Disruptive doctors must know they can get help

(Editor's note: This is the second of a two-part series on disruptive physicians. The October 2008 issue of Healthcare Risk Management discussed how this behavior can threaten patient safety and lead to liability. This month's article provides more advice on how to deal with those professionals.)

Dealing with disruptive physicians is no easy task, even if you recognize the importance of preventing their bullying, abusive behavior. Creating a culture in which such interaction is not tolerated is a good step, but you also must be willing to get physicians help when they need it.

In a recent alert to health care providers, The Joint Commission warned that disruptive physicians can threaten patient safety and announced new standards requiring health care organizations to create a code of conduct that defines acceptable and unacceptable behaviors and establishes a formal process for managing unacceptable behavior. The new standards take effect Jan. 1, 2009, for hospitals, nursing homes, home health agencies, laboratories, ambulatory care facilities, and behavioral health care facilities across the United States. (Editor's note: For the full Sentinel Event Alert, go to http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_40.htm.)

Risk managers are unlikely to know just how much disruptive physicians are affecting their organizations unless they make a concerted effort to ask those who are affected, says David Maxfield, a consultant in Provo, UT, who has studied communication issues in health care and co-authored the book Influencer: The Power to Change Anything (McGraw-Hill; 2007). He says one of the first steps in addressing the issue is to solicit input from the affected parties. Maxfield recently worked with a hospital administrator who sent an e-mail requesting reports about disruptive behavior, hoping to get a half-dozen that might give her some sense of what type of incidents were occurring.

"She got 12 replies in the first day, and then they started pouring in," Maxfield says. "People were walking up to her crying, saying they hadn't told anyone because they didn't think anyone cared."

Maxfield cautions that you must avoid letting physicians feel besieged when the institution starts addressing disruptive behavior. He recalls working with one hospital that was implementing a physician code of conduct, starting in the operating room, when the doctors started to complain that they were being cast as the bad guys. They also felt that the code of conduct was one more in a long series of demands and ultimatums put before them.

"They suggested that, at the same time, we also look at the conditions and behaviors that led physicians to flip out and act in unacceptable ways," he says. "What they found was that, a lot of times, the physician wasn't reacting to any one single incident, but because whatever was happening was part of a longstanding pattern. Once the hospital was willing to say they wanted to address those problems and lower the stress levels, they found more acceptance from the physicians."

Some problems years in making

Disruptive physicians often have a pattern of such behavior that goes back for years, sometimes decades, says Michael Williams, PhD, a principal with the Professional Renewal Center in Lawrence, KS, which treats physicians whose careers are in jeopardy because of disruptive behavior. An early intervention with those doctors could prevent an ongoing problem that gives the physician a bad reputation among peers and staff, which then makes all interaction more difficult, he says.

Streamlining response procedures can help, Williams says. In too many cases, he says, health care organizations must follow such a long, complicated procedure with a series of committees and hearings that it is years between the incident and any resolution. That isn't fair to the physician, and it doesn't do much to improve staff perception either, he points out.

Medical bylaws should provide for some type of disciplinary action short of suspension, Williams suggests.

"Bylaws often only allow you to suspend the doctor's privileges when the offense is significant enough and, of course, organizations are often loathe to do that," he says. "When you have something available that is less than a suspension, then you are more likely to use that option and be able to shape the behavior. Otherwise, the only option is a nuclear option, which can be good for ending behavior but not shaping it."

Any risk manager interested in addressing disruptive behavior must commit to a broad effort that encompasses prevention, immediate intervention, and then post-event analysis, says Alan H. Rosenstein, MD, MBA, vice president and medical director of VHA West Coast in Pleasanton, CA, who has conducted extensive research on the topic and spearheaded his health care system's response. Rosenstein's research with VHA facilities and staff was part of The Joint Commission's basis for issuing the recent call to action.1

"This is not an issue where you can just say you're going to prevent it from happening or you're going to respond after the fact," he says. "You should try to prevent it from happening; but in reality, there still will be some events and you have to be ready to respond appropriately."

The goals of any action plan should be to prevent the events from occurring, but also respond to the events in real time — not days or weeks later. That quick response is essential to keeping disruptive behavior from harming patients or staff, Rosenstein says. Then after the event is addressed in real time, there must be a follow-up later to review what happened.

To implement any plan, Rosenstein says, the risk manager should recruit a physician champion who can spearhead the effort with his or her colleagues. That will greatly increase the chances of success, he says.

Based on his work with VHA facilities that addressed the issue, Rosenstein offers this summary of some of the key steps he says can minimize the dangers of disruptive physicians:

1. Assess the frequency of disruptive behavior and the seriousness. One good method is a confidential survey of staff and physicians.

2. Understand what factors can prompt disruptive behavior. The stress of working in health care is one obvious catalyst, but many other factors may be at play, including race, ethnicity, and economic pressures. Assess what issues may be at play in your own facility and also between certain people.

3. Secure a commitment from top leadership in the organization and then publicize that commitment. Make sure everyone in the organization knows that your top leaders are behind this effort and will not tolerate disruptive behavior.

4. Establish clear policies and procedures, and then enforce a zero-tolerance policy for violations.

5. Encourage incident reporting and make it safe for staff to do so without retribution. Also have a system in which you quickly and consistently respond to those reporting disruptive behavior to assure them that the report is taken seriously and being investigated.

6. Facilitate discussion of the problem among staff and physicians. Offer forums in which people can talk freely. Lunch meetings are one option, but so are more formal avenues such as task forces and medical staff meetings.

7. Provide education and training for both physicians and staff. The first step is simply raising awareness about the problem, and then you can move on to more specific issues such as stress management, conflict management, and assertiveness training.

8. Help staff and physicians improve communication by providing appropriate training and resources. There are many options available, including crew resource management.

9. Have a methodology for intervening in disruptive behavior. Know what you will do when you get a report, be ready to respond, and apply this policy consistently. Some VHA facilities use a "Code White" call for assistance when disruptive behavior requires mediation. It also is important to have a procedure for immediately debriefing those involved to get a clear picture of what happened and how it might be prevented in the future.

Reference

1. Rosenstein AH, O'Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf 2008; 34:464-470.

Sources

For more information on disruptive physicians, contact:

  • David Maxfield, Author, Provo, UT. Telephone: (801) 724-6334. E-mail: dmaxfield@vitalsmarts.com.
  • Alan H. Rosenstein, MD, MBA, Vice President and Medical Director, VHA West Coast, Pleasan-ton, CA. Telephone: (925) 730-3003. E-mail: arosenst@vha.com.
  • Michael Williams, PhD, Principal, Professional Renewal Center, Lawrence, KS. Telephone: (785) 842-9772. E-mail: mwilliams@prckansas.org.