Zen and the art of dealing with difficult physicians a three-fold path for enlightened leaders.

Dealing with difficult people can drain the energy out of many well-meaning leaders.

Indeed, when an organization breeds too many tough cookies and not enough resilient leaders, everyone's energy can be siphoned off into a cultural "dark side" of distrust, paranoia and back-stabbing.

Health care organizations are especially vulnerable to tyranny of ill-mannered people because they typically have not invested in communication and leadership skills for physicians. Moreover, many organizations prefer to deal with difficult physicians only when they've crossed the line to "disruptive."

What's the solution to this vexing challenge?

Physician leaders who want to successfully manage difficult physicians can look to Zen principles for an answer. The Zen three-fold path teaches that the art of dealing with conflict begins first with managing yourself and extends to managing yourself with the other.

Fortifying support comes from the collective organization that can develop the skills and the leverage to reinforce a code of conduct when behaviors are unacceptable.

The First Path: Manage yourself

Many physician leaders squirm at the thought of confronting a fellow colleague about offensive behavior.

To keep your cool, focus on the behavior, not the person. Be aware of any bias you may harbor because of behavior style differences between you and the other person. It is imperative that you conduct your discussion without anger, and without a punitive or judgmental tone.

Moreover, assume that the difficult physician is innocently unaware of how they come across (unless he is a repeat offender who has shown no signs of behavioral development or improvement.)

It is surprising how many times physicians are mortified to learn they have insulted someone or hurt other people's feelings, even when it is obvious to everyone else around them.

Managing yourself well, without anger, fear or panic, will be especially challenging when you are the target of negative emotions.

For example, an angry physician is in your office expressing his disdain about how your initiative is going to hurt his department. His loud outburst is probably causing a physiological response consisting of rapid heart rate, raised blood pressure and tensed muscles--which your body is conditioned to interpret as anger or fear. Maintaining a calm demeanor and communicating respectfully will be extremely difficult when your body is screaming at you, "Yell back! Hit back!" or "Run!"

For maximum leadership effectiveness, do not express anger or defensiveness or shrink back in panic. The magic of Zen is that by demonstrating impeccable self-management during these moments of verbal assault you actually build more personal power.

Not power over the other, but the power to respectfully direct that person's negative energy to more productive use.

The Second Path: Coaching approach

When you attempt to guide the behavior of a difficult physician, look at your goal not just as defusing a difficult situation, but also as an opportunity to develop the potential of that physician.

Strategies for dealing with conflict are very similar to strategies for developing and leading a high performance organization.

To help you keep the conversation supportive and nonjudgmental, follow this seven step discussion format that employs a coaching approach to achieve the desired end:

1. Describe the observed or reported behavior and the effect it had on others.

2. Probe for additional information.

3. Probe lot acknowledgment of the event and the effect.

4. Suggest or request a new behavior.

5. Ask for agreement.

6. Offer organizational support for new skills development.

   (Or provide specific information
   regarding code of conduct and
   the consequences for failing to
   adhere)

7. Agree on next steps for follow up.

Dr. B

Because you are the medical director of the hospitalist group, the nursing supervisor of the intensive care unit asks you to deal with hospitalist Dr. B., who made several angry remarks to clinical colleagues.

While on duty last night he was heard by the ICU nurse making disparaging comments on the phone to emergency physician Dr. M.

Within a few minutes after a patient's arrival to the ICU, Dr. B. raised his voice at the ICU nurse asking why the patient wasn't receiving the treatment he had ordered.

The nurse apologized to Dr. B., but was upset and complained later to her nursing supervisor. In addition, to the nursing supervisor's complaint, Dr. M. from the ER has also contacted you with concerns about the Dr. B's attitude. Both Dr. M. and the nursing supervisor say they respect Dr. B's clinical skills and abilities.

On the day you hear this report, you ask Dr. B. to spend 15 minutes with you.

Your dialogue should follow the seven-step discussion format and may go like this:

You: "Bob, last night you communicated with Dr. M. in a manner that he found unsettling because of your anger. Nurse B from the ICU also felt insulted and hurt by your tone of voice. It appears that two family members also overheard you and questioned the nurse about whether there was a problem with the ICU staff. What happened? What was the situation from your perspective?"

Dr. B: "The ER staff is not following the admission protocol for the--diagnosis; and worse than that, their evaluation was incomplete. My evaluation of the patient led to a different diagnosis that required a change in protocol. This delayed us getting the appropriate treatment to the patient."

You: "Bob, what I'm hearing is that you were concerned about the ER staff following the protocol and also whether the admitting diagnosis was accurate."

Dr. B: "Yes, that's correct."

