Conflict Management 
Robert Sinyard, Gady Barutwanayo, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
Conflict within the field of surgery is 
inevitable. Considering the complexity of systems 
issues, the high stress of surgery, and imperfect 
people, we should expect to encounter conflict on a 
daily basis. In fact, some conflict should be 
welcomed because it can identify opportunities for 
improvement, to achieve better care. An operating 
theater or ward where people are afraid to speak up 
out of a desire to “avoid conflict” is a dangerous 
place indeed. So the focus of this chapter is not on 
how to avoid conflict, but how to maximize the 
productive type of conflict and minimize the 
personal and detrimental type. 
 
Benefits of Conflict:  
 
Healthy, task-oriented conflict can produce 
numerous benefits:  
 
Conflict Encourages New Thinking 
Although it is often assumed that people 
avoid conflict, many people actually enjoy conflict 
to a certain degree because it can be the stimulus for 
new thinking. Considering a different point of view, 
which sometimes comes with conflict, can open up 
new possibilities and help to generate new ideas that 
might otherwise have not been considered. 
 
Conflict Raises Questions 
Organizational conflict usually leads to a 
series of questions for those on both sides of any 
issues. These questions can lead to new ideas and 
breakthroughs 
in 
thinking 
that 
can 
benefit 
individuals, departments, and organizations. When 
there is no conflict, nothing changes. There is no 
need to question or challenge the status quo. Conflict 
represents an opportunity to reconsider, which can 
lead to breakthrough thinking. 
 
Conflict Builds Relationships 
Being agreeable is nice, but encouraging 
conflict can actually strengthen relationships. 
Organizational 
conflict 
between 
individuals, 
departments and even competitors can help to build 
relationships through mutual understanding and 
respect. Learning to listen and listening to learn leads 
to insights valued by both sides in any conflict 
situation. Leaders who sincerely value the opinions 
and ideas of their subordinates are not only more 
effective leaders, they are also considered more 
valuable by their employees. If an employee feels 
that management values their opinion, that employee 
will value the work more and overall morale will 
increase. 
 
Conflict Opens Minds 
Organizations that teach employees how to 
manage conflict effectively create a climate of 
innovation that encourages creative thinking. Minds 
are 
opened 
to 
new, 
previously 
unexplored 
possibilities. Considering new ways of approaching 
challenges and meeting the demands of a competitive 
business world can result in improvements that 
benefit staff as well as the organization. 
 
Conflicts Combats Stagnation 
Organizations that avoid conflict avoid 
change. Avoiding change is futile and can lead to the 
demise of even successful organizations. Companies 
that encourage staff to approach conflict in positive 
and productive ways can beat the stagnation that 
opens the doors to competitors, challenging their 
ability to provide customers with new and innovative 
solutions. 
 
Managing Yourself 
Consider each interaction in the overall 
context. To “win” the present “battle,” while failing 
to achieve your long-term goal is an overall loss. The 
conflict that happens in the operating room should be 
part of the daily life of any surgeon. If there is no 
conflict, you should ask yourself whether the theater 
staff and you have the same vision for improvement. 
This is not to say that you should trigger conflict 
intentionally. Rather, when conflict happens, it 
means that your team members have their own 
solutions to the problems you face. Value their 
thoughts; often, the worker “on the ground level” 
knows the solution to the problems that vex 
leadership. The way you handle the present conflict 
is the key to winning or losing your team members’ 
trust. 
Conflict Management 
Robert Sinyard, Gady Barutwanayo, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Consider your desired long-term outcomes. 
One example of a desirable long-term outcome is 
psychological safety, an environment where people 
continue to provide honest, accurate information. If 
your team members are afraid or otherwise unwilling 
to provide honest feedback, patient safety is 
compromised.  
 
Psychological Safety exists when team members 
know they can share ideas, thoughts, and 
questions, or even admit mistakes, without being 
punished, humiliated, or having their reputation 
damaged. 
 
