Table 3.

Internal medicine and emergency medicine perspectives on contextual issues that drive interdepartmental conflict.^*

Topic/perspectives	Representative IM quotes	Representative EM quotes
Discussion request as priming for conflict Shared: The discussion request can cause defensiveness, especially for emergency physicians when notifications lack further details.	That’s the way the system is set up…. The discussions are only around conflict and never were they, “You did a great job. I’m so impressed with your workup”….It’s only around “Why can’t this patient go home? Are you sure you’ve thought things through?”... Sometimes I just have a small question, but then I’m like, “They’re gonna think that [I have] a criticism, when...I just actually have a question.” IM attending #2, FG B It takes a lot of energy on our part to raise that flag because often we know it’s going to be a conflict. You have to feel very strongly...once we already feel strongly, there’s already extra emotion in there. IM resident #7, FG A	That [discussion request] relays as contention...I know me, personally seeing the red MD [icon]...I have a little bit of a block and I go on the defensive.... EM resident #1, FG G The worst is when they say, “Just please call.”...They don’t give you any information about what their question is...I have no idea what to expect. I’m just going into this conversation blind...Yeah, you’re defensive, right off the bat. EM resident #4, FG D
Knowledge of the other person and their workflow Shared: Opportunities to get to know one another personally and their workflows can be helpful.	[W]e get that the emergency room’s super busy because we...rotate [there]....We know that it’s like a constant flow of patients and that you have five minutes to see a patient, but on the flip side, if they rotated with us [on IM services], they might see how much pressure there is to discharge patients and the complexities of managing [10–20] sick inpatients at once... IM residents #2, FG C	In terms of the actual decreasing animosity during these conversations....it’s, honestly, just knowing these people outside of work. I think that putting a face to a name, having been out to dinner or had a drink with somebody, I think it’s a lot easier to call them. EM attending # 1, FG H
Clinical workload/volume Shared: Patient volume makes requests/interactions harder.	….the issues that we have with the ED stem from that global issue of a large number of people trying to be squeezed through a tiny little entry point into a thing that has a limited number of beds...Our issues [with emergency physicians] can’t be fixed unless this is fixed… IM resident #7, FG A We all think about the pressures on us, but everyone’s pressures...and the volume [keep] going up...everyone’s already frayed. Now these innocuous things like, “Hey, can I have more information about the patient?”...are all viewed in the context of, “They’re just making me do more and I don’t have any bandwidth for it.” IM attending #1, FG B	[Y]ou’ll get to a point where there’s 25 in the waiting room, 10 in rooms waiting to be seen. At that point you just gotta hustle and get everything done as fast as you can….those are times where we feel the most pressured and those [discussion requests] and stuff start to paper cut you a little bit more. EM resident #3, FG G
Release valves Shared: My department does not have a release valve, while my counterparts do.	It’s not that I’m trying to hold [emergency physicians] to an impossible standard, and not that I’m trying to get out of work. It’s that we’re seeing the other side where there is no release valve. Their release valve is us, and our release valve is nothing. IM resident #7, FG A	...If an ambulance is coming [to the ED], you have to make room. You have no ability to turn them away, ask them to go elsewhere. There is no release valve. EM attending #2, FG F [In the ED,] it’s not like you can say, “I have to stop working because I have too many patients,” ...that generates a lot of friction and animosity when you get told [by IM physicians], “Well, I can’t take this patient right now because I’m too busy,” ....because nobody in the emergency department has that option...that generates a lot of friction. EM attending #1, FG I
Impact of rapid workflow in ED IM: Emergency physician rapidity can conflict with patient safety. EM: Emergency physician rapidity is based on patient safety decisions.	Their [emergency physicians’] metric is that they’re trying to get people up to the floor as fast as possible... and they don’t always take us seriously when we’re trying to explain the reason why we don’t think it’s safe for them to go. IM resident #7, FG A	I think there’s a perception [of emergency physicians] we’re always into “get ‘em [patients] out [of the ED]”...[I]t’s not appreciated on the medicine side that...a slow [emergency physician] is a dangerous [emergency physician], and that if you let the place get jammed up....then that patient who is in that waiting room with 20 [others] ...actually could be having an acute [myocardial infarction]….That is not an economic decision or an efficiency decision. It’s a patient safety decision. EM attending #2, FG F

^* Bolded sections added for emphasis.

IM, internal medicine; EM, emergency medicine; ED, emergency department; FG, focus group.