing makes it a little bit less meaningful. So I prefer acknowledgement if there's nothing to apologize for, meaning like, I acknowledge that this cannot be easy, that this should be easier or it's unfortunate that this cannot be easier. Because again, it's about the behavior, it's about what was happening, it's not about the individuals you're talking to. People are good. People want the best for their patients. Physicians want the best for their patients. Clinicians want the best for their patients. This is about a behavior that was not good. This is not about the good in people's hearts. Respect, again, regardless of the level of that relationship, regardless of who's in charge, who's not in charge, or are they both fellows, is one attending, one fellow, or chief and faculty, respect. Gotta have respect. Gotta acknowledge your respect for those people's roles and skills and all of that. Make it legit, legitimize the disappointment, the anger. Use words again. Call the behavior, call the feelings. It will make it easier for everybody and it will make it easier for you to resolve that conflict as well. Be supportive. Conflict is never easy. It's never easy for those involved. If people say, like, I am not conflict averse, I struggle with believing in that. No one likes drama. Some people draw drama, but no one likes it. Be mindful of that and be supportive. Again, just want to make sure that you have one example of a framework. There are others there. There are, like, ask, tell, ask, and things like that, but I personally like this one a lot because, again, acknowledges emotions, acknowledges how hard this is, and sets a tone for a partnership because that's, honestly, one of the safest ways of showing people that you are on their side and you want the best resolution, whatever that can be. Might not be ideal. Please be very mindful and aware that I did not use ideal. I said the most meaningful and the most helpful resolution, so thank you, and I'm going to pass it to Lee. Thanks, everybody, for coming, seriously. You know, CHESS has always been a wonderful conference, right, and there's a tremendous amount of scientific knowledge that gets exchanged, but we don't focus on some of these soft skills, so I'm incredibly grateful that the American College of CHESS Physicians prioritized this session. I'm even more relieved that somebody showed up to listen to what we have to say. So my name is Lee Morrow. I'm a professor at Creighton University in Omaha, but I'm really housed over at the VA, and I have been for seven or eight years now the director of the National Mobile Simulation Program, and so I always look at things through a very different lens of how can we simulate things so that we perhaps do better when events happen. And I found it really fascinating in your responses that although everybody says you have a fair degree of conflict inherent to your jobs, only 21 percent of people have any formal training in it. That is a really, really sorry disconnect. I think that, you know, if you think about the population of patients that we take, they are incredibly fragile and vulnerable due to critical illness, right? And we have a responsibility to make sure that we work as a team and don't drop the ball because they don't have any reserve for our failures. So part of us not dropping the ball requires really, really clear communication so that we have that effective teamwork. Unfortunately, I think many of us in our day-to-day job, we walk through the ICU and most of our time we function pretty autonomously, right? We make rounds together and we all sort of talk a little bit, but the majority of our day are each of us going about our jobs. But it's that rounding and that superficial communication that happens that ultimately leads to this working independently yet achieving a collective success mentality that then sort of makes us think that we are really awesome communicators. Because let's be honest, the majority of the time, things don't go sideways on us and that effective communication really isn't at the forefront. It's during those times where things fall apart. The ICU crisis where the tension in the room goes up, the anxiety goes up, and what happens to our communication skills? When they need to be their best, they go to their absolute worst. And when that happens, all we do is increase the likelihood that we make crappy decisions, that something gets missed, and ultimately the patient gets harmed. And also when we have that lousy communication in the middle of the crisis, that's when we generate conflict, and often that conflict lives way beyond the initial event. So I have a very, very important question for you on the poll. Get ready here. Are you a fan of Star Trek? All right, let's see what we got here. Oh, look at this. Yeah, I kind of fall in the I prefer Star Wars category, too. But the reason I'm asking you about Star Trek is because of the Kobayashi Maru. So you Star Trek people, anybody know the Kobayashi Maru? Show of hands, please. Yeah, here they go. Yeah, we got some real Star Trek nerds, awesome. So for those who are like me and not a Star Trek person, there was an episode in the TV show Star Trek that featured this episode, the Kobayashi Maru. And Kobayashi Maru translates literally from Japanese to little wooden boat. And I think that that is like an awesome metaphor for a critically ill patient trying to navigate everything that's happening to them, right? Well, in the TV show Star Trek, the Kobayashi Maru was a training simulation that Captain Kirk had to go through. And essentially, Captain Kirk is navigating the USS Enterprise and they have a stranded ship of women, children, civilians, right? The Kobayashi Maru. And they have to make a decision. Do I go and rescue the Kobayashi Maru knowing that my ship is going to get destroyed and I'm going to sacrifice all of my soldiers? Or do we just let the Kobayashi Maru be enslaved by the Klingons, right? So the simulation, no matter what they do, they are going to ultimately lose. So we, in the simulation lab, took the Kobayashi Maru to create a medical simulation based on that same premise, that in the ICU, we often feel that we have these unwinnable clinical situations. And anybody who sat in on a root cause analysis knows that there's always a component of communication interwoven through those disasters, right? So the Kobayashi Maru is the unwinnable medical simulation. So how does this play out? Well, we bring the learners into the simulation lab and we tell them there's been a horrible tornado that came through Omaha, and because of