You, the surgeon, function as team leader in 
the operating room. Your main goal is to influence 
your team members by creating an environment of 
comfort where everybody feels free to talk even 
during conflict. It is good for you to share with your 
team members what your objectives are and what 
works well for you. 
Success requires clear communication. When 
leading a team, one of your primary responsibilities 
is making sure your team works well together. Often, 
individuals with varying personalities comprise these 
teams. The ability to recognize potential conflicts 
between individual team members and resolve them 
quickly is essential for the projects to proceed 
successfully.  
Consider your own assumptions. Be willing 
to admit that you might be wrong about something 
that you think you know. As you may have noticed, 
this can be difficult for surgeons, since we often have 
in-depth knowledge about a highly specialized topic. 
We may have a hard time admitting that there are 
things we don’t know. But there are many factors at 
play during a patient’s care, most of which are not 
under our direct control or even occurring with our 
knowledge. Worse, people “under” us might have a 
different, perhaps even better understanding of some 
of these factors.  
In a rapidly advancing and changing world, 
the advantage goes to the one who is willing to let go 
of assumptions when the evidence shows that they 
are incorrect. There simply is no room in healthcare 
for the “command and control” approach anymore. 
Those days are over; patient safety and everyone’s 
workplace satisfaction are the better for it. 
 
Preparing for Difficult Conversations 
When you’ve had a negative interaction or anticipate 
there might be conflict, preparation makes all the 
difference. First of all, manage your own emotions. 
Conflicts escalate and often become unproductive 
when the involved parties are too emotionally 
charged to engage in rational dialogue.  
 
Emotional Awareness is the ability to recognize 
and make sense of your own emotions and those 
of others. 
 
Possessing the emotional awareness to sense others’ 
or your own emotional temperature rising in a 
situation is essential for engaging in task-oriented 
conflict. Emotional awareness helps keep healthy 
conflict from spilling over into personal attack. 
 
The Ladder of Inference 
 One of the best tools for cooling down your 
own emotional temperature prior to engaging in a 
difficult conversation is the Ladder of Inference. 
Conflict Management 
Robert Sinyard, Gady Barutwanayo, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
 
The Ladder of Inference. During times of conflict, it is all too 
easy to subconsciously move up the ladder, adding meaning to 
others’ behavior moving “upwards” from there. It is much less 
instinctive to climb downwards examining and questioning 
whether your assumptions and conclusions are valid. Source: 
Biogeographist, CC BY-SA 4.0 
https://creativecommons.org/licenses/by-sa/4.0 via Wikimedia 
Commons 
 
Simply, the ladder helps us strip away our 
assumptions and deal with facts, enabling us to 
consider alternative explanations. Similar to the 
process for creating a differential diagnosis, using the 
Ladder of Inference can prevent us from anchoring 
on specific and often negative narratives. The 
following vignette is a classic example of the ladder 
of inference in action. 
 
Imagine you’re in heavy traffic and already 
late to work. A saloon car from two lanes over front 
of you cuts in front of you requiring you to slam on 
your brakes. You mutter something under your 
breath and wonder why some people think they’re 
more important than everyone else. As fate would 
have it, that car takes the same route to the hospital 
that you do. It hurriedly pulls into the parking spot in 
front of you at which point the driver hurriedly gets 
out and sees you. You roll down your window to give 
him a piece of your mind!  But before you can, he 
apologizes profusely for cutting in front of you in 
traffic while opening the passenger door to help his 
wife who is actively in labor. You smile and tell him 
it was ‘not a problem at all,’ wishing them the best 
as they scurry into the emergency room door. 
 
Did you notice the difference between your 
initial assumption in traffic as compared to your final 
emotional state? An initial narrative about another 
person’s selfishness was actually a story created in 
your mind because you had incomplete facts.  
In the world of healthcare, most people are 
truly invested in providing great care to patients, but 
we often assume the worst. The ladder of inference 
helps us deconstruct these assumptions, in order to 
construct more positive ones. When you know you 
need to engage a consultant, a nurse, a trainee, or 
even a patient about something that has the potential 
to cause conflict, or already has caused it, try using 
the ladder of inference via the following two 
questions: 
 
1. What are the facts of this situation? 
2. Why would a reasonable, rational, kind person 
behave this way? 
 
To illustrate, let’s apply these two questions 
to an example closer to home: 
 
You’re the senior trainee of the thoracic 
surgery service. While rounding in the morning you 
notice that a lobectomy patient on postoperative day 
3 has a new 3 cm pneumothorax after his chest tube 
was removed yesterday. The patient is asymptomatic 
but you think the patient probably needs another 
chest tube. After rounds, you call the consultant 
surgeon who asks that you not place a chest tube but 
instead carefully watch the patient during the day 
and repeat an x-ray in the afternoon. You 
communicate the plans for all the patients to the 
other trainees under your supervision and head off 
to the operating room.  
Conflict Management 
Robert Sinyard, Gady Barutwanayo, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Later on, while you are in the patient care 
area, a nurse approaches you and asks you how 
much suction he should be using for the patient’s 
chest tube because he forgot to ask the intern after 
she placed the tube at bedside. 
 
