Confront, Correct, Counsel Disruptive Physicians

New physicians are also assigned mentors for their first three years in the practice to help with the workplace cultural assimilation. There are regularly scheduled individual meetings three or four times a year to provide feedback. "Sometimes it's easy. 'You're doing great. See you in three months,'" Levy says. "Sometimes it's more difficult. 'We've been hearing you're having problems. How can we help you?' So the awareness is there?"

'Rules are what we fall back on'
Fields says it's not enough to simply have a firm set of rules. "Rules are what we fall back on when things aren't going well," he says. "If you are only talking to a doctor when they are 'in trouble,' it creates a bad environment and so having regularly scheduled opportunities for feedback that can be positive and critical is important. It's better to reinforce what is right instead of what is wrong."

Fields says physicians have to get over their reluctance to report abusive behavior by colleagues. "Physicians think of a culture of the physician as a single entity, a box within themselves in terms of their operations," he says. "Unfortunately, that leaves managers of practices as oftentimes the ones who have to deal with this, and probably inappropriately so."

If, despite your best efforts, there is a workplace incident, document it thoroughly. "A key downfall is physicians never make any notes," Reynolds says. "They don't like doing personnel management or review. When there is an incident very little is written up. So when you want to do something once this person is shown to have bad behavior, you may not have a trail that shows a pattern of bad behavior. Every person has lost their temper at one time or another, but if this is a pattern that needs to be dealt with it is important to have a paper trail and document things."

To avoid potential litigation later, Rich says get a signature for every document.

"It should be documented, dated, and signed," he says. "The language should not indicate bias or opinions be of a psychiatric nature, but it should document exactly what happened based upon interviews with the people who observed it and then the physician or other personnel should sign it. The physicians involved should sign it, and that should be part of their personnel file for the doctor so later if you've got to make a case you've got it there. If it involves counseling, the physician who is the subject of the counseling should sign it as well. If there is an agreement for the physician to change his behavior as a condition of continuing with the group, that should be in writing and signed."

Confront, but don't judge
Stick to the facts, Rich says. Document the alleged abuses and insist on corrective action without taking sides. If you think the problem physician is a substance abuser, or just plain nuts, keep it to yourself. "If there is a challenge in court later, the disruptive physician's attorney may argue that the decision was based upon, for example, psychiatric or behavioral diagnoses that your medical group was unqualified to make and may well have been wrong on those diagnosis," Rich says.

He says showing bias or making judgments "adds nothing and it may undercut legitimacy of the corrective action the medical group has instituted. It's much better to use simply the objective facts of what occurred, which speak for themselves."

Reynolds says it's critical that physician leaders who want colleagues to change negative behaviors build trust and rapport "before it gets to the point where lawyers are involved." That's hard to do, she says, when the problem physician is feeling set upon. "Don't show bias. Don't be judgmental," she says. "You have to lay out what expected behavior is, but, if you come in and start pointing fingers, that person is going to react and withdraw and they will be on the phone with their attorney in a nanosecond."