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Squelch Disruptive Docs or Face Consequences

 |  By jcantlupe@healthleadersmedia.com  
   September 13, 2012

One of your top cardiologists, a crackerjack moneymaker for your hospital, just had a great meeting with you about clinical goals. Everyone is smiling.

When the meeting ends and everyone disperses, your doc colleague is a different guy. Out of your view, he is loud and intimidating. He questions others' judgments and cuts people off in mid-sentence. He's abusive to the nursing staff and aides.  Essentially, his behavior can undermine everyone's work, and be a detriment to patients. His actions are the very model of disruptive physician behavior, a phrase gaining weight in the healthcare lexicon.

This behavioral scenario isn't a figment of my imagination, or an anomaly. It is a too-common occurrence in hospitals and physician groups, and can even crop up in the operating room, says Liz Ferron, manager of clinical services and senior consultant for Physician Wellness Services in Minneapolis, MN, a company that helps physicians and health organizations through issues including managing behavioral problems.


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No tolerance for mistakes
"The physician is feeling frustrated by some processes, or things aren't moving quickly enough," Ferron says, by way of explaining some of the "reasons" behind the behavior. Of course, there are a host of them, anywhere from stresses at home to the most likely: "someone who's a perfectionist, who doesn't allow mistakes or tolerate them," as Ferron puts it.

But the cranky outbursts are also open for public view. "Patients themselves see and know what's going on, and they may say, ‘we really don't like the way he treats other staff," Ferron says. "If these physicians are never given feedback, they are truly clueless about how they are impacting people around them."

Unfortunately, physician and hospital leaders too often tolerate such behaviors and don't give culprit docs the necessary feedback to halt the improper conduct, says David Danielson, JD, CPA, senior vice president for clinical risk management at Sanford Health, the largest medical facility in the Fargo, ND and Sioux Falls, SD regions.
 

"If there's a failure anywhere, it's with leadership"
Danielson oversees enterprise-wide clinical risk management programs and evidence-based practices to improve coordination of care. Dealing with disruptive individuals is an integral part of overall safety/risk/quality management programs run by hospitals and physician practices, he says.

"What's interesting is that if there's a failure anywhere, it's with leadership," Danielson explains. "They get scared at the last minute and back down, and yet the behavior goes on. Once leadership gets on board, there's a call for action. "

Those calls for action have been intensifying over the years.

In 2009 the Joint Commission issued an alert about "behaviors that undermine a culture of safety," noting that "intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction" and cause unwarranted employee turnover.

In 2011, a study of 840 physicians sponsored by the American College of Physician Executives (ACPE) and QuantiaMD, found that 77% were concerned about disruptive behavior at their organizations. More than one third of physicians said that disruptive behavior occurs at least once a month at their institutions, while more than one quarter reported incidents once per week. And more than 10% said that such incidents occur on a daily basis.

At least 99% of physicians believe that disruptive behavior ultimately affects patient care.

Physician stress / burnout  a factor
While the survey reported that more than two-thirds of those who responded believe their organizations have a "clear, well-enforced policy" and "structured method" to report disruptive incidents, almost one quarter did not feel comfortable "directly confronting" the behavior, or feel well prepared to deal with incidents.
Last year, in a Physician Wellness Services/Cejka Search survey , 87% of physicians identified themselves as moderately or severely stressed and/or burned out, and 62.3% of physicians identified themselves as more stressed and/or burned out compared to three years ago.

Get out in front of bad behavior
It's important to "look for early signs before a disruptive event occurs," says Alan Rosenstein, MD, MBA, medical director of Physician Wellness Services. He has focused research on the impact of disruptive behaviors on nurse-physician relationships, as well as patient safety and operational issues.

"Creating a solid foundation must start at the organization level, to create strong clear policies, and it applies to everyone—no exception," Rosenstein says. 

For both hospital systems and physician practices, disruptive physician behavior can be expensive if left unaddressed, causing fallout from potential litigation to the cost of hiring replacement physicians, Rosenstein says.

The expense of problematic behavior can run as high as $1 million or more. That estimate covers impaired productivity and efficiency, as well as the costs to recruit and hire new staff as well as litigation expenses, according to Rosenstein.

Despite the potential impacts, only less than 16% of organizations have initiatives in place to deal with stress and/or burnout, they're either a) not enough, b) not relevant, c) not access or d) unknown, according to a Physician Wellness Services/Ceja Search study.

Hospitals and physician groups need to step back, evaluate their personnel policies, examine how their physicians are interacting with staff and patients, and let physicians know that there may be consequences for their negative behaviors.

Termination is only one option
At the same time, it is important to make it clear that the physician doesn't necessarily have to be fired, or quit, depending upon their actions, says Danielson of Sanford Health. Through an extensive, cooperative process, the physician can maintain his or her position by taking steps to acknowledge, and eventually overcome, the abrasive behaviors, according to Danielson.

Sanford Health's human resources department works with its clinical and administrative staff to ferret out the root causes of such behaviors, and it organizes individual approaches to deal with disruptive behaviors, Danielson says.

"You have to feel you are ahead of the curve. Identify [the problematic] people and give them the assistance they need," he says. In some cases, the process can save hospitals from firing a physician, he adds.

Danielson works closely with Physician Wellness Services. Danielson also has been involved in the Vanderbilt University's Patient Advocacy Reporting System, an evidence-based assessment process designed to address behavioral issues that could impact patient safety and quality, as well as help reduce malpractice claims.

Various tools can be used to not only prevent disruptive behavior, but to deal with it if it occurs, according to Rosenstein.

Once a physician is agreeable to being counseled about disruptive behavior, he or she can be involved in "focused assistance." This offers various options, including coaching, various wellness activities, educational seminars, and revised scheduling. Beyond that, anger management counseling, and support for substance abuse are offered, according to Rosenstein.

Physician Wellness "tries to partner with physicians to be successful," says Ferron of Physician Wellness Services. "We're doing a psychosocial assessment of various different factors that may be contributing to behaviors."

Stop bad behavior before it starts
Overall, it's important to stop disruptive behavior, or recognize the signs, even before it starts. "We try to head it off at the pass, working with the doctors and what's driving their behaviors and ideas, so that you can prevent it before you get to the disruptive stage," says Scott Hurst, who most recently served at CHRISTUS Spohn Health System in Corpus Christi, TX, as director of physician alignment and recruitment.

Putting up with the disruptive physician is getting old. "Everyone's been getting sick and tired of disruptive behaviors, notwithstanding Greg House on ‘House'," says Danielson. He was referring, of course, to the title character in the Fox TV show, "House," an irreverent misanthrope who is chief of diagnostic medicine at a leading teaching hospital. A look at some of the things House has said, reveals his abrasiveness.

"The integrity and reputation of an organization is more than any one individual, no matter how good he is, even Greg House at his best," Danielson says.

Danielson, Rosenstein, and Hurst will be speakers on the HealthLeaders webcast, "Managing Disruptive Docs in a New Era of Hospital-Physician Relations."

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Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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