that, people can't get to the hospital. We've got sort of a staffing crisis. So you all are being brought to the PACU to babysit these four stable PACU patients, right? The first patient had a CT-guided lung nodule biopsy. Everything went fine, just waiting for the veteran's wife to show up and take him home. The second patient had a thyroid needle biopsy. Again, everything went swimmingly, just waiting for a bed upstairs because they're going to do an overnight observation on that patient. The third patient is over there on the right. You can see, we call him Stumpy. He's had a below-knee amputation there. Again, everything went perfect in the operating room. We're just waiting for a bed upstairs. And then patient number four, status post-bilateral carpal tunnel release, smooth sailing in the OR, wife's on her way here trying to navigate all the downed tree branches and such. So we just have to babysit these four stable patients. Everybody with me? All you get to manage these four patients is one crash cart. Whatever you might need is on a crash cart, right? So that's the simulation. What do you think is about to happen? Badness, right? Lots of badness. And that's exactly what happens. Patient number one is developing a tension pneumothorax, right? Patient number two is developing this enlarging neck hematoma, and the airway is about to be threatened. Patient number three, Stumpy, he's got a bleeding with hemorrhagic shocks. So in that amputated leg, there's a reservoir that you fill with fake blood, and we can flip on a motor and start literally pumping blood out. Hence, the blue tarp underneath only one of the mannequins there. And then our carpal tunnel release is slowly developing a STEMI. Remember how I told you that they could only use what's on the crash cart? Well, half the stuff is missing, and the half of the stuff that's there is all broken. So, you know, the laryngoscope, there's no batteries in it, the Ambu bag has a big hole in it. So it's really intentionally the Kobayashi Maru. Everything goes wrong that possibly could go wrong. So this is an example of a bunch of people who are partaking in the Kobayashi Maru, and you can see the stress on these folks' faces as everybody slowly gets worse and if you don't figure out what's happening and deal with it pretty quickly, multiple patients code. Anybody tried to run multiple codes with only one crash cart? Yeah, how did that go for you? Exactly my point, right? And then you look at that top right picture, Eric there just looks completely defeated, right? I mean, he just looks like this is a no-win situation, which is what we're going for here. But ultimately, they go into this simulation thinking like most medical simulations, this is about testing my knowledge, right? And this simulation really has nothing to do with knowledge. This simulation is all about communication. So after they have this disastrous, incredibly intense and stressful simulation, really why this simulation works is what happens afterwards. So we literally schedule 90 minutes of debriefing time. I mean, usually with a simulation, you know, 10 minutes of debriefing, 15 minutes if you've really got something good going on. No, the only way this one works is to have a very long structured debrief delivered by people who do a lot of simulation and can tease out very sensitively a lot of these concepts that the others before me have already talked about. In addition to the group debriefing, we also have one on one individual debriefings. And really the goal here is to get everybody into that mindset that this is a safe space. We were working as a team. We've succeeded in some ways as a team, but we failed in a lot of ways as the team and how did communication play into those wins and those losses. We also have every single person who participates in the Kobayashi Maru do an anonymous evaluation of all of their peers using the good old plus delta model. The plus is what did you do well. The delta is what should you have done differently. So you get anonymous feedback from all of the other people that were in that simulation with you regarding what perhaps you need to think about improving on. And then depending upon how you roll this out and use it, it really drives what happens on the back end. We've used it to create increasingly complex personal improvement plans. And we've tied that back with some of the data on learners where we can sort of look at the domains on their evaluations for communication skills. And believe it or not, the people who have the most robust personal development plans and actually make progress on those things with their mentors have measurable changes on outcomes. Very scant data that we've got, but it's fascinating because ultimately that's really what we're trying to do here is help people become better communicators. Now what nobody on the panel has told you is that this case that we've been using today is a very real case. When I was the program director, I literally walked into that giant mess one morning and it was very real. And as you heard, it was also very raw and neither of the people worked the process very well. They said they were committed to resolving the conflict, but at the end of the day, they both thrived and fed off of the conflict for various reasons as Kelly talked about. And ultimately what I learned personally from that case is the importance of forgiveness and getting them to understand that forgiveness does not mean that you forget about the conflict. You do not try and erase the emotions related to the conflict. Rather, forgiveness is about accepting that the conflict happened, accepting how it made you feel, accepting the consequences that ultimately came because of it. But then being able to cognitively let that conflict live in the past. And I think that that's our role as the intensivists in the ICU, working with people with different backgrounds, by default becoming the mediators of these conflicts. It's up to us to try and help the participants as we resolve the conflict, get that sense of closure and understand the importance of forgiveness. Now if anybody is interested in the Kobayashi Maru, you want to do it at your hospital, just shoot me an email, lmr.crayton.edu. Kobayashi Maru was created by the VA with federal taxpayer dollars, which means it's open source and I'd be happy to share it with anybody who's interested in having it. Questions for the panel?

conflict resolution

effective communication

high-stress situations

healthcare field

Kobayashi Maru

understanding conflicts

mediator

high-conflict personalities