No doubt a conversation with your intern is 
warranted. But as you feel the hairs on the back of 
your neck rising in anger, you realize that maybe the 
ladder of inference might be helpful here. Well, at 
least you’ll give it a try before you go have a very 
difficult conversation with your intern. First, what do 
you actually know? The intern placed a chest tube 
without your permission? The intern defied the plan 
from the consultant surgeon?  
Actually, none of that. Those are narratives 
laced with inferences. All you know is that the nurse 
is reporting that a patient has a new chest tube. What 
if you did a little more fact finding? For instance, 
suppose you ask the nurse which patient he is 
referring to and you find that there is a trauma patient 
who just got admitted and needed a chest tube? 
Suppose the patient actually has a nasogastric tube 
and the nurse just misspoke? Do you feel your anger 
cooling off already? Much more fact finding, as 
addressed in Question 1, is necessary in this 
situation.  
But, for the sake of the exercise, let’s say that 
you go into the room and indeed see the patient in 
question, sitting with a chest tube in. How could your 
intern do something so horrendous- change the plan 
and not even discuss it with you? How could she be 
so insubordinate? Feel the anger rising again? See 
those inferences sliding in again? Question 2 helps 
us not move up the ladder of inference so quickly. 
Ask yourself, “why would my intern, who I know is 
well intentioned, reasonable, and rational place this 
chest tube?”  
Immediately, this assumption of positive 
intent leads to alternate explanations. For instance, 
what if the patient started decompensating acutely 
and a tension pneumothorax was suspected? Or what 
if the consultant came in and rounded with the intern 
and he asked for the chest tube to be placed? Simply 
considering these possibilities is likely enough to 
bring the emotional barometer down to a reasonable 
place. With a better understanding of the facts and an 
assumption of positive intent, you’re ready to contact 
your intern and dig further. 
 
The Advocacy-Inquiry Technique 
 
As a surgeon, you must be aware of the 
implicit hierarchy. You are at the “top.” The people 
you interact with have interacted previously with 
surgeons; likely they have been reminded, in not-so-
subtle ways, about this hierarchy and their place in it, 
below the surgeon’s. But the best way to resolve 
conflict, and to encourage effective communication, 
is to not use the “command and control” behavior 
that this hierarchy suggests. The Advocacy and 
Inquiry technique is based on two ideas  
1. You have a clear understanding of what is 
happening with the patient. In most cases of 
conflict, you have observed that the plan has not 
been followed somehow. 
2. Since the plan has not been followed, the person 
you’re addressing must be aware of some 
information that you are not.  
 
You give your perspective, usually an 
observation, then give the other person a chance to 
explain the reasons for your observation. In effect, 
you give them the benefit of the doubt and refuse to 
climb up the Ladder of Inference. You strive to be 
“curious rather than furious.” 
 
The Advocacy – Inquiry technique is 
demonstrated in statements such as:  
● “I see that the patient did not receive their 
enoxaparin this morning. Why is that?”  
● “I see the patient has not yet been taken to the 
operating theatre. Are you encountering some 
obstacles?” 
 
There are always obstacles in the way of what is best 
for the patient. Most are system issues, not personal 
ones. Create an atmosphere where your team knows 
you want to help them solve these problems.  
The opposite of this approach is a direct 
confrontation. “Why haven’t you given the 
enoxaparin?” “Why haven’t you taken this patient to 
the theatre yet?” The unspoken assumption, 
conveyed clearly by your tone of voice, is that the 
Conflict Management 
Robert Sinyard, Gady Barutwanayo, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
person you are addressing must be either lazy, stupid, 
or insubordinate.  
You are much less likely to create a culture 
of safety with the latter approach. The system issues, 
the ones that really stand in your way, will remain 
unsolved as you engage in useless conflict against 
people, rather than useful conflict to find solutions to 
these issues.  
You may also find that people around you, 
offended by your assumptions, begin to passively 
resist you and engage in small acts of “sabotage.”  
 
