Do you have a difficult physician in your OR?

Address problem now, or risk patient safety

They tell staff they are stupid. They expect staff to answer their pages. They berate staff members when they relay information about test results that delay surgery. More complaints of dysfunctional behavior are about physicians than any other staff, according to some same-day surgery managers.

"I go across the country from New York to California, and the stories are the same in every OR," says Suzanne Broadwater, RN, MBA, chief operating officer of Hingham, MA-based Ambulatory Surgical Centers of America, which is a limited partner and manager of 17 ambulatory surgical centers. "It’s a time-honored problem," she adds.

Often, physicians who are approached about their difficult behavior don’t understand, says Michael A.E. Ramsay, MD, chief of anesthesiology and pain management at Baylor University Medical Center in Dallas.

"We’re all Type A personalities — mostly high strung, with high IQs," Ramsay says. "That means we have high math and science skills, not high people skills."

But those personality traits don’t mean that managers should ignore difficult behavior by physicians, he emphasizes. "Once you have a dysfunctional physician in a stressful workplace, you start to develop a loss of morale and team spirit; you get increased turnover of staff; you get poor communication; and staff will withhold information from the physician because they’re frightened of another outburst from the physician," Ramsay says.

When staff withhold information, it’s not the physician who suffers, but the patient, he emphasizes. "This may be information on the patient’s well-being, and patient safety might start to be at risk. It’s important that whatever organization is in charge, whether hospital or physicians group practice, that dysfunctional behavior in a physician is recognized early and intervention is made."

Here are some typical comments from difficult physicians, along with tips from your peers on how to address them:

"Answer my page."

When a surgeon’s beeper goes off, he or she might expect a staff member to answer the page, although that person is involved in patient care.

"You have to bring him back to reality," says Camille L. Collette, RN, BSN, CNOR, clinical nurse IV at Beth Israel Deaconess Medical Center in Boston. "The patient comes first. This is why you’re there."

Some physicians insist you take care of matters that aren’t priority, Collette says. "You just have to stand your ground as a patient advocate."

"You don’t know what you’re doing."

Demeaning treatment by physicians is one of the most common problems that same-day surgery staff report. If your staff have a lot of self-confidence, they should consider this response, Ramsay suggests: "If you’d explain exactly what you want, we’re here to help you." Be very respectful in your reply and not inflammatory, he advises.

In a previous position at another hospital, Collette was visiting the OR in a management role when a surgeon couldn’t get a piece of equipment to work properly and threw an instrument at Collette. She left the area. "He was in no frame of mind to even discuss it." Instead, she took her complaint through administrative channels. "There are many scenarios in which they take out their anger and frustration on the first person they see," Collette says.

"Why wasn’t I given this information earlier?"

When blood work is delayed or abnormal results are relayed to physicians, staff may bear the brunt of their anger because the case might be delayed. "It’s information that can only be delivered once it’s known by the staff," Ramsay says. "They don’t have crystal balls."

Don’t respond aggressively, but speak in a calm, clear manner, he suggests. "Just point out the facts of the situation, where the information was, how they got it, and that the physician got it at earliest possibility."

"Have you heard the one about . . . ?"

Off-color jokes aren’t uncommon in ORs, but staff need to be careful that they don’t have a double standard, Broadwater warns. "They seem to accept the jokes from their favorite physicians," as well as affectionate pats on the back, she says. However, "if they don’t like the physicians, they don’t like anything they do."

You can’t have it both ways, she emphasizes. "These physicians who have been reported or counseled, they’re quick to notice you’re accepting that behavior from someone else." (For information on dealing with sexual harassment, see Same-Day Surgery, September 1998, p. 121.)

In any uncomfortable situation involving physicians, don’t take the comments personally and react defensively, Collette advises. "Just state the situation, in your viewpoint, and usually they respond to that," she says.

Don’t confront physicians one-on-one, Ramsay advises. Consider bringing a colleague of the physician’s to the discussion so you have a "good cop, bad cop" scenario, he suggests. "That way the physician feels that someone is on his side, but you’re all concerned about him. If you do it right, with good data presented in a clear way to the physician, most will listen and change behavior, particularly if there is a protocol out there about what will happen if behavior won’t change." Some same-day surgery managers prefer to have a medical director talk to the offender privately.

Emphasize to physicians that a cooperative attitude will ultimately help them get better care from the staff, Ramsay suggests. "If you’re a good leader, you can pull that off. If you can’t pull it off, if someone clearly is a difficult person, you have to weigh whether it’s worth having [that physician] on board."

For more information on dealing with difficult physicians, contact:

Suzanne Broadwater, RN, MBA, Chief Operating Officer, Ambulatory Surgical Centers of America, P.O. Box 773, Hingham, MA 02043. Telephone: (781) 258-7119. Fax: (781) 741-8127. E-mail: sbroadwater@ascoa. com.

Camille L. Collette, RN, BSN, CNOR, Clinical Nurse IV, Beth Israel Deaconess Medical Center, Boston. Telephone: (617) 667-0115. E-mail: ccollett@caregroup.harvard.edu.

Michael A.E. Ramsay, MD, Chief of Anesthes-iology and Pain Management, Baylor University Medical Center, 3500 Gaston Ave., Dallas, TX 75246. Telephone: (214) 820-3296. Fax: (214) 820-6612. E-mail: docram@baylor dallas.edu.