Susan Reynolds, MD, is not a regular viewer of the television show "House," the medical drama that features a brilliant but obnoxious physician who is tolerated in spite of his abusive behavior with colleagues and personal shortcomings that include drug abuse.
"I hate House. There is no way in the world that that doctor would ever exist," says Reynolds, the president and CEO of the Institute for Medical Leadership in Los Angeles.
Reynolds should know. At one time a practicing emergency physician, Reynolds now provides medical groups with coaching, counseling, and strategies for handling problem doctors. Business is good.
Scott A. Fields, MD, professor and vice chair of family medicine and COO at Oregon Health & Science University system, says every physician has the potential to become disruptive or abusive at certain times, in certain situations.
"What we should be worried about are patterns of behavior," Fields says. "Probably 5% of physicians may fit this problem area, but they take up a lot of your time."
J. Peter Rich, a partner at McDermott Will & Emery LLP, says the Los Angeles law firm has even dealt with disruptive physicians in solo practices. "They wonder why they have constant turnover in their staff," Rich says. "They may well benefit from counseling to try to cut their ridiculous turnover costs. In some cases, the physicians are good at dealing with patients, but when it comes with staff they can't keep their temper and they don't know how to treat people properly."
Disruptive behavior can be caused by many factors, internal and external. The troubled physician could have mental health or substance abuse issues. He or she could be working through domestic issues with a spouse, children, or aging parents. There could be dissatisfaction with the practice's business, or philosophical differences with the way care is delivered. Sometimes, some people just don't work well together.
Then, there's the souring economy. Reynolds says doctors aren't exempted from the rough financial times that are affecting everybody's bottom line. "Reimbursements have been cut, overhead keeps rising, and a lot of physicians have been feeling the pinch, which will put them in a bad mood to start with," she says.
That bad behavior can manifest itself in just as many ways, says John-Henry Pfifferling, at the Center for Professional Well-Being in Durham, NC. "It manifests itself in staff crying because they've just been dressed down, treated uncivilly or abusively. It manifests itself in hostile work environment lawsuits. In manifests itself in premature turnover and increase absenteeism. It manifests itself in passive-aggressive behavior," Pfifferling says.
Pfifferling says physicians who confront abusive colleagues are doing everyone a favor. "Because otherwise, everybody loses, including patients," he says. "Because the staff is going to be less empathetic with the patients because they can't stand working for the docs, waiting for the docs to be abusive or humiliating or degrading or disparaging or hypercritical for whatever they've done not perfectly or 'wrong.' And the more defensive or stressed your colleagues or staff are, that is going to be felt by the patients."
"If you really care about your colleague, then you'll not enable the behavior and not continue to cover up or deny or procrastinate about dealing with it," Pfifferling says. "You will confront and say this is what is going on and say this is not acceptable."
Unfortunately, if the intervention isn't done correctly, it could create more trouble. The offending physician could make a counter claim for racial, gender, or disability discrimination.
So, what do you do?
It starts with prevention. Having in place a top-to-bottom and clearly spelled-out workplace culture that expressly forbids negative and abusive behaviors toward colleagues, staff, and patients is critical. "A little bit of prevention along the way also gives leadership the opportunity to help set culture and expectations," Fields says.
With the respective workplace culture in place, Rich recommends a thorough screening process on the front-end. "It's easier to keep out a disruptive physician than to kick one out," he says. "The first question is 'has the group done its due diligence in investigating the physician it's bringing on, either as an employee or a partner?' "
He says the medical group should require the physician to provide a thorough work history, including internships, residencies, medical staff privileges, state license voluntary relinquishments, and any information regarding any prior disruptive behavior. "If he lies, that is grounds for termination later," Rich says.
Rich recommends that new physicians read and inform themselves about your practice's internal code of conduct so they can't later deny knowledge about inappropriate behavior. "Write it into their contact that they agree to act in a civil manner toward colleagues, patients, and others and grounds for termination if they involved in disruptive behavior," he says. "You can expand it beyond the four corners of the practice because outside behavior may bring the group into disrepute."
Abe Levy, MD, the medical director and chief quality officer at Mount Kisco Medical Group PC, in Mount Kisco, NY, says the 190-member physician group makes in clear in the hiring and orientation process that abusive behavior is taboo. "We have a number of policy documents, which new physicians sign," he says. "They sign a policy on privacy, knowing that they cannot look in any patients' electronic record without professional reasons. They sign a policy on fraternization with employees. They sign a policy on workplace harassment. There is a whole list of policies they sign to make them aware of what we expect."
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."