Give me the, somebody tell me an example of a conflict that they've had. I mean, don't give me the details. Just say who with. I mean, where have there been conflicts? Spouse? What else? Siblings. Sibling? Oh yeah, man, I can see my grandkids. Good God almighty, those young things fight each other like crazy. Who else? Co-worker. Co-worker. Anesthesia. Because they refuse to sedate them? Or pretty much. Pretty much, yeah. All right, let me just kind of run through it rather than have to take more time. You know, there can be, you're gonna run into conflict everywhere. Patient demands, you know, a partner about medical management, you know, you'll get, and I always say when you put two doctors together, when you got one doctor, you're pretty good. When you got two together, you got a problem. You get three together, you got more of a problem. So all this consolidation and bringing groups together, the complexity, is creating more needs to be skilled at these kind of things. I mean, it's more pressure on us to get along. The attending. The nurse. And the nurse, remember, is the subordinate. So the nurse is gonna feel like every conversation you have with them, they're down here. They never feel, there's very few that feel equal. So you gotta remember in that conversation, you may think it's going good, but with the nurse, it's not. Spouse. Political. How many families have been divided over what's the politics of recent days? You know, family members you won't talk to, or they won't talk to, you can't understand it. Or whether, you know, you can go, vaccinated or unvaccinated. Given an unfavorable performance review of feedback. I gave that feedback to that doctor, but somehow or another, you know, he still talks to me. Period, critiquing a colleague's work. Bullying. A neighbor. Police. You're a person of color and diversity. When we're different. Well, all these things are worth examples of conflict that we've had. And the last thing I had up there that I need to go back is personality, and I'm gonna, I'll expand on that just a little bit, just to give you maybe some science behind why we have conflict. You know, the consequences are clear. Safety, quality, productivity, happiness, everything takes a hit, you know, when there's conflict. So, I think personality can play a role. I want to talk a little bit about Myers-Briggs and FIRO-B. But these are tools that sort of measure who you are and how you relate to people and how you think. How many have had their Myers-Briggs? What, about half the people? And I'm an ENTJ. Is anybody else ENTJ? How many I's are there? Yeah, raise your hands higher so I can see you. And how many E's are there? Okay, more E's. So, let me go into Myers-Briggs a little bit, because I think sometimes there's conflict between us because we don't understand each other's personality and how we think. So, you know, Myers-Briggs is divided like this. You take the test and you come out being more of an extrovert or more of an introvert. That's E or I. You're more sensing versus intuitive, which is N. And sensing, what that means is that you're somebody that has to have a lot of data, whereas intuitive doesn't need much data. So, I'm more intuitive. So, if you're presenting a patient to me and you've gone down to all the labs and all the different stuff, and I've already figured out what it is, I don't want to hear anymore, you know. But there's other, some people that are S's, you can't tell them enough. They'll ask you, what about this X-ray? What about the femur? You know, you'll think, what the hell's a femur got to do with this? And so, but that's because they're S's and they need it. Some are more thinking versus feeling. And you know, some, it's like you have this question, somebody's not picked for an all-star team in Little League, you know. Somebody will say, I won't pick this Johnny because he's good, but he's never been on an all-star team. It would be great for him. But the thinking coach would say, no, his batting average is half of what this other guy's is and we need this other kid because the performance and numbers are there, they should be there. So that'd be, you know, thinkers and feelers would decide differently on that. And the other part of it is this, are you, do you make a quick decision or you can't make a decision? You perseverate. That's a P versus a J. And this is probably where a lot of people, oh shoot, let me go back. You know, for example, we went on a trip once with somebody who was a terrible P, so you can't decide on what restaurant, can't decide on what they're gonna eat. 30 minutes into it, they're still undecided over the menu and stuff like that. So I think that if you try to understand who's the extrovert, who's the introvert and how they make decisions, how they process the information, it helps you work better with them if you're aware of it. So some organizations actually put on their desks or have them wear a badge that says what their Myers-Briggs is so that you can get along, if there's a cultural problem and things like that. The other test that I like to use is the FIRO-B. You ever heard of FIRO-B? Anybody ever taken that test? It's Fundamental Interpersonal Relationship Orientation Version B. It's not whether you're gay or straight. It's about three measures of how we relate to other people. And it measures control, inclusiveness and affection, which is really about transparency. So it measures a scale of one to nine. So what it is, control, how much control do you need and how much control do you like from other people? So I worked with a CEO once, the scale is one to nine. I think he was a 13 on control. Whereas my control score was pretty low and my score was low on wanting to be controlled. So I hated to be controlled. He had to have control. We were like oil and water. We couldn't get along. We just couldn't make it work. But I made it work. I just had to put up with it. But it helped me understand him a little better. It helped me work with him a little bit better. And now he's a good friend and we do a lot of stuff in the community after our retirements. Inclusiveness is, for example, if you're not invited to a party, does it bother you? Or do you like to have big meetings with a lot of people? Some are low on inclusiveness and they like to have small meetings. Others are high on inclusiveness and have big meetings. Somebody feels left out. So you can have conflict with people because they weren't included. Why didn't you talk to me? Well, they're high on inclusiveness whereas you may be a little bit low and that could lead to conflict there. And transparency, some people just don't tell you anything. Whereas I'll tell you everything. I'm about a nine on transparency and that gets me into trouble. It makes me a terrible negotiator. You know, with zero-sum, if I'm negotiating for a car, I always give the whole thing away. But when I'm negotiating, people know I have no hidden agenda. And they know that they can trust what I'm coming with because they know Charles is transparent. He doesn't hide anything. Never found him to hide anything. So I mean, it works both ways. So just understanding when you relate to people how you do this. When I reorganized the medical staff early in my career when medical staff was still kind of a big deal, my inclusiveness score was very low so I eliminated all the committees. I put one person in charge of the committee. And we totally, we got rid of the big medical staff meetings because all they were was a big complaint session. People get on a soapbox and have their, actually want to grind on somebody. So it totally changed the culture, made the relationships better. But some people that like high inclusiveness didn't like it because they felt left out. And I'll tell you, there is, it's not that one way is right or wrong. It's just you need to be aware of how you, how you follow these scales of control, inclusiveness, and transparency. DISC is another one. I won't go into this. You can see the different characteristics. A lot of people use that. And so that's the personality aspect of conflict, of which really has helped me work with my coworkers. If I can turn my brain to think, what's their Myers-Briggs? What's their FIROB? This is where we're having conflict. I can understand a little bit better. How to deal with it, you can compete, accommodate, avoid, compromise, collaborate, et cetera. But I think the key word I wanted to put here is that you've got to have a courageous conversation. So the key to managing conflict is to talk. And how do you do that? Has anybody read the book, Crucial Conversation? That's another great book you need to read. And let me try to explain this diagram. The whole book's on this diagram. What you have when you're interacting with somebody is you're in this zone of safety here. So here's me and there's you over here. And we are talking with each other or we're dealing with an issue with each other, whatever it may be. And if your zone of safety is very large, it's a big circle, like a good friend, your best friend, you can say anything to them. And it doesn't bother them at all, no matter how horrible it is or what. But if you're talking to somebody that doesn't like you, you don't get along very well, you got a very small circle, then when you interact, you know, your adrenal gland starts pumping, you get short of breath, your heart's doing that. And what do you do? Don't you feel it coming on when you're angry? You either withdraw or you act out. You yell or scream or get angry and say something you wish you hadn't said. Or you take your ball and go home and sulk or get passive aggressive. And so, the key here when you're having conflict with someone is you gotta figure how am I gonna enlarge this zone of safety so that we can talk to each other? I'm sitting here thinking the major challenge, how do you get a Democrat and a Republican to get a large zone of safety? I don't know, you know, you do it this way. And this is an acronym that's in the book about share your facts, tell your story, ask others for their path, talk timidly and encourage testing. So, I really don't wanna go into the details of it, but the key word here is tentative. So, when you're talking with someone, you gotta have a major conversation with. Don't come across so cocksure. You know everything, you're telling them everything. You gotta come across to them, could it be this, maybe? Have you thought about that, perhaps? But you know for sure what it is, but you don't wanna say it that way. You wanna say it in a tentative manner. Because as soon as you say something that's more definitive, they get defensive and they start to shut up. Whereas if you go into the conversation to be tentative and to be curious and to truly listen to what they have to say, the active listening I was talking about, then that circle will start to get bigger. And you use the Dale Carnegie stuff and you use the creep stuff, it makes the circle bigger. And then there'll be less conflict and everybody'll get along a little bit better. So before you have that crucial conversation, make sure you got your motives right, you're not out for revenge. You want them to be successful, you want them to get along with you well. Take your emotion out of it as best you can, that's tough to do. Gather the facts and stick to the facts and not just your opinions and be curious. And with that active listening, who you work with. And what you're gonna run into when you go out and practice, you'll hear things about disruptive physician behavior. I just threw this in here so that you'll be aware of it. It's something I've dealt with my whole career. I came up with the first policy in our institution about physician behavior and when it's disruptive and how you handle it. And the key to it is you define it. I'll show you one definition you can use. I mean, disruptive behavior can be physical, emotional, could be a pattern, hard to define, it's like pornography, you know it when you see it, but you can't totally define it. But, and then when you first deal with it, you have a collegial crucial conversation. It's one-on-one. So if you have one-on-two, the first meeting, they always said they're ganging up on me. So whenever there's three people together in a meeting, it's always two-on-one. So when you have meetings, make sure it's one-on-one. If you're being called into a meeting with two people and you, bring somebody else with you. If it's the first time, unless it's something going on. So it's very important how many people are in a meeting. So one-on-one's collegial, two-on-one is not gonna be collegial. So what you do, you have the first conversation, if the behavior doesn't improve, you escalate it next, we have another meeting with two-on-one, two people-on-one with a letter saying, if you do this anymore, there'll be consequences, you outline what the consequences are. And then if there's a third event, next event, then the letter spells out exactly what's gonna happen. So that's how you sort of manage the marginal performer or somebody with a behavior problem. So keep in mind, one-on-one collegial to start with, it keeps going two-to-one to handle it. And