You: "The issue of adherence to the protocol is important for us to address as a group. We will explore whether there are breakdowns in the process and how to remedy this as a team. What concerns me today is the effect your communication had on the morale of the staff and the confidence of a patient's family. Are you aware of the effect you had on them?"

Dr. B: "Maybe I overdid it, but I really didn't mean to upset anyone."

You: "Are you open to a suggestion for how you can better instruct and guide the ER physicians in using this protocol?"

Dr. B: "Yes, of course."

You: "Good! Here's a way to communicate that might be more effective next time:--. How does that sound to you?"

Dr. B: "Thanks for the suggestion."

You: "You know, Bob, the hospital offers a very good physician leadership seminar series; one of the modules is on communication. I found it very helpful when I took the course last year. Would you be interested in enrolling in the seminar series? The course is open to the whole medical staff and I think you'd learn a lot that would be helpful for you."

Dr. B: "That sounds interesting."

You: "I would like us to revisit this again and see how the new communication strategy is working for you. Are you willing to do that?"

The dialogue uses a coaching approach to deal with a physician who has behaved unprofessionally. The physician leader focuses on the behavior that needs improvement and then suggests a new communication skill to try. He closes with a follow-up plan.

Continuing problems with Dr. B

What if this is not the first time you have spoken to this physician about the behavior? If you are dealing with this physician for repeated unprofessional conduct and he has not responded to coaching from you or others, you will modify the conversation.

You: "Bob, this is now the fourth time we've had a report about this specific behavior. According to our physician code of conduct that you agreed to follow when you joined the group, the next step is for me to recommend placing you on probation for six months. During that time, according to our code, if there is another incident, it will mean suspension of your hospital privileges for six months and a leave of absence without pay from the group. Can you repeat what I've said, so I know we have a common understanding?"

The Third Path: Building physician leadership

In the previous scenario, the physician leader refers to two areas of organizational reinforcement for a physician whose behavior is unprofessional:

1. Leadership and communication skills development

2. A code of conduct with associated disciplinary action

These are the two components along the third path of our Zen journey. This degree of organizational support is essential. But unfortunately, it's the missing link for many health care systems.

Building competent physician leaders

Without an infrastructure dedicated to improving the leadership and communication skills of every physician in your organization, you are forever stuck in the tyranny of the disruptive doctor.

Consider that most physicians have never had formal training in effective communication--even during medical school. It is no wonder that many flop in the area of human relations.

Even physician executives who complete some leadership training are often shorted by a lack of ongoing coaching or mentoring to help them successfully apply new skills to the real situations they deal with.

An organization that is serious about reducing the negative impact of difficult docs will invest in building an infrastructure that teaches physicians how to succeed as respectful communicators.

This is not a one-time "charm school" for repeat offenders, but a year-round offering of mining, education and seminars that cover the basics of physician leadership and communication.

Following up with one-on-one or team coaching is another layer of skills reinforcement for physicians. This can be accomplished by outside coaches or physician leaders who have been trained in some basic coaching techniques.

Developing a code of conduct

Another essential reinforcement along the third Zen path is a formal code of conduct for physicians. The code is a statement declaring, defining and demanding mutual respect.

Ideally, the physician group or medical staff creates the code. To serve the group, the code must clearly spell out behavior that is desired versus behavior that is unacceptable.

In addition, a "ladder" approach to reinforcing the code should describe the consequences when a physician takes a step down in professional conduct. To be effective in promoting desired physician behavior, the code must also provide development support at each step to help the physician climb back up the ladder. Support can be in the form of therapy, coaching, training or personal renewal time.

A code of conduct reflects the physicians' collective commitment to rise above unprofessional behavior. Honoring that commitment means sometimes following through with a tough consequence.

Once a physician drops to the last rung of the ladder, one more incident will lead to the harshest consequence, which is usually termination or legal action. What often happens is that organizations fail to act and the physician finds himself perpetually clinging to the last rung. The group may fear losing a highly productive or prestigious clinician. Or they may fear a legal countermove if they follow through.

Failure to appropriately enforce a physician-supported code of conduct, however, undermines every physician who has courageously committed to adopting the code and is deliberately following it.

It is reasonable to delay enforcing a consequence only if the organization has neglected to offer any professional development support to pull the physician back up the ladder.

Here is the real truth about enforcing the code at the last rung: The organization is not kicking out a disruptive physician who slips off the last rung; rather, the physician has made a series of choices to part with the group.

Zen and free will

The Zen approach to dealing with difficult physicians, while borrowing from the ancient, incorporates several modern leadership ideas. Self-knowledge and self-management are key components of emotional intelligence. Managing others by focusing on behaviors and results is a core principle of results-driven leadership.