Healthy Team Dynamics 
 
Studies of patient safety clearly show that the 
patient is safest when all members of the team are 
empowered to speak if they have a concern. Patient 
outcomes clearly improve as communication and 
team dynamics improve. The advantage that a well-
functioning team brings is as clear as the advantage 
of using the right medicine or performing the right 
operation.  
As a leader, you set the tone in the patient’s 
care. Your example will determine whether there is 
good 
team 
dynamics. 
Model 
excellent 
communication by speaking clearly, listening 
carefully, and acting on the concerns. Be gracious 
and grateful for others’ input, even when it’s 
negative. In fact, you should seek out negative 
feedback. Serious personality differences between 
some members of the team must be set aside for the 
common goal of excellent patient care.  
 
Ad hoc / On the Spot conflict management 
Despite the utility of all the techniques above, 
there are often situations which don’t allow for any 
rehearsal. These acute moments of conflict are often 
the most dangerous because we’re likely to let our 
emotions get the best of us. Try to convert acute 
conflicts to planned, emotionally calmer ones if at all 
possible. For instance, in a heated moment with a 
consultant, you might consider asking if it would be 
okay to call her back shortly or, in the operating 
room, to speak in private after the case. This should 
give you time to enact some of the techniques 
described above. For those moments where this is not 
possible, here are a few brief thoughts:  
First, try to remain emotionally aware. If you 
sense your pulse skyrocketing, acknowledge it. 
Some find that a few deep breaths through the nose 
helps slow down an accelerating sense of fury or 
outrage.  
Second, try to assume positive intent. 
Reminding yourself that the person on the other side 
of the conflict is a good person and wants good for 
the patient- this approach can help you view her/him 
differently. Similarly, try reminding yourself to be 
curious about why someone is doing something 
seemingly egregious, understanding that they intend 
good for the patient.  
Third, humble yourself, no matter who is at 
fault, and ask for help. This approach will often 
defuse any difficult situation. Virtually all who are in 
healthcare went into the field in order to help others. 
Frequently we can appeal to this sense of service. For 
instance, imagine you're calling a consultant in the 
early hours of the morning. Your opening statement 
may lead to conflict or prevent it. “Hi, this is a 
consult for…” as compared to “Sorry to bother you 
at this time, but we need help with a difficult 
situation and I think your expertise would be really 
useful.”  
Finally, and most importantly, prioritize the 
patient. No matter the conflict among team members, 
providers, or systems issues, choosing to do the right 
thing for the patient in front of you is typically 
something everyone can agree on. Finding this 
common ground is likely the best place to start for 
resolving any conflict. 
  
Conclusion 
It’s worth concluding with three quick 
thoughts regarding growth from conflict both 
personally and interpersonally. Great leaders use 
their experiences to promote growth. It’s been said 
that we don’t grow from our experiences, we grow 
from reflecting on them. If you want to improve the 
way you manage conflict, try scheduling regular time 
to review your past week and consider how you 
performed during times of duress, particularly as it 
relates to conflict. How well did you manage your 
emotions? Did you assume positive intent? Did you 
prioritize the patient? If you had to do it all over 
Conflict Management 
Robert Sinyard, Gady Barutwanayo, Richard Davis 
 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
again, how might you have done it differently? Is 
there anyone that you need to reach out to in order to 
resolve something that still feels unsettled? Do you 
maybe even need to apologize? Admittedly, making 
room in our busy schedules for this time of reflection 
is challenging. But if we don’t, we’re unlikely to 
make any changes next time. 
Second, try your best to view episodes of 
conflict (and any failures in management on your 
part) as opportunities to grow, not indictments of 
your ability. Adapting a growth mindset, even to 
your worst failures, puts you in a frame of mind that 
will maximize your learning and avoid burnout. 
Encouraging this type of mindset into your team is 
equally as important. 
Finally, 
consider 
scheduling 
regular, 
bidirectional feedback sessions with critical team 
members, direct reports, or learners. The higher you 
move in the hierarchy of surgery, the more reluctant 
people are to give you honest input about your 
performance. It will be up to you to solicit this crucial 
information. Scheduling these sessions regularly and 
informing colleagues that they will be expected to 
give and receive performance-based feedback, 
normalizes a culture where feedback is expected and 
appreciated. This type of culture is essential for 
handling inevitable conflict and developing a 
thriving, productive workplace climate. 
 
Robert Sinyard, MD MBA 
Massachusetts General Hospital 
USA 
 
Gady Barutwanayo MBBS 
AIC Kijabe Hospital 
Kenya 
 
Richard Davis MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
December 2022 
