Table 4.
Problems and recommendations at individual and department/hospital level for reducing emergency/internal medicine physician conflict and enhancing collaboration.
| Problem | Individual level recommendation | Department/hospital level recommendation | Comment/rationale |
|---|---|---|---|
| Problems Related to Disposition | |||
| Emergency and IM physicians do not have shared understanding of reason for admission (eg, need for intravenous medications, lack of social supports, diagnostic uncertainty), especially when patients were seen by an emergency physician who has since completed their shift (T) | Emergency physicians routinely document specific reason for admission. | Change e-signout template to include specific reason for necessity of disposition decision (rather than alternatives such as home or ICU). | Prevents misunderstandings/disagreements between emergency and IM physicians. |
| Disposition decisions around need for admission or ICU are sometimes debatable (T) | Emergency and IM physicians work together to create pathways and disposition rulesa. | Create pathways and disposition rulesa. | Allows input/expertise of each department in decisions, creates clarity, partially removes these decisions from contentious discussions, capitalizes on complementary inter-departmental knowledge bases. |
| Problems Related to Context | |||
| Disposition discussions approached with defensiveness (R) | Emergency and IM physicians approach each other with curiosity and open-mindedness rather than defensiveness. | Implement interdisciplinary teamwork, conflict negotiation and mitigation training. | Transforms discussion requests from potentially contentious disagreements to satisfying opportunities for interdisciplinary, patient-centered problem solving. |
| Physicians do not know each other well personally (R) | Emergency and IM physicians attend joint social eventsa and engage in small talk when able. | Organize joint social eventsa and trainings. | Facilitates respectful interactions and teamwork. |
| Physicians do not understand each other’s workflows and priorities well (P) | Emergency and IM physicians ask each other about their priorities and concerns when working together. | Organize joint trainings,28,29 interdepartmental retreats or workgroups, trainee rotations, and leadership meetings. | Enhances each group’s appreciation of the downstream consequences of their own actions on their counterparts’ lives and work, allowing for emphasis of shared values. |
| Inpatient demands and inpatient volume make interactions with emergency physicians harder for IM physicians (R) | Reduce strain of admitting and caring for inpatients, eg, through changes to call schedules and geographic admitting, pharmacist involvement in medication reconciliation, streamlined outside record acquisition processes, reduced clinical documentation requirements,30 or additional attendings and advanced practice providers.31 | Reduces strain that challenges IM physicians’ relationships with emergency physicians. | |
| Communication with IM physicians via page/phone is challenging for emergency physicians (P) | IM physicians always provide information on what they need in page for request for more information. | Implement two-way text paginga. | Reduces disruption to emergency physician workflow. |
| Prolonged ED boarding time strains EM/IM interactions (R) | Reduce ED overcrowding and boarding, eg, through strategies such as flexibility in nursing resources,32 dedicated hospitalist-led ED boarding teams,33 or creation of psychiatry observation units.34 | Decreases emergency physician stress, makes revisiting admissions decisions easier, reduces likelihood of needing to revisit admission decision made by an off-service emergency physician colleague, and makes discussions with/fulfilling additional requests from IM physicians easier. | |
| Notification of request for information/discussion is perceived as primarily negative by emergency physicians and so is “triggering” (P, R) | IM physicians use request for discussion/information system also to pass on positive feedbacka. | Adjust e-signout system to include a way to easily provide and encourage positive interdisciplinary feedback. | Makes requests less triggering. |
Superscript “a” denotes respondent recommendation.
IM, internal medicine; EM, emergency medicine; T, task conflict; P, process conflict; R, relationship conflict.