Managing a clinical disagreement means establishing what each person knows, making the patient-care concern explicit and agreeing a workable next step. It is not a contest to secure an admission, defend a specialty or appear more assertive. The safest conversation may change your position as well as the other clinician's.
This original exercise addresses the managing-conflict domain described in ABEM's Certifying Exam materials, reviewed on 27 September 2026. It is not a recalled station, an official negotiation script or a statement about local admission rights.
Define the disagreement before assigning motives
The fictional patient is Morgan, an adult who developed reduced consciousness and respiratory depression after an uncertain opioid exposure. Initial treatment restored alertness and adequate breathing. The emergency team requested review for continuing monitored care because the exposure was unclear.
A receiving clinician questions whether admission is necessary, having been told that Morgan is now awake and breathing normally. The emergency physician believes discharge is unsafe. Both clinicians say they are concerned about appropriate care, but they are working from different information.
The learning task is to make that discrepancy visible. A response such as "your team always refuses these patients" adds an assumed motive without clarifying the clinical problem. A response such as "you are probably right" avoids conflict but may abandon an unresolved safety issue.
The AHA 2025 special-circumstances guidance, checked on 27 September 2026, recognises recurrent respiratory depression after initial opioid reversal and the need for continued assessment. This exercise does not prescribe a universal observation duration or disposition rule.
Give the clinicians different role cards
Emergency physician card: Morgan initially improved, but the last nursing assessment recorded increasing drowsiness and slower breathing. You have not yet personally repeated the examination. The substance, formulation and possible co-exposures are unknown. You want immediate reassessment and an agreed monitored plan, not simply an administrative acceptance.
Receiving clinician card: The referral summary says Morgan is fully alert with normal observations. You have not heard about the new nursing concern. You know that an observation area may be suitable for some patients, but you do not know whether it can provide the monitoring or escalation needed here. You are willing to reconsider if the clinical circumstances have changed.
Facilitator card: Reveal the discrepancy only if the clinicians exchange their current information. Do not make either role deliberately unreasonable. The exercise should test information gathering and negotiation, not reward the learner for defeating a caricature of an obstructive colleague.
Observer card: Record when new information is elicited, when assumptions are corrected and whether the plan acquires a responsible clinician. Note interruptions and tone, but do not reduce the assessment to politeness alone.
Elicit the other clinician's concern
The emergency physician might open: "I think we are working from different updates. Could you tell me what you understand about Morgan's current breathing and the concern behind your suggested plan?"
The receiving clinician replies: "I was told the observations had normalised and there was no ongoing support requirement. I am trying to establish whether the patient needs an inpatient bed or can safely use the observation pathway."
That answer identifies a genuine question. The disagreement is not necessarily about whether Morgan deserves care. It concerns current physiology, the reliability of the exposure history and the capability of the proposed setting.
The learner can respond: "That was the earlier position. The nurse has now reported increasing drowsiness and slower breathing. I am reassessing that immediately. I do not think we should make a discharge or transfer decision from the earlier observations."
Notice the difference between reporting a concern and overstating it. The clinician has not yet confirmed a recurrence, so it should be described as a new report requiring urgent assessment, not already proven treatment failure.
State the safety issue using concise evidence
Once the bedside reassessment is complete, the fictional findings confirm reduced ventilation and increasing difficulty staying awake. The emergency team resumes appropriate respiratory support and seeks urgent senior help. The patient-care task takes precedence over continuing the telephone debate.
The learner should then update the receiving clinician: "Morgan has recurrent respiratory depression on reassessment. We are treating that now. The question is the level of monitored care and escalation support required after stabilisation, rather than whether the earlier normal observations justified discharge."
AHRQ's TeamSTEPPS DESC tool, last reviewed in July 2023 and checked for this article on 27 September 2026, offers a way to discuss a specific concern and possible resolution. It is particularly directed at conflict management; it should not become a lengthy communication ritual that delays urgent clinical action.
For this scenario, the useful adaptation is short: describe the changed finding, explain the consequence for care, propose the next review and agree who will do it. The clinician does not need to recite the acronym aloud.
Find a shared plan rather than a vague agreement
A workable plan should answer four questions. Who is responsible now? What care is continuing? Who will decide the next setting? What finding requires immediate escalation?
