TCT.14: How to minimize conflict in the cath lab

WASHINGTON, D.C.—If you want your cath lab to run efficiently and safely, you need a director with clear vision and the ability to take charge, even—make that especially— in times of strife, a physician leader said Sept. 13 at the Transcatheter Cardiovascular Therapeutics scientific session.

“In this very complicated work environment called the cath lab, if you don’t have a clear chain of command and leadership by the cath lab director, the environment is ripe for conflict,” warned Ehtisham Mahmud, MD, chief of cardiovascular medicine, director of the Sulpizio Cardiovascular Center and director of interventional cardiology and the cardiac cath lab at the University of California San Diego Health System.

An effective cath lab director needs to create a healthy work environment that provides high quality, cost-effective care. More than serve as a sounding board for others, a cath lab director today must motivate staff and educate administrators to achieve common goals.

“It cannot be about the bottom line alone,” he said. “It has to be done effectively. Some things will cost more, but as long as overall we deliver high quality care, then the value proposition is always there.”

Physicians should be board-certified interventional cardiologists who are good operators, Mahmud said. Today’s cath lab should include subspecialized operators experienced in complex cases as well.

The cath lab director will need to address physician outliers, who Mahmud divided by professional behavior and clinical outcomes. Professionalism covers work habits, behavior and attitude; for instance, physicians who have temper issues or who chronically start cases late.

“They want their case to start on time, regardless of what happens to other people,” he said. “They don’t care about staff time or their colleagues and they don’t understand that their behavior could affect staff and their colleagues’ morale adversely.”     

Look for constructive rather than punitive solutions, he said. Assign a physician assistant to facilitate the habitual late starters or schedule them at the end of the work day so they can’t set back others’ schedules.

An effective leader has to address disruptive behaviors early but be judicious. Rather than confront a physician in the heat of a conflict, Mahmud recommends in less serious instances taking a pause to let all sides cool down. Then listen, contemplate and look for a middle ground. “Find a way to compromise and accommodate,” he said.

In more serious situations, the director should provide detailed and specific information about the problem, allow the physician to contribute and then respond constructively. “You also have to give clear expectations,” he advised.

Physical or verbal abuse should be dealt with immediately, though.

The cath lab director also should be cognizant that the healthcare system and not the individual may be the source of conflict. And while ideally rules should be applied equally, in reality cardiology programs with superstars often give them some leeway.

“Clinical issues with respect to outliers should be predefined,” Mahmud said. “These are the issues that automatically will lead to a review. They should be done routinely. You can’t cherry pick people and pick on them.”

Faced with physicians who have adverse clinical outcomes, the director should take a systematic approach. Make a predetermination of the frequency for reviewing cases and invite the physician to be present when the cases are discussed, he recommended.

Mahmud was one of four speakers who presented talks at TCT as part of the Society of Cardiovascular Angiography and Interventions (SCAI) Cath Lab Leadership Boot Camp. SCAI launched the boot camp at its 2014 meeting in May.