At the hospital’s monthly interdisciplinary meeting, a lively discussion takes place: Is there an optimal pathway for patients who present to the emergency department with chronic abdominal pain? One by one, representatives from emergency medicine, general surgery, gastroenterology, pain management, radiology, nursing, and hospital administration make recommendations. At one point, a debate arises as to whether patients might be more appropriate for disposition to an observation unit versus the inpatient ward, and it becomes clear no consensus can be reached. Someone makes the suggestion that all patients be monitored in the observation unit for the first 24 hours, asserting that this is “what’s best for the patient.” Without further objection, the team’s focus shifts to the topic of multimodal pain management. The issue of final disposition remains unresolved.
This sort of group dynamic is familiar to many of us working in complex health care environments. Claims that a favored approach is what’s best for the patient may be made in good faith but often have the effect of shutting down further discussion and silencing dissent. To understand why this phrase is so pernicious, it helps to understand the purpose of interdisciplinary dialogue in the first place. When physicians, nurses, and administrators with different perspectives and diverging interests come together, opinions as to what’s best for the patient should vary. The goal, then, is not to perfectly align opinions and agendas to reach consensus but to balance them and emerge with an informed, actionable outcome. That said, how does one go about making interdisciplinary discussions more productive? Is there a way to use “what’s best for the patient” not as a bludgeon but as a rallying call?
Table 1: Key Features of Productive and Nonproductive Discussion
| Productive Discussion | Nonproductive Discussion |
|---|---|
| Open-ended questions | Closed-ended questions |
| Exploratory responses What does this accomplish? How? Why? |
Confirmatory responses Right? OK? |
| Psychological safety | Consensus-seeking |
| A balance of inquiry and advocacy | Ego |
| Strong advocacy without sufficient inquiry |
Strategies for Productive Conversations
Much ink has been spilled on this topic, but for clinician leaders, we suggest leveraging many of the same skills that we employ in taking a patient’s medical history.1–3 Practice open-ended inquiry, focus on the “how” and “why,” search out facts and missing information, promote inquiry, test assumptions, seek alternate explanations, and avoid judgmental or conclusory statements. Leaders should promote an environment of psychological safety by allowing all participants to speak up, encouraging and applauding dissent, and identifying when differences in status or seniority interfere with debate (see Table 1). A healthy debate should focus on the thought processes, assumptions, and underlying data—rather than opinions—that team members used to arrive at their conclusions.
Figure 1. When using Argyris’ Ladder of Inference, team members share the subset of data they used and how it was interpreted to make inferences, judgments, and conclusions. This focuses debate on data interpretation and the thought process that went into creating a recommendation. After taking action, new data inform future decisions.
Agreed-upon frameworks, such as Argyris’ Ladder of Inference (see Figure 1), help teams appraise claims on the basis of objective data and the decision-making process.4 When evaluating a claim using Argyris’ Ladder, team members identify the objective data and underlying assumptions used to draw conclusions. Team members then explain the decision-making process used to decide on a course of action based on those data and assumptions. By seeing how team members arrive at their conclusions, the team as a whole can better evaluate claims and come to agreement as to a course of action. This framework has the benefit of being recursive, as outcomes from one round of inquiry lead to additional data and further conclusions.
Kantor’s four-player model (see Figure 2) focuses on the “who” of a team, characterizing individuals based upon their roles in the decision-making process: movers (propose, steer), followers (support, build on), opposers (critique, change), and bystanders (observe, ask questions).5 While seemingly simplistic, this methodology highlights distinct functions within all decision-making teams. In the absence of these functions, decision making may suffer, so team leaders should consider assigning roles up front before starting the process.
Figure 2. Kantor’s four-player model proposes that a more productive discussion comes from healthy debate. A team leader can facilitate debate by assigning roles to approach a proposal from different viewpoints. This ensures the proposal is thoroughly evaluated before approval.
Devil’s advocacy and dialectical inquiry are two other time-honored forms of structured debate (see Figure 3).2 Both methods empower team members to evaluate objective data, identify underlying assumptions, and assess potential outcomes. With devil’s advocacy, specific team members are assigned to critique the current leading recommendation, eliminating the emotional charge required to be a lone dissenter when the team’s efforts are focused on moving forward. Dialectical inquiry involves forming small groups to critically assess two or three different proposals in parallel, with each group evaluating another group’s recommendation. Regardless of method, when debate closes, the team as a whole should emerge with a shared set of facts and assumptions from which a final recommendation can be made.
Figure 3. FIGURE (left). Devil’s advocacy identifies and critiques the underlying facts and assumptions that must be true for a proposal to achieve its aims. At the end of debate, the team should reevaluate said assumptions and draft a final recommendation. FIGURE (right). Dialectical inquiry critiques the facts and assumptions of two or more proposals. The team then creates a set of shared facts and assumptions that should be used to reshape a current proposal or develop a new one.
Planning Up Front Leads to Productive Debate
Employing a structured framework for debate requires effort up front, but the payoff is higher-quality decision making and a healthier balance of cognitive conflict as opposed to emotional conflict.2,3 These methods may feel burdensome in the moment, but better decisions and more highly functioning teams save costs—time, money, and effort—down the line.1
When thoughtful inquiry and open discussion are encouraged, the statement “what’s best for the patient” changes from a conversation stopper to the common ground team members rally around. By focusing on the “why,” interdisciplinary teams can engage in productive conversation and come up with thoughtful solutions that impact not just what’s best for patient but for the entire health care system and for the community.
Dr. Mahan is a clinical fellow in emergency medicine at Harvard Medical School in Boston. Dr. Kosowsky is assistant professor at Harvard Medical School.
References
- Milkman KL, Chugh D, Bazerman MH. How can decision making be improved? Perspect Psychol Sci. 2009;4(4):379-383.
- Schweiger DM, Sandberg WR, Ragan JW. Group approaches for improving strategic decision making: a comparative analysis of dialectical inquiry, devil’s advocacy, and consensus. Acad Manage J. 1986;29(1):51-71.
- Schwenk CR. Effects of devil’s advocacy and dialectical inquiry on decision making: a meta-analysis. Organ Behav Hum Decis Process. 1990;47(1):161-176.
- Kim DH. Transformational leadership. The leader with the “beginner’s mind.” Healthc Forum J. 1993;36(4):32-37.
- Kantor D, Koonce R. Consequential conversations. TD Magazine. 2018;72(8):50-55.
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