The code of conduct is a physician version of a mission and values statement. What the Zen approach adds to modern leadership is the reminder that we operate every day with free will and the ability to choose how we behave.

We can ignore the physiological urges that say "attack in anger" or "ran away in fear" and instead we can choose to verbalize in a respectful and honest manner.

Once you integrate that idea into your consciousness, it is nearly impossible to tolerate someone's difficult behavior.

Profiles of Difficult Docs

Difficult docs are often well-meaning physicians who could use some guidance

In working with physician leaders, I find that strategic initiatives are often derailed not so much by the "disruptive" outlier but by a broader cast of characters who are a milder shade of difficult.

Leaders should assume that physicians who appear to be acting their worst may actually have the best intentions. In fact, I know several physician executives and key contributors who began their journey to leadership with the label of "difficult" or "too outspoken."

As a leader, it is important for you to understand a few behavioral styles and personal motivators in order to help these physicians grow professionally and move from a difficult phase into productive participation.

See if you recognize these five profiles:

Passionate Perfectionist

This is a physician who is competent, maybe even outstanding. In their drive to achieve their version of perfect, however, they are quick to point out the shortcomings and failings of nursing and other support staff. It's not unusual for this physician to publicly rebuke people either to their face or through the patient chart.

Characteristically, passionate perfectionists are unwilling to entertain that humans are not machines and that a faulty system, not people, is often the culprit when things don't go according to plan. More importantly, the perfectionist's condescending manner can sink the morale of colleagues--nursing staff in particular.

Like most perfectionists, they harbor an intense fear of failure and want to control as many variables as possible to ensure their work meets their high standards.

As a physician leader, you will find that passionate perfectionists are usually willing to improve their communication once they understand how their negative cloud undermines their drive for good results.

In addition, the passionate perfectionist benefits from a deeper understanding of how "process" versus "people" work in concert to achieve good outcomes.

Cynical Sweetheart

Every health system has at least one cynical sweetheart. This is the person who blurts out in the middle of a department meeting, "That idea is a crock of--!" Everyone in the room smiles nervously and rolls their eyes with a here-he-goes-again understanding.

They typically forgive his frequent loose cannon outbursts because everyone knows deep down he has a heart of gold. Unfortunately, the forceful naysayer intimidates many in the department and inhibits them from participating fully in important discussions. (Who wants to be verbally clubbed upside the head?)

As a physician leader, keep this bit of folk wisdom handy: "A cynic is a passionate person who's been disappointed too many times." Assume that a cynical person--particularly one who verbalizes loudly and in public--cares very deeply and wants to contribute.

Your strategy will be to help them find the best avenue to leverage their courage and verbal talents.

Different Drummer

Society often has a difficult time understanding the artists and creative types among us. But at least artists are easy to recognize.

In medicine, creative physicians have limited outlets for expression and indeed they often present themselves in ways that puzzle mainstream physician colleagues. We sometimes find ourselves feeling awkward in their company and are quick to label them as difficult.

Physicians who are different drummers can come across as strangely aloof or annoyingly animated, as clumsy communicators or eloquent grandstanders. They may passionately champion innovative ideas far beyond the status quo, only to find that their personal intensity prevents anyone from actually understanding their message.

As a physician leader, your job is to actively seek the input of the different drummers and invite them to develop and channel their ideas for the benefit of the organization. As a leader, it is imperative that you be flexible with different drummers. Demonstrate some creativity in how you craft an outlet for their talents.

Territorial Titan

The territorial titan is likely in a chair or director position, assigned with the management of a department. The titans torment by their zealous accumulation and protection of staff, money and projects.

While tenacity might be an occasionally useful strategy to maintain hard-won achievements, the territorial titan won't let up. His overly defensive nature makes collaboration difficult, creating roadblocks for important cross-department projects.

In addition, the titan fosters an adversarial environment, spreading an us-versus-them mentality throughout his team. In dealing with a territorial titan, a physician leader must avoid engaging in battle mentality discourse, while at the same time not shy away from meeting the titan face-to-face when situations arise.

The territorial titan will let down his guard if he feels his opinion is heard, therefore good listening and reflecting are important skills the physician leader will employ.

The wise physician leader will also craft a discussion that begins with acknowledgment of the titan's accomplishments before engaging him about how both of your teams can achieve shared goals.

Truly Troubled

These physicians may have an addiction or serious psychological problem. Addiction to either drugs or alcohol impairs their clinical judgment and may jeopardize patient safety.

The psychological problem may be a short-term impairment such as anxiety or depression that may represent grