Year : 2015 | Volume
| Issue : 4 | Page : 457-463
Conflicts in operating room: Focus on causes and resolution
Joginder Pal Attri1, Gagandeep Kaur Sandhu1, Brij Mohan1, Neeru Bala2, Kulwinder Singh Sandhu3, Lipsy Bansal1
1 Department of Anesthesia, Government Medical College, Amritsar, Punjab, India
2 Department of Psychiatry, Government Medical College, Amritsar, Punjab, India
3 Department of ENT, Civil Hospital, Faridkot, Punjab, India
Department of Psychiatry, Government Medical College, Amritsar - 143 001, Punjab
Source of Support: None, Conflict of Interest: None
|Date of Web Publication||16-Sep-2015|
The operation theater (OT) environment is the most complex and volatile workplace where two coequal physicians share responsibility of one patient. Difference in information, opinion, values, experience and interests between a surgeon and anesthesiologist may arise while working in high-pressure environments like OT, which may trigger conflict. Quality of patient care depends on effective teamwork for which multidisciplinary communication is an essential part. Troubled relationships leads to conflicts and conflicts leads to stressful work environment which hinders the safe discharge of patient care. Unresolved conflicts can harm the relationship but when handled in a positive way it provides an opportunity for growth and ultimately strengthening the bond between two people. By learning the skills to resolve conflict, we can keep our professional relationship healthy and strong which is an important component of good patient care.
Keywords: Anesthesiologist, conflict, operating room, surgeon
|How to cite this article:|
Attri JP, Sandhu GK, Mohan B, Bala N, Sandhu KS, Bansal L. Conflicts in operating room: Focus on causes and resolution
. Saudi J Anaesth 2015;9:457-63
|How to cite this URL:|
Attri JP, Sandhu GK, Mohan B, Bala N, Sandhu KS, Bansal L. Conflicts in operating room: Focus on causes and resolution
. Saudi J Anaesth [serial online] 2015 [cited 2020 Mar 28];9:457-63. Available from: http://www.saudija.org/text.asp?2015/9/4/457/159476
| Introduction|| |
The operation theater (OT) environment is the most complex and volatile workplace where two coequal physicians share responsibility for one patient. In the past, anesthesia was seen as behind the scene specialty, where anesthesiologist was considered as one of the surgeon's assistance who administers anesthesia. Immense development in the field of anesthesia slowly changed the position of anesthesiologist from surgeon' assistant to an independent specialist. This change demanded respect and acknowledgment of each other's knowledge and ability. In the developing countries, the role of an anesthesiologist in the successful outcome of surgery is not acknowledged by the general public. Even on the professional perspective, the surgeon is considered as the primary physician and anesthesiologist is assumed as a consultant, who is asked to participate in the peri-operative care of the patient. Lack of recognition of the role played by anesthesiologist both inside and outside the operating room (OR), lack of appreciation from the surgeon and poor social interaction with the patient lowers self-esteem of an anesthesiologist. Difference in information, opinion, values, experience and interests between a surgeon and anesthesiologist may arise while working in high-pressure environments like ORs which may trigger conflict. , Conflict can range from a minor disagreement to personality clashes and sometimes physical confrontations.  Quality of patient care depends on effective teamwork for which multidisciplinary communication is an essential part, and any disruption in the communication may lead to inefficient patient care. , Hence, a good professional relationship between the surgeon and anesthesiologist is very important for the high-quality patient outcome and to lower professional burnout.  The present article reviews the various causes of conflict between surgeon and anesthesiologist, their resolution and how to avoid conflicts and maintain healthy working relationship in ORs as everyone has a right to be treated with dignity and respect in the workplace.
| Professional Relationship Between Surgeon and Anesthesiologist|| |
A professional relationship is an association between two or more physicians, whether short term or long term that is based on the provision of services by the professional. Boundaries of this relationship are based on providing services in a safe and appropriate manner which is often defined by professional ethics codes.  The relationship between surgeon and anesthesiologist is entirely professional where to approve each other's method of working for a common goal that is, care of the patient.  In this working relationship, patient first comes to the surgeon. He then engages an anesthesiologist for peri-operative care of the patient, with a trust that anesthesiologist would work in the best interest of the patient. Anesthesiologist then reciprocates this trust with the same amount of understanding, loyalty and sincerity and, of course, professional excellence. Surgeons are the primary care physicians, and their goal is to carry out the surgical procedure as they are under patient pressure or hospital pressure to perform surgery without delay.  Anesthesiologist does the assessment of co-morbid conditions; optimize the patient for surgery and reassure the patient regarding the proposed anesthesia plan.  In good working liaison, both perform their duties as teamwork and a good surgeon listen to his anesthesiologist concern regarding patient care and respects his instructions in the OR when the patient's safety is at risk.
| Causes of Conflict|| |
No relationship is more crucial than that of a surgeon and anesthesiologist in the OR. When two highly educated and experienced physicians work together in a high-pressure work environment such as operation rooms, disagreement is a common occurrence as each individual has his own way of thinking, has different values and beliefs and reacts differently in different situations, this may lead to conflict.  Studies reported that at least 20% of the physician executive's time was spent in dealing with these conflicts.  So it is very important to explore the various causes that trigger the conflict between surgeon and anesthesiologist.
Lack of appreciation of the role of anesthesiologist
Anesthesiology has always been considered as behind the scene specialty. Patients consider surgeons as their primary care physicians, and they have hardly any knowledge of the role of anesthesiologist in the OR. Patients do not realize the value of preoperative assessment which is geared to decrease the anesthetic and surgical risk. They do not follow the anesthesiologist's instructions and attribute their overall safety and well-being to their surgeon.  A study was conducted to assess the knowledge of paramedical staff about the role of anesthesiologist in patient care. It was very disheartening to know that only 49.20% of the staff knew that anesthesia was a different specialty and out of them 60% knew that they have a definitive role in OR. 35.85% considered anesthesiologist as assistants to surgeon and rest have no idea what the anesthesiologist do.  This lowers the self-esteem, especially given the amount of effort required to achieve this expertise. Lack of appreciation from the surgeons, patient's unawareness of their role in OR and nonrespect to their instructions leads to frustration and triggers conflict between surgeon and anesthesiologist.
Lack of communication
Operation theater is the most demanding work environment where interdisciplinary teamwork is required which is based on effective communication among team members. Incorrect or incomplete information regarding patient is a frequent source of misunderstanding among surgeon and anesthesiologist. Each individual may interpret lab investigations or co-morbid medical conditions of the patient differently based on his or her professional experience. Misunderstanding leads to breakdown in communication which may further increase the chances of conflict. 
In the hierarchal decision-making pattern, the attending physician is at the apex of decision-making. But in the OR this hierarchy is blurred as the decisions regarding patient care are complex, and each team member may act as a final authority in difficult situations.  If an anesthesiologist postpones surgery in view of some pressing medical conditions in order to evaluate or optimize the patient, surgeons become upset as they want the main job done. Various studies reported that incidence of cancellation of surgeries due to anesthesia related causes (i.e., poorly controlled systemic diseases) are 2-14% and may reach 21.8% in tertiary care center and surgery related cancellations due to unplanned procedures may reach up to 18.2%. ,, But delay or postponement of surgery on the behalf of anesthesiologist is always a major source of conflict in OR. There is a general perception among anesthesiologists that surgeons are dominating and centralized in decision-making and are fairly goal oriented and single-minded about operating the patient and may sometimes ignore the patient safety.
Personality traits, personal factors and differences in values and beliefs can affect the working environment in OR. Perfectionism, compulsiveness and aggressiveness found in surgeons and anesthesiologist can make it more difficult for them to acknowledge each other's expertise.  This may have devastating effect on cohesive teamwork. Disruptive behavior and uncooperative work attitude of both anesthesiologist and surgeon can ruin the atmosphere of ORs.
Shortage of work facilities
Shortage of facilities, staff nurses, surgeons and anesthesiologists in operating rooms has been identified as a major source of poor working environment.  Shortage of staff leads to overwork and stress and sleep deprivation. Sleep deprived person loses the ability to think clearly and may have a very low threshold for conflict.  There are increased chances of developing disruptive behaviour in stressed and sleep deprived person. 
Conflict of interests
When financial, research and other incentives compete with the primary obligation of patient care : c0 onflict of interest arises.  When a financial relationship exists between surgeons and patients, patient's safety may be compromised as there is patient pressure on the surgeon to go ahead with the surgical procedure as soon as possible. Sometimes surgeries are performed under pressure from hospital to meet targets. Another cause of conflict between surgeon and anesthesiologist is the amount of remunerations the anesthesiologist gets in lieu of his services provided to the patient. It is a general feeling among anesthesiologists that they are paid less for their services, given the amount of time they devote in patient care while administering anesthesia.
Ethical and legal issues
Ethical conflicts can arise in OR regarding disagreement over informed consent, treatment plans, degree of preoperative investigations and other directives that limit treatment or do not resuscitate orders. , In view of growing frequency and intricacy of ethical dilemmas in medical practice, these invariably complex situations may become problematic. There are no clear-cut hospital policies to regulate anesthesiologist-surgeon working relationship and to protect doctors from malpractice claims. Thus, fear of litigation pushes the physicians to perform an act which is not beneficial for the patient but just to provide a good legal defense against any claim. Anesthesiologist may order additional lab tests in order to avoid malpractice issues and sometimes their cost may outweigh the benefits.  This may delay surgery, upsets the surgeon and becomes a source of conflict.
Lack of anesthesia clinics
In some hospitals, lack of preoperative clinics leads to poor interdepartmental coordination as patients cannot be assessed and prepared properly before surgery. This leads to increased number of cancellation on the day of surgery and may irritate the surgeon.
| Effects of Conflict|| |
In the smooth working of operation rooms, it is very important for surgeons, anesthesiologists, nurses and OT technicians to work as a team. Teamwork is a complex process that relies on group dynamics such as group composition, cultural values reconciliation and group cohesion. But in reality working relationship between surgeons and anesthesiologists are considered to be troubled by 77% of the anesthesiologists in a hospital based study.  Troubled relationships leads to conflicts and conflicts leads to stressful work environment which hinders the safe discharge of patient care. 
Break in communication
When interpersonal conflict takes place, the most disastrous effect is loss of communication between the two physicians. Poor communication and coordination between the surgeon and anesthesiologist played a dominant role in the occurrence of preventable medical errors.  For, e.g., during surgical procedure if patient goes into severe hypotension due to excessive blood loss and the surgeon and anesthesiologist are not on speaking terms, they may not act in collaboration and ultimately patient may suffer.
Negativity and hostile working environment
Troubled relations bring negativity to the environment and promote disruptive behavior. Physician with disruptive behavior may use abusive or threatening language, degrading comments or intimidating physical contact and sometimes may use public derogatory remarks about patient care. This makes the working atmosphere more hostile and difficult to work in thus decreasing work performance. 
Loss of resources
Conflict in OR decreases productivity as the valuable time is lost in dispute resolution. It also brings negative publicity and media coverage. The quality of patient care suffers and may bring a bad name to the hospital. This can lead to loss of hospital revenues and heightened financial crises. ,
Effect on health of physicians working in operating room
Regular conflict leads to stress, and when stress becomes persistent all parts of the body's stress apparatus (the brain, heart, lungs, blood vessels, and muscles) become chronically over-activated or under-activated. Such chronic stress may produce physical or psychological damage over time and can lead to various types of anxiety disorders, depression, adjustment disorders, hypertension, insomnia, substance abuse (increased consumption of drugs and alcohol), obesity, heart disease, diabetes, gastrointestinal problems (stomach ulcers) etc. 
Regular conflict in the operating rooms hinders effective patient care and may lead to medical errors. Negative publicity, dissatisfaction among patients and deficiency in medical care act as an instigating factor for malpractice claims. 
| Conflict Resolution|| |
Conflicts are normal as the two individuals cannot be expected to agree on everything at all times. Since OR conflicts are inevitable, learning to deal with them in a healthy way is crucial. Successful conflict resolution requires mutual respect among surgeons and anesthesiologists, careful listening, adherence to issues, recognition of differences and acknowledgment of the emotional aspects of the disagreement. Whenever a conflict arises in the operating room, following steps may be followed to resolve it.
Anticipate and be prepared
Conflict is common in OR, and one should be prepared to face it. Having clearly articulated policies and procedures available in OR can be helpful in resolving the conflicts in a healthy way. For, e.g., if the argument arises over the hours of fasting for elective surgical procedure and clearly defined guidelines regarding nil per oral (NPO) policy are available, conflict can be resolved easily.
Identify the source of conflict
Identifying the precise source of conflict by going through the events that lead to it, is the crucial step to understand and resolve conflict. Recognize the shared frustrations resulting from inefficiencies within the system.
Always start resolving conflict from nonjudgmental point where all pertinent factors are taken into consideration. When you clearly recognize the conflicting needs and are willing to examine them in an environment of compassionate understanding, it opens pathway to problem-solving and improved relationships.
Maintain good communication skills. Let each participant speak clearly and also listen carefully. Conflict triggers strong emotions and can lead to hurt feelings, disappointment and discomfort. By staying calm and controlling emotions, one can accurately interpret both verbal as well as nonverbal communication. When you are in a middle of the conflict, paying attention to other person's nonverbal communication may help you to understand what he wants to say. A simple nonverbal signal such as calm tone or concerned facial expression can diffuse the conflict. Many arguments can be resolved by communicating in a humorous way as this can help to say things that otherwise will be difficult to express. Take care that you laugh with the person not at them.
Avoid conflict in public
If you think that confrontation with a colleague is necessary, it should be done in a private place and not in public. Third party, which may be a colleague, other specialty consultant or a neutral mediator, can help to depersonalize the issue and diffuse tension.
Dealing with a disruptive physician in operating room
This can be challenging situation. General mechanisms to diffuse conflict cannot be applied as a whole in this situation as physician's pathological personality makes all reasonable attempts futile to resolve conflict. Various mechanisms , used in conflict resolution are : a0 voidance 0 that is , 0 inconsequential disagreement : i0 t is difficult to apply as conflict is difficult to avoid in OR. Yielding that is, own position is wrong : c0 an be applied, when one is aware that he or she is wrong. Collaboration that is, focuses on goals rather than meeting demands can be time-consuming but can bring a sustainable change. Compromise that is, unable to reach collaborative agreement : i0 s a backup strategy where both sides have an intention of inflicting pain and gain. Competition that is, no conciliation is possible : i0 t further damages the relationship of the two parties. The best mechanism to be followed for a disruptive person is avoidance or some form of compromise which is consistent with patient safety.
We are incorporating some of the case scenarios occurring in ORs as follow:
A 10 years old boy was posted for elective inguinal hernia repair under GA at 8 a.m. in the morning. A day before surgery, anesthesiologist instructed the parents of the patient to keep him NPO 8 h before the scheduled procedure. Patient reported at 8 a.m. after taking milk and biscuits at 6 a.m. Considering the risk of aspiration, anesthesiologist approached the surgeon to postpone the case for at least 6 h as patient had not followed the instruction regarding NPO. Surgeon started arguing that as the milk is liquid, patient can be taken for surgery after 4 h of fasting. Argument took an ugly turn and surgeon started threatening the anesthesiologist that he would report to higher authorities that anesthesiologist is not willing to give anesthesia to my patient, and i am also willing to take responsibility of the patient if anything goes wrong. In order to control the situation, compromise was struck to wait at least 6 h for procedure. Now in this situation, anesthesiologist's instruction were not followed, surgeon was dominating and used threatening language and was single minded to go ahead with the surgery. Conflict was avoided by adopting a compromise mechanism, but patient safety was kept in mind.
A 65-year-old female having noninsulin-dependent diabetes and hypertension was posted for elective cholecystectomy. Patient did not report in regular preanesthetic clinic. Patient was wheeled in the OR on the day of surgery and anesthesiologist was called to assess the patient. On reviewing the history and investigations, it was decided that patient needs echocardiography and cardiologist opinion for cardiac status before surgery. Case was postponed. Surgeon was furious that how echocardiogram will change the course of cardiac pathology and shouted, "patient has come to me for cholecystectomy not for echocardiogram." Now in this case surgery was postponed for additional investigations to identify existing medical conditions and to plan anesthesia accordingly. Cancellation of the surgery was the cause of conflict but patient's safety was the top most priority. Here collaboration as a mechanism for conflict resolution was used.
On a busy elective OT day, onco-surgeon was going to operate a 70-year-old patient of carcinoma thyroid with neck metastasis. Other routine cases were also on the list. Anesthesiologist requested the chief of the surgery to allow the onco-surgeon to operate on a table having invasive monitoring as the case is complicated. Surgeon scolded at the anesthesiologist "who are you to decide that which case is to be operated on which table" and he was not willing to listen to anything and was using degrading language. In view of patient's safety intervention from the chief of anesthesiology was sought, and patient was put on invasive monitoring table. Now, in this case, surgeon behaved in a manner as if he was the "captain of the ship" and was a cause of conflict. But firm stand taken by the chief of anesthesia in favour of patient safety was again an example of collaboration.
There is a common problem that surgeon do not adhere to the OT timings. They would come at their own convenience and then starts dictating the anesthesiologist the course in which patients would be operated. Sometimes fasting children and even diabetic patient, who should be operated as first case, are ignored. When the surgeons are confronted on these issues, disagreement rapidly degenerates into shouting match and many a time witnessed by the patient's also. This disruptive behavior sometimes takes the form of abusive language, derogatory remarks and physical confrontation. This leads to hostile work environment, and patient care is compromised as dealing a physician with disruptive behaviour is time-consuming and futile. The best mechanism to deal with such kind of behavior is avoidance.
| Recommendations to Avoid Conflicts at Work Place|| |
Managing conflicts requires emotional maturity, self-control and empathy.
Maintain good communication skills
Always keep the communication lines open and show mutual respect and never forget the primary goal- to ensure best patient care. Avoid engaging in actions that threaten your reputation. Be vigilant how your behavior and actions reflect on yourself. Don't hold on to old hurts and resentments.
Setting ground rules
Identifying and agreeing to ground rules at the outset establishes an efficient approach to get the work done, and difference of opinion can be solved. Establish rules of conduct and unambiguous shared standards and common goals.
Strengthening professional relationship
Teamwork is an integral part of patient safety in OR. There should be clearer job descriptions and well-defined roles based on relevant competency of each specialty. If professional relationship develops a bond of friendship, it would remove all barriers and helps to cement relationship. Further inter-professional education and training programs that may enhance professional's knowledge and skills should be encouraged. Confidence training and engaging in support groups for self-esteem enhancement can be beneficial. The problems created by disruptive physicians should be openly discussed, and policies should be developed to deal with them.
Establish an institution conflict management program and foster group cohesion where personal and organizational conflicts can be resolved.
Highlighting the image and status of anesthesiologists in public by media may go a long way to boost the morale of anesthesiologists and to create awareness about the role of anesthesiologist in surgical outcome.
Follow guidelines and adopting training programs
Various guidelines available to deal with the common causes of conflict should be followed. Such as:
- American Society of Anesthesiologists guidelines for the ethical practice of anesthesiology and modern curriculum on ethics  which was formulated to assist the practising anesthesiologist to deal with conflicts related to ethical issues.
- Anesthesia crises resource management training  which is analogous to crew resource management to improve the patient safety through team coordination and communication.
- Interdisciplinary team training programs for health care workers  developed by institute of medicine to decrease the incidence of preventable medical errors.
- Guidelines for fee structure of an anesthesiologist prepared by the anesthesiologist's society of different countries should be followed in a uniform manner.
- Taking time off from work at regular intervals will remove the person from stressful work environment and helps to rejuvenate both physically and psychologically. Persons who regularly take time off work to go on vacations, report significantly higher well-being than their counterparts who are glued to their work year-round.
| Conclusion|| |
Conflict between surgeon and anesthesiologist is damaging for the effective care of the patient and for their own health as it leads to professional burnout, mental stress and physical problems and decreases the productivity of work. Unresolved conflicts can harm the relationship but when handled in a positive way it provides an opportunity for growth and ultimately strengthening the bond between two people. Taking conflict in a stride and learning the skills to resolve it in ways that increases understanding, builds trust and strengthens relationship will go a long way in creating a professional relationship healthy and strong which is an important component of good patient care. Focus should be on avoiding the conflict and if it is inevitable, then resolving it. To this direction, specific interventions are needed to aim for cultivating respect and peaceful collaboration between surgeon and anesthesiologist and to foster high standards of patient safety and quality of care.
| References|| |
Studdert DM, Mello MM, Burns JP, Puopolo AL, Galper BZ, Truog RD, et al.
Conflict in the care of patients with prolonged stay in the ICU: Types, sources, and predictors. Intensive Care Med 2003;29:1489-97.
Jackson SH. The role of stress in anaesthetists′ health and well-being. Acta Anaesthesiol Scand 1999;43:583-602.
