Friction by Definition'

Conflict at Patient Handover Between Emergency and Internal Medicine Physicians at an Academic Medical Center

Zahir Kanjee, MD, MPH; Christine P. Beltran, EdM; C. Christopher Smith, MD; Jason Lewis, MD; Matthew M. Hall, MD; Carrie D. Tibbles, MD; Amy M. Sullivan, EdD

Disclosures

Western J Emerg Med. 2021;22(6):1227-1239. 

In This Article

Abstract and Introduction

Abstract

Introduction: Patient handoffs from emergency physicians (EP) to internal medicine (IM) physicians may be complicated by conflict with the potential for adverse outcomes. The objective of this study was to identify the specific types of, and contributors to, conflict between EPs and IM physicians in this context.

Methods: We performed a qualitative focus group study using a constructivist grounded theory approach involving emergency medicine (EM) and IM residents and faculty at a large academic medical center. Focus groups assessed perspectives and experiences of EP/IM physician interactions related to patient handoffs. We interpreted data with the matrix analytic method.

Results: From May to December 2019, 24 residents (IM = 11, EM = 13) and 11 faculty (IM = 6, EM = 5) from the two departments participated in eight focus groups and two interviews. Two key themes emerged: 1) disagreements about disposition (ie, whether a patient needed to be admitted, should go to an intensive care unit, or required additional testing before transfer to the floor); and 2) contextual factors (ie, the request to discuss an admission being a primer for conflict; lack of knowledge of the other person and their workflow; high clinical workload and volume; and different interdepartmental perspectives on the benefits of a rapid emergency department workflow).

Conclusions: Causes of conflict at patient handover between EPs and IM physicians are related primarily to disposition concerns and contextual factors. Using theoretical models of task, process, and relationship conflict, we suggest recommendations to improve the EM/IM interaction to potentially reduce conflict and advance patient care.

Introduction

Background

Interactions between emergency physicians (EP) and internal medicine (IM) physicians are frequent and complex. The US Centers for Disease Control and Prevention reported 139 million visits to emergency departments (ED) in the US in 2017; 14.5 million of these resulted in admission, the majority of which were to medical services.[1] Conflicts in priorities, opinions, and perspectives between these two departments are to be expected.[2–4] The EP makes rapid diagnostic, management, and disposition decisions while simultaneously triaging a high volume of acutely ill pattients; IM physicians, on the other hand, must attend to more detailed workup, diagnosis, and treatment plans while managing bed and staffing resources on the hospital ward.[5,6]

Evidence across healthcare settings suggests that suboptimal interdepartmental interactions and inadequately managed conflicts can lead to adverse impacts on patient safety, healthcare systems workflow, physician wellbeing, and employee retention.[7–11] For emergency medicine (EM)/IM interactions specifically, unresolved conflicts and communication failures during patient handoffs between physicians are associated with higher risks of medical errors and adverse events.[9,12–14] Understanding the nature of interactions between these groups and optimizing collaboration during patient admission is therefore a high priority for research and, ultimately, patient safety and care.[6]

Although the presence and nature of workplace conflict has been studied in various healthcare settings, rigorous research specifically aimed at elucidating the nature of conflict in the EM/IM interaction remains limited.[15,16] Expert opinion and consensus have highlighted differences between departments in terms of work demands and culture, such as different levels of attention to detail and comfort with initial clinical ambiguity.[6,17] Others have pointed out the pernicious impacts of a silo mentality between these two groups.[18] A small survey of Australian EM and IM residents[19] and an interview study at a US hospital[16] each found that departments differed in their assessment of the adequacy of patient workup in the ED prior to admission, with IM physicians frequently desiring information beyond that which EPs normally provide.

A survey study at a US academic medical center[5] also found admitting medical services felt they received inadequate information from EPs, and that EPs frequently felt defensive in their interactions with their admitting medical colleagues. Focus group studies of Canadian EPs and IM and general surgery physicians have shown that familiarity and trust were important determinants of quality of communication between these departments,[20] and that historical factors, attitudes and values, actions, external stressors, and trust could either produce or mitigate interdepartmental conflict.[3]

Goals of This Investigation

We aimed to describe and explain the interactions and reasons for conflict between these two groups in the context of EM/IM handoffs. Our goal was to provide empirical evidence to inform interventions to enhance interdepartmental interactions and, ultimately, improve patient and physician outcomes.

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