Diagnosis and therapy for the disruptive physician. (Behavior).

TODAY AND FOR THE next 100 years, physicians seeking to provide the best possible care must orchestrate delivery in large systems that include a diverse group of personnel--from technical experts in critical care and transplantation to public health nurses and home health aides.

One of the major advantages of these large groups is that physicians can aggregate human resources--such as increased access to specialists, support staff and complex services--to do their jobs.

But with these major changes, it is important to foster an attitude of mutual respect and collegiality. Any disrespectful behavior can be considered disruptive or abusive and can lead to organizational dysfunction.

While there is no generally accepted definition of disruptive behavior, it generally refers to a style of interpersonal interaction that can lead to substandard patient care and interfere with the orderly operation of the organization.

It's important to recognize that harmonious and respectful relationships among health care providers are essential ingredients of quality care. Many institutions adopt codes of conduct.

Everyone except physicians

Codes of conduct are nothing new in health care, but to a large extent they were often viewed as a standard of conduct for everyone except physicians. In the new dawn, professional, respectful interactions and technical excellence are likely to be of equal importance in determining the true worth of a physician.

Some costs of disruption, such as defending lawsuits and recruiting replacement personnel for those who leave the organization because of a disruptive physician, are relatively easy to quantify.

But loss of morale among caregivers and dysfunctional teams providing ineffective or substandard care is much more difficult to quantify.

Financial costs

The cost of hiring personnel is substantial since many of those who choose to leave have superior technical skills and outstanding experience in specific areas.

For instance, the loss of an experienced scrub nurse or perfusionist in the cardiovascular program can lead to losses from canceled cases, paying staff during downtime and searching for employees with similar expertise.

Recruiting is often more difficult because the bad news about poor working conditions caused by a disruptive physician travels quickly in medical circles.

A more troubling aspect of the financial cost is the legal implications for institutions. Employees could sue claiming a hostile work environment. Worse yet, an injured patient could sue claiming that the disruptive conduct created an unsafe environment where patient injuries were possible.

Morale

Individuals are more likely to perform best in the workplace when they feel valued as members of the team. And as teams become larger and more complex, low morale in one area or in one team member may have a domino effect.

The disruptive physician may create an environment where ongoing education is not fostered. A more injurious and far-reaching problem may occur in an academic institution where a disruptive physician serves as a mentor to trainees who may pattern their behavior after the mentor.

Patient care

Team members may attempt to placate the disruptive physician at the expense of their patients.

If a team worker is concerned that certain information might inflame or provoke the disruptive physician, the worker will be less likely to provide that information even when the information is necessary and appropriate.

Team workers may fail to be forthright in discussions about individual clinical decisions, as well as overall quality of care. Team members may even withhold information with the hope that the disruptive physician will be more vulnerable.

Some team members may reject continuous quality assessment and process evaluation since they could be singled-out for undue or harsh treatment.

A disruptive physician may jeopardize the very processes that make a team successful.

Recognizing disruptive behavior

It's critical to differentiate between the disruptive practitioner and the committed practitioner who demands excellence.

Criticism offered privately with compassion and in good faith with the aim of improving patient care should not be viewed as disruptive. The search for excellence should be encouraged in all organizations.

Conduct that is disruptive should not be tolerated. Classic symptoms of the disruptive practitioner can be easily recognized.

Many of us can relate to people with these traits in our work environment. The symptoms are obvious to team members and discussed in private corners at every opportunity.

Disruptive practitioners believe they are the only ones who care and any problems are due to the incompetence of other team members.

Disruptive behavior can be due to stress, substance abuse and psychiatric or organic disorders. However, the behavior must be addressed regardless of its etiology.

Managing disruptive physicians

Alternatives for managing the disruptive physician include collegial intervention and formal investigation as outlined in an institution's bylaws and policies.

The principal objective of a policy is to ensure high standards of patient care and preserve a professional work environment.

Collegial intervention is the first step and appropriate for less serious incidents. Typically, collegial intervention involves a candid discussion with the physician regarding the questionable conduct.

Early on in the process, discussions can be educational, explaining avenues for voicing concerns about quality or suggesting other means of dealing with the frustrations that led to an outburst.

If conduct doesn't improve, collegial intervention sessions should become more direct and include a clear, unequivocal warning about the consequences for continued inappropriate behavior.

Collegial intervention brings three important benefits:

* It serves as a wake-up call to physicians who may not realize the impact of their conduct,

* It affords an opportunity to establish a record of the offending conduct and the steps taken to remedy the conduct. All too often, years of disruption are evidenced by nothing more than fading memories and an occasional complaint.

* Collegial intervention creates an opportunity for progressive discipline. This is important because, typically, no single. incident of bad behavior is sufficient to take serious disciplinary action.

A formal investigation is necessary if the incident is serious or if informal mechanisms are unsuccessful. Examples of serious conduct requiring immediate investigation are:

* Physical assault of a patient, hospital personnel or other staff member

* Conduct that violates state or federal law

* Conduct with an adverse effect on patient care

With both collegial intervention and a formal investigation there are several critical steps to take:

Fact-finding

Fact-finding is important to understand the incident and get a proper history of the patterns of behavior. In all instances, complaints should be in writing. Reassure the complainant that this information will be held in confidence and will not be revealed to the disruptive physician at this stage in the proceedings. Disruptive physicians are usually in positions of authority and subordinates are at risk for further harassment. Advise complainants that if there are any acts of retribution or other acts of disruptive conduct, immediate action will be taken.

Meeting

Meet with the disruptive physician to outline the nature of the complaint and allow the physician to respond. It is important, however, to plan this meeting in advance. Establish objectives and think through how they can be achieved.

1. Do not let the disruptive practitioner set the agenda.

2. Document the meeting.

3. Stay focused on inappropriate behavior, not its cause.

4. Do not send mixed messages.

Sticking to an agenda is very helpful.

For example, if the disruptive physician tries to shift the focus of the meeting and complains about the incompetence of a nurse or the inefficiencies in the operating room or the non-compliant patients, remind the physician of the purpose of the meeting and offer to discuss other matters at another meeting. Also tell the physician that, regardless of the underlying reason, inappropriate behavior will not be tolerated.

Documentation is very important in both collegial intervention and a formal investigation. It is the institutional memory. It is critical if an adverse action is necessary or if the problem ends up in court.

The tone and type of documentation will vary depending on the type of complaint and the number of times corrective action is attempted, Document all corrective action taken.

Also, don't send mixed messages. For instance, while it might be tempting to start the meeting with a preamble about the value of the practitioner to the organization and then focus on the complaint, avoid this approach because it sends mixed messages and is unlikely to yield a satisfactory resolution.

Blunt, direct, honest communication is the key.

Resolution

Make the resolution clear and unambiguous.

Progressive discipline is usually recommended for behavioral problems. This might include a letter of counsel or reprimand followed by a short-term suspension.

Another useful tool is notifying the disruptive physician that appointment or employment is contingent on acceptable behavior as outlined in the code of conduct. Failure to abide by this code of conduct can result in termination of appointment or employment.

When this approach is taken, it's essential to clearly define acceptable and unacceptable behavior and schedule reviews to determine compliance with the code of conduct.

Follow-up

A very important final step in either collegial intervention or a formal investigation is the follow-up to the complainant. Inform the complainant that the concerns are taken seriously, that a resolution is formulated and a mechanism for monitoring behavior is in place. Specific disciplinary actions should not be shared with the complainant. However, the complainant should be invited to report future acts of inappropriate conduct.

Niranjan Kissoon, MD, is chief of pediatric and critical care medicine at Wolfson Children's Hospital in jacksonville, Fla., and a prQfessor at the University of Florida.

Susan Lapenta, JD, is a partner in Horty, Springer and Mattern law firm in Pittsburgh, Pa.

George Armstrong, MD, is director of medical affairs at Wolfson Children Hospital in Jacksonville, Fla.

RELATED ARTICLE: IN THIS ARTICLE.

A disruptive physician can alienate staff, drive away patients and even land your organization in a lawsuit Consider same practical advice an how to identify and deal with disruptive physicians.

Characteristics of a Disruptive Physician

* Clever

* Controlling

* Charismatic

* Egotistical

* Tenacious 

* Explosive

* Intimidating

* Vindictive

Elements of a Policy to Manage Disruptive Physician Behavior

* A definition of disruptive behavior

* A changed for reporting complaints and concerns about disruptive behavior

* A review or verification process to ascertain the validity of any complaint

* A process to notify the disruptive physician of the complaint

* An opportunity for the physician to respond to the compalint

* Proposed corrective action commensurate with the behavior

* An understanding of who will be involved at various stages of the process

* Guidelines for confidentiality

* Protection for individuals who file complaints

* A monitoring system to determine whether the disruptive physician's behavior improves

Source: Derived from the Report of the Council on Ethical and Judicial Affairs

CEJA Report 2-A-00