Katz JD. Conflict and its resolution in the operating room. J Clin Anesth 2007;19:152-8.
Gillespie BM, Kermode S. How do perioperative nurses cope with stress? Contemp Nurse 2003;16:20-9.
Schaefer HG, Helmreich RL, Scheidegger D. Safety in the operating theatre - Part 1: Interpersonal relationships and team performance. Curr Anaesth Crit Care 1995;6:48-53.
El-Masry R, Shams T, Al-Wadani H. Anesthesiologist - Surgeon conflicts at workplace: An exploratory single - Center study from Egypt. Ibnosina J Med Biomed Sci 2013;5:148-56.
Mechanic D. Managed care and the imperative for a new professional ethic. Health Aff (Millwood) 2000;19:100-11.
Parker BM, Tetzlaff JE, Litaker DL, Maurer WG. Redefining the preoperative evaluation process and the role of the anesthesiologist. J Clin Anesth 2000;12:350-6.
Lipcamon JD, Mainwaring BA. Conflict resolution in healthcare management. Radiol Manage 2004;26:48-51.
Kirschbaum K. Physician communication in the operating room: Expanding application of face-negotiation theory to the health communication context. Health Commun 2012;27:292-301.
Bhattarai B, Kandel S, Adhikari N. Perception about the role of anesthesia and anesthesiologist among the paramedical staffs: Perspective from a medical college in Nepal. Kathmandu Univ Med J (KUMJ) 2012;10:51-4.
Studdert DM, Burns JP, Mello MM, Puopolo AL, Truog RD, Brennan TA. Nature of conflict in the care of pediatric intensive care patients with prolonged stay. Pediatrics 2003;112:553-8.
Frederich ME, Strong R, von Gunten CF. Physician-nurse conflict: Can nurses refuse to carry out doctor′s orders? J Palliat Med 2002;5:155-8.
van Klei WA, Moons KG, Rutten CL, Schuurhuis A, Knape JT, Kalkman CJ, et al.
The effect of outpatient preoperative evaluation of hospital inpatients on cancellation of surgery and length of hospital stay. Anesth Analg 2002;94:644-9.
Parsa P, Sweitzer B, Small SD. The contribution of a preoperative evaluation to patient safety in high-risk surgical patients: A pilot study. Anesth Analg 2004;100:S14.
Thomas EJ, Sexton JB, Helmreich RL. Discrepant attitudes about teamwork among critical care nurses and physicians. Crit Care Med 2003;31:956-9.
Ogbimi RI, Adebamowo CA. Questionnaire survey of working relationships between nurses and doctors in University Teaching Hospitals in Southern Nigeria. BMC Nurs 2006;5:2.
Howard SK, Rosekind MR, Katz JD, Berry AJ. Fatigue in anesthesia: Implications and strategies for patient and provider safety. Anesthesiology 2002;97:1281-94.
Puttagunta PS, Caulfield TA, Griener G. Conflict of interest in clinical research: Direct payment to the investigators for finding human subjects and health information. Health Law Rev 2002;10:30-2.
Rosenstein AH, O′Daniel M. Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. Am J Nurs 2005;105:54-64.
Waisel DB, Truog RD. Informed consent. Anesthesiology 1997;87:968-78.
Truog RD, Waisel DB, Burns JP. Do-not-resuscitate orders in the surgical setting. Lancet 2005;365:733-5.
Davies JM. Team communication in the operating room. Acta Anaesthesiol Scand 2005;49:898-901.
Piper LE. Addressing the phenomenon of disruptive physician behavior. Health Care Manag (Frederick) 2003;22:335-9.
Gerardi D. Using mediation techniques to manage conflict and create healthy work environments. AACN Clin Issues 2004;15:182-95.
Chassin MR, Becher EC. The wrong patient. Ann Intern Med 2002;136:826-33.
Levinson W, Roter DL, Mullooly JP, Dull VT, Frankel RM. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA 1997;277:553-9.
Porter-O′Grady T. Constructing a conflict resolution program for health care. Health Care Manage Rev 2004;29:278-83.
Aschenbrener CA, Siders CT. Part 2, Conflict management. Managing low-to-mid intensity conflict in the health care setting. Physician Exec 1999;25:44-50.
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63:763-70.
Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21 st
Century. Washington DC: National Academy Press; 2001.