It's Not About Winning or Losing: How Consultants Navigate Disagreement in Serious Illness

Disagreement between consulting and primary clinicians is common when caring for seriously ill patients. While disagreements are often distressing, the optimal way to prepare clinicians to navigate these disagreements is unknown.

The aim of this study was to better understand consulting fellow and attending physicians' experience with disagreement and explore the skills that would help physicians better navigate these disagreements.

We conducted semi-structured individual interviews of fellow and attending physicians from three consulting specialties-palliative care, nephrology and gastroenterology. Two investigators independently analyzed the data using inductive thematic analysis.

We interviewed ten first-year fellows and nine attending physicians. When disagreements were perceived as going poorly, participants frequently interpreted the disagreement as a comment about their expertise or identity. Trainees found disagreement especially challenging and there were clear differences between fellows and attendings regarding their perception and approach to disagreement. Attendings felt communication was as important to promoting a good relationship as coming up with the "right" decision. Participants described communicating about disagreements directly and recognizing the perspective and interests of the other party as feeling productive. Participants described receiving little training in how to navigate disagreement and attending physicians have acquired skills to navigate disagreement over time.

Our results suggest that fellows in consulting specialties who care for seriously ill patients do not feel prepared to navigate disagreements. Attendings may have acquired skills to handle disagreement through experience that could be taught to fellows, such as specific communication techniques, relationship building and perspective taking.