if it gets formal consequences, then you take care of that later. So I've had to have many conversations here and I've had to fire physicians and they've sued us. And we've had to deal with depositions for days and lawsuits and unfortunately, when we follow this policy and you do it the right way, just like, you know, like Klaus was talking earlier about malpractice stuff, you know, if you do your training programs, do everything the right way, there's much less chance you'll get sued, much less chance you'll lose this kind of thing here. And this one particular physician I had to do this with was a French-Canadian perinatologist. And every time, you know, she has the Canadian-French accent, so every time I hear Celine Dion talk, I get this knot in my stomach. Because this was the worst behavior I'd ever seen in anybody, this doctor. She sued us and I spent two days in a lawyer's office taking depositions and her lawyer non-sued it and dropped it because he realized she was the problem, it wasn't us. So there's our definition. I've got it in the handout if you want it. Talk about verbal attacks or impertinent comments or non-constructive criticism. You know, and you don't want to write things in the chart. You know, one thing you don't want to do is don't, when the lab doesn't do something for you or somebody didn't come through, or the anesthesiologist doesn't do what you want, don't write it in the chart. You can talk about it, but don't put anything in the chart that's judgmental about behavior and stuff or demeaning somebody else. Always leave that to the side and only put the pertinent clinical stuff in the chart. So anyway, the roadmap for this is you recognize it, don't avoid it, take advantage of it, be a positive leader, have the crucial conversation, seek first to understand them, not be understood, value the voice, channel your best Dale Carney, give and receive feedback, commit to change and strive for happiness and trust. And what I'm gonna do in the breakout is we will talk a little bit more about trust and happiness and those kind of squishy things. So I've ran through that quick crowd so we can catch up a little bit. Thank you. Let's do this. Let's take a question or two and then I want to demonstrate that I'm a good listener and I'm tentative and I'm getting input from you all as to how to do the breakouts. But first of all, are there any questions from our virtual audience for Chal at this point? Or any questions or comments from fellows or faculty in the room? Thank you so much, Dr. Noonan, for such a great both talks, very insightful. Just one of the questions from the previous talks I was hoping you'd elaborate on. You know, I think especially with your vast experience and your leadership and how candid you were, would you be able to expand more on kind of the differences between the American Association of Physician Leadership, which I know you were extensively involved in, and then MMM, and then MBA? Okay. Well, the AC, it was ACPE, American College of Physician Executives, a guy named Roger Schinke put it together about 30 years ago, 35 years ago, and his whole purpose of the organization was to train doctors with leadership and management courses. You can take one course or two or three or take it all the way to an MMM, that's what, a master's degree. It was such a practical, they would bring the best professors from business schools to different locations around the country, and you go to a fall institute and a spring institute and take courses. So you could put your toe in the water, you know, and I would send a number of my physicians that were cantankerous and difficult and don't get it and go to this course and they'll come back and say, you've changed my life. I didn't know there was a scientific way to look at all their problems, rather than me just sitting there complaining all the time, I can now have skills to do that. So that's what that organization did. They, you know, Roger passed away and he retired, and so they have new leadership now, they changed the name to American Association of Physician Leadership. It's still pretty much the same organization, and you can take courses through them, take just one course if you want, or two or three, and you get CME for it, so rather than take clinical CME, you can get this CME, and so it still counts, and if you really want to make a career of it and take it further, you can take it right into a master's degree. But if you just want to have enough skills to get you by in your job as a medical director or doing the head of some project, you can get the financial skills, negotiation skills, those kind of things, quality skills, to be able to do the work, so it's sort of a, whereas a college, you know, you might have to go through the whole MBA program, with them, you can pick and choose the courses you want to take, and you network with more doctors and that kind of thing, so that's kind of, it's still ongoing. Do you want to comment on it, Joe? You took some of the courses there, and was it valuable to you? There are all different topics, leadership and management people are outstanding, and you can go all the way to a triple M degree in management and medical management, or an MBA focused in healthcare. They're not really different in the end. The MBAs are, each university offers a little bit different, but they're essentially the same. But the coursework in and of itself can be very helpful for specific instances like you know. So what I did to get my MMM is I spent about three years taking the course, it's got, I forget how many hours, 150 or 160 hours. Then I became a certified physician executive, we took another capstone course that we teach docs how to interview and how to present themselves, their leadership philosophy, their values, projects, and competencies. And they have to say that, well you know, from memory, and how to share that kind of stuff. And then they go on and take four eight day sessions over a year and a half at whichever institution they're going to go to. And then in between, you have about 15 hours of homework a week. That's the kind of time commitment it takes for that. I did something similar, the initial part of the program like Joe did, and then there are different choices of universities that can then take you to an MBA in that case program. And I did it through University of Amherst. Mass, UMass is the MBA one, yeah. Yeah, okay. And I went to Carnegie Mellon and got the MMM.

Conflict and Personality

Dr. Charles Noonan

relationship conflicts

personality differences

Myers-Briggs test

FIRO-B test