For the fictional encounter, the emergency physician retains responsibility during active stabilisation. The receiving clinician agrees to attend with the relevant senior decision-maker to assess the appropriate monitored setting. The team checks whether the observation area's staffing and escalation arrangements meet the patient's needs rather than assuming that any bed labelled "observation" is suitable.
The plan should also preserve uncertainty about the exposure. A new collateral account might identify a longer-acting preparation or possible co-exposure, but that information still needs verification. It must not be treated as a reason to stop observing the actual clinical course.
AHRQ's handoff guidance, checked on 27 September 2026, emphasises transfer of responsibility alongside information. In the exercise, "we will review" is incomplete until it is clear who accepted the task and how the current team will be contacted.
Compare two dialogue branches
Escalating branch:
"You have to take this patient. We cannot keep dealing with this."
"You said they were fine. This is not an admission problem."
"Then I will document that you refused."
The clinical update has been lost. Neither participant has checked whether the patient's condition changed or whether the proposed setting is capable of providing care. Documentation is being used as a threat rather than as an accurate record of the clinical reasoning and agreed responsibilities.
Cooperative but firm branch:
"The referral described the initial improvement. There is now recurrent respiratory depression, and we are providing support. Can we agree that the disposition decision needs a fresh assessment?"
"Yes. I had not received that update. I will attend, and we should involve the senior team if ongoing support is required."
"Thank you. I will remain responsible while we stabilise Morgan. Please contact me directly when you arrive so we can review the current findings together."
The second branch does not guarantee agreement in every real encounter. It shows how the same concern can be expressed without implying that the other clinician already knew information they had never received.
Introduce a result that changes the negotiation again
After stabilisation, a pharmacist identifies a credible possibility of a longer-acting exposure from available records. At the same time, Morgan's partner reports that other medicines may have been taken. Neither account establishes the full ingestion history.
Ask the learner to update the shared plan without inventing a precise observation duration. The relevant response is to integrate the exposure information, recurrent symptoms and monitoring needs, with toxicology or poison-centre advice where appropriate. The patient should not be categorised solely from the first substance named.
Alternatively, run a second version in which the new nursing observation proves to be a documentation error and the bedside reassessment is reassuring. The learner must then acknowledge that correction. Remaining firm about safety does not mean preserving an argument after its factual basis changes.
Escalate persistent disagreement without abandoning care
When agreement remains elusive, the learner should state the unresolved clinical concern and use the institution's actual escalation route. The exercise can make a senior emergency physician and a receiving-service senior available. It should not invent a universal rule about which specialty must admit the patient.
A professional escalation summary is factual: "We disagree about whether the proposed setting can safely monitor this patient after recurrent respiratory depression. The current emergency team is continuing care. We need senior review of the setting and responsibilities."
That is different from claiming the other clinician is negligent, lazy or unwilling to help. Those conclusions are not established by disagreement alone. The record should distinguish observed events, reported information, requests made, responses received and the resulting care plan.
Debrief the patient-care consequences of the conversation
| Communication behaviour | What the observer should identify | Consequence for the fictional patient |
|---|---|---|
| Clarifying the other account | The clinician asks which observations informed the decision | Outdated information becomes visible |
| Reporting a new concern accurately | A nursing report is distinguished from confirmed reassessment | Urgent verification occurs without overstating certainty |
| Naming an executable request | A clinician, task and report-back arrangement are specified | Review has an owner |
| Revising a position | The learner changes the plan when evidence changes | The patient is not trapped in the original argument |
| Escalating appropriately | Unresolved safety concerns go to the actual senior route | Care continues while disagreement is addressed |
Per iatroX product information, September 2026, conversational practice can be paired with Tutor-led exploration of the reasoning behind a decision. Use a fictional case when rehearsing these conversations. Do not upload identifiable referral exchanges or assume an AI transcript establishes professional competence.
Frequently asked questions
Does successful conflict management mean persuading the other clinician to agree with me?
No. It means reaching a justified patient-care plan, which may require either clinician to revise their position after new information is exchanged.
Should I continue negotiating while the patient deteriorates?
Urgent clinical care takes priority. Allocate appropriate help, stabilise the patient and make the changed situation clear before returning to the disposition discussion.
Does this exercise establish which specialty must admit the patient?
No. Admission responsibilities and escalation routes depend on the institution and circumstances; the exercise teaches clinical communication rather than a universal administrative rule.
Work through the reasoning behind a difficult clinical disagreement →