Laboratory stewardship programs ensure proper test ordering and interpretation while reducing financial toxicity for patients. Implementing stewardship policies — such as reducing reference laboratory send-outs, not ordering large panels when smaller panels will suffice, or transitioning from historical tests to modern assays — usually goes well, since most clinicians are competent and committed to doing a terrific job.
However, this article is not about them. Rather, it’s about the smaller, but still significant, percentage of clinicians who push back on established laboratory stewardship policies, creating friction with lab professionals who are also committed to doing a terrific job. In these situations, lab leaders can benefit from cultivating their skills in conflict management.
Managing conflict in stewardship is not about being nice; nor does it require you to act like a bully. Rather, it is about deploying a toolkit and having the courage of your convictions. Based on our experiences, as well as those of other members of PLUGS (the Patient-Centered Laboratory Utilization Guidance Service), we have assembled four practical tips to help laboratory leaders manage stewardship conflicts effectively.
1. Reduce or eliminate emotional emails and texts
A foundational rule of conflict management in laboratory stewardship is to dramatically reduce or eliminate the use of email and text messages to express emotional content. If a clinician gets upset about a restricted test order, firing off a clever, insulting, and lengthy defense only communicates that you are not a seasoned conflict management professional.
Email and text are efficient for transmitting straightforward information about your schedule and availability. When conflicts are not involved, they are also great ways to share facts and documents. But when disagreement arises, these tools can be easily misinterpreted and often escalate the situation.
If you feel compelled to write a heated response detailing why an ordering provider’s demands are unreasonable, our advice is to go ahead and write it — but save it to a personal journal and practice the ancient art of the “letter never sent.” Once your anger has dissipated, delete the draft and schedule an in-person meeting, allowing time for thoughtful preparation.
Stewardship application: Imagine that a clinician sends an angry, three-page, bulleted screamer of an email to a lab professional because a new test panel was sequestered for review by the stewardship process. Rather than responding in kind, consider communicating the following succinct and professional message by email or text: “Hello, I received your note about the panel. Can you please send me some times when we can schedule a personal meeting or Zoom call to discuss? I am available this afternoon and have good availability tomorrow and Wednesday as well. Thanks.”
2. Stick to the facts
When a stewardship boundary is enforced, clinicians may become defensive, introducing tangential arguments or even attacking your character or the performance of the lab. They might claim that laboratorians do not care about patients, or that a specific instance reminds the clinician of the time your lab made an (unrelated) error.
The best way to counter this is by remaining factual. Your job is to address the lab stewardship problem without condescending to the person criticizing you. Adopt the philosophy that you are dealing with a competent clinician who comes to work to do a terrific job — which is usually correct. Specifically, do not allow the conversation to drift into a debate about who is more ethical, or how well clinical practices were managed at a previous institution.
Hate will grow like a weed if you nourish it with the fertilizer of “I am smarter than you” or “I could not care less about your previous hospital.” Good stewardship practice is to depersonalize the situation and frame your responses in terms of established policies and the rationale behind them.
Examples of reducing unnecessary conflict
Angry provider | Your response |
| “At my previous institution, we ordered this profiling panel whenever we wanted. You’re just trying to micromanage my practice in an area where I am an expert.” | “I appreciate your expertise. Our institutional lab stewardship policy requires that we review requests for new tests so that we can establish medical necessity criteria and reduce the likelihood of high patient out-of-pocket expenses.” |
| “The laboratory obviously doesn’t care about the turnaround time for these critical cancer patients.” | “This meeting will be useful, since it is about establishing approved clinical pathways for cancer genomic profiling. The pathways reduce turnaround times and increase the accuracy of test ordering.” |
3. Prepare face-saving measures and plan the space to meet
Conflict management is not about wielding your authority as a CLIA director or lab administrator, as temporarily satisfying as that might feel. Instead, before entering an important stewardship meeting where there has been some previous conflict, identify realistic face-saving measures to help the clinical team accept stewardship policies and boundaries without feeling minimized.
Furthermore, at in-person meetings, it is worthwhile to arrange the space in a way that helps lower the emotional temperature. Thus, if a meeting requires multiple laboratory representatives and clinical stakeholders, avoid a confrontational layout where opposing teams line up on opposite sides of a conference table.
Arrive early, mix up the seating arrangement, and bring a lab team that matches, but does not exceed, the professional status and hierarchy of the attendees. In one-on-one interactions where there is a history of conflict, it can sometimes be helpful to invite a neutral third party to promote calm behavior. For virtual meetings, ask everyone to turn their cameras on. This can help de-escalate situations, since seeing faces builds empathy; at the same time, be mindful of what your own body language is communicating.
Stewardship application: A medical department strongly resists transitioning from an expensive, unapproved external laboratory for cancer genomic profiling to an equally valid, highly efficient in-house assay. Instead of issuing a blanket denial, the stewardship team prepares a face-saving compromise. The laboratory agrees to allow the use of the external vendor to test for one highly complex tumor sub-type where the data are still evolving, while establishing the in-house assays as the standard for the remaining cancer profiles.
Additionally, the stewardship team arranges for collaborative educational and research opportunities regarding the in-house test, so that care providers and lab personnel can learn, teach, and perhaps even publish together. Face-saving measures protect the dignity of all parties while supporting the overarching clinical and academic goals of your institution.
4. Be a “broken record” with key phrases
When clinicians realize that a laboratory policy is firm, they may attempt to widen the argument to overwhelm a younger supervisor or administrator. In these moments, a reasonable approach is to employ a “broken record” technique. This involves choosing a concise, calm, and accurate core phrase and repeating it as needed to keep the discussion on topic.
Pairing the broken-record technique with specific, non-escalating phrases allows the supervisor to acknowledge the clinician’s perspective while firmly maintaining stewardship guardrails. Useful phrases include:
- “This meeting is specifically about ... ” This keeps the stewardship goals narrow and prevents historical grievances from derailing the discussion.
- “I appreciate that you said that ... ” This affirms that the clinician has been heard without agreeing to deviate from standard policy.
- “That would be a separate conversation. With regard to this meeting …" Use this when a provider tries to bring up unrelated personal or operational complaints.
Stewardship application: A disgruntled care provider demands that the lab rapidly process and send out a sample for a new test that has not been approved by the stewardship committee. The provider is shouting “I know what I am doing! You are wasting my time and blocking clinical care!”
Despite feeling intimidated, the junior laboratory supervisor smartly chooses to deploy the following broken record technique: “I appreciate that you are concerned about your patient’s timeline for this test. Our policy is that a new test being ordered rapidly like this must be reviewed by the laboratory physician on call. She will call you to discuss it in the next 30 minutes.”
If the provider continues to vent, the supervisor remains calm, repeating: "I hear your frustration. Our policy is that a new test request like this is reviewed by the laboratory physician on call. She will contact you in the next 30 minutes.”
Preparing for a long-term collaboration
The most successful laboratory stewardship programs reduce the chance of a high-conflict scenario by actively participating with clinical teams and regularly giving them positive reinforcement for their excellent test ordering practices. This helps the lab team avoid becoming the “bummer” department that only shows up to deliver bad news, deny tests, or issue corrections to clinicians.
When lab leaders develop a reservoir of goodwill, clinicians are more likely to perceive stewardship policies as rational and protective rather than as bureaucratic obstacles.
Summary checklist for laboratory stewardship leaders
- Stop the electronic escalation: Strongly reduce the use of email or text messages for any emotional or conflict-driven communication.
- Maintain narrow scope: Stick to clinical data and facts; pivot away from responding to personal attacks in kind, and do not initiate any of your own.
- Design the environment: Bring appropriate peers to stewardship meetings, and don’t be afraid to mix up the seating arrangements.
- Repeat key phrases: Use the “broken-record technique” to maintain guardrails, depersonalize conflicts, and move toward resolution.
Michael Astion, MD, PhD, is director of regional laboratories, director of point-of-care testing, and co-director of reference laboratories in the department of laboratories, Seattle Children’s Hospital and a professor of laboratory medicine and pathology at the University of Washington in Seattle. +EMAIL: [email protected]
Jane Dickerson, PhD, DABCC, is the division head of lab medicine and medical director of the core lab and reference lab services at Seattle Children’s and Elizabeth and George Smith Endowed Chair in Molecular Diagnostics and a professor of lab medicine and pathology at the University of Washington. +EMAIL: [email protected]
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