It is of no surprise that the term mediation creates a visceral repulsion among most healthcare providers. It is synonymous with the litigation process. Since most healthcare providers that have any experience in litigation is related to medical malpractice, there are very few neurons between “medical malpractice lawsuit” and mediation experience.
In fact, prior to my education in this field, I perceived all mediation as a pre-trial requirement demanding a negotiated solution, where the physician is expected to capitulate and allow insurance adjusters to drive down the value of a medical malpractice claim that could be completely frivolous, yet “get the case settled”. All my colleagues tell me the same thing and even great defense cases have defense attorneys who still advocate for settlement. It is an economic machine for lawyers and judges that does not reflect justice or even what is right or wrong. 
I’ve sat through several mediations all of which were ”mediated” by retired lawyers and I can attest that this is not the Mediation taught in academic ADR programs. This mediation is coercive legal negotiation in which the lawyer – mediator tries to convince both parties that the trial process, regardless of strength in argument, has no better chance of winning than shooting ducks with a 12gauge shotgun from a subterranean blind at dawn in the middle of winter.
So, it is of no wonder that the label of mediator on one’s white clinical coat, may be seen as a scarlet letter around the hospital instead of “come talk to me I’m your friend.”
In the same vein, Conflict Engagement Specialist carries with it the ring of an important title, education, and inquisitive engagement that may in fact crack open the door of traditionally stoic healthcare professionals who are bent on convincing the world they are right, quickly dispositionally defensive and cynical that either colleague or subordinate in the healthcare environment is open to a collaborative and strategic approach to dispute resolution. I know, I sound cynical, but anyone with a few years in the system knows I am also probably right (That’s the surgeon in me talking of course!)
Between the list of skills in this week’s overview and the very informative article by Debra Gerardi, we are provided a glimpse into the world of ADR intersecting with healthcare conflict. As a scientist, the Venn diagram keeps popping into my head. I believe one of the great skills we can offer is active listening, as Ms Gerardi points out, “ ..listening is typically restricted to information needed to move through the day and is rarely done at a level that enables understanding of a situation where there may be collaboration.“ I can certainly understand now the alternative mindset that requires patience (not patients) and reflective insight with this ADR training. I appreciate the specific recommendations in this article as an academician because it lets me define how to do this job as a physician, shifting from clinical responsibility to conflict management skills. I like sentences like, “effective conflict management in the clinical setting include, being present in the moment, listening for understanding, mutuality, openness, and reflection.” I can get my mind around that!
It is apparent that the healthcare providers from our didactic readings have transitioned from the clinical responsibilities in healthcare to a more active and likely all time consuming exhausting role as conflict resolution professionals within their healthcare organization. Perhaps the greatest difficulty as we set out in this field will be to redefine the skills that we bring to the table and utilize the ADR toolbox developed through this educational process. Frankly, it will always be easier for me to listen to a clinical story, rapidly develop a differential diagnosis and recommend a host of laboratory and imaging studies to get to the bottom of the problem. This clinical process is no longer an academic exercise but a daily reality. When we choose to submerge ourselves into the third-party role as facilitator, mediator or coach, we will ask the environment that is so harshly critical of mistakes and perceived errors in medical care, to give us some latitude and allow us to learn the ADR skill sets as a practical application of this academic knowledge.
As this will take some time, I take solace in the fact that the resultant outcome of dispute resolution can be interpreted in Gestalt and ethereal overview of conflict in general. If the disputants failed to resolve their differences, this does not necessarily mean that the third-party neutral is not competent. That is very different than the exacting and quite critical demands placed on clinical care, which rarely awards excellence or heroism in clinical outcomes, but quickly castigates and harshly judges poor results, stoning anyone involved in a single patient’s misfortune. Hopefully, institutions that label us “MD, FNP and RN”, will accept our refocused interests and allow us to expound ADR philosophy as our new mantra.
Let us scientifically investigate the impact the effects of this hostile work environment. Referencing Maxfield et al work with the AORN and AACN on “The silent treatment.” we see the discussion on this 2010 study of 6500 nurses and nurse managers discussed the impact of compromised communication for any reason in the healthcare work environment. Hostility between personnel creates this miscommunication and prevents sharing critical patient data. As this study points out, “creating a culture where healthcare workers speak up…the study shows that healthcare professionals’ failure to raise the following three concerns when risks are known undermines the effectiveness of current safety tools: 1. Dangerous shortcuts 2. Incompetence 3. Disrespect.” So what we see in our personnel hostility is profound disrespect for each other and our system, when a failure to communicate puts patient safety directly in harm’s way.
In 2004, Gerardi addressed this as a critical need in any work place and we must consider similar solutions within our hospital environment. He described the use of mediation techniques to identify conflict early and develop a plan to resolve it by “listening, re-framing the concerns raised, identifying commonalities and clearly defining decisions”. We have at our disposal several well tested dispute resolution techniques and several people within our organization trained or expressing a desire to be trained in this professional management role that our organization desperately needs. As Maxfield solutions suggest “… when it comes to creating healthy work environments that ensure optimal quality of care, individual skills and personal motivation won’t be enough to reduce harm and save lives unless speaking up is also supported by the social and structural elements within the organization. Changing entrenched behavior in healthcare organizations will require a multifaceted approach and, to this end, the authors provide a series of recommendations leaders can follow to improve people’s ability to hold crucial conversations.” We must adopt guidelines which are memorialized by employee contractual procedure and an institutional commitment at every level, from senior management to hospital personnel and provider-nursing communication. The doctrine we create and offer for ratification includes a methodology to identify and address access to our system of conflict management for the employees. Here, we outline for reporting abuse; a safe method to report this abuse and not suffer discrimination, retaliation, or termination; the methods our hospital will take to address this report and remedy the issue; the method of investigation of accusations and corrective education when abuse has occurred; and lastly, the follow up communication methods for the person reporting the initial issue. Indicate how the reporting person will receive information about the outcome of the abuse report.
Renaissance Reflections of a Physician and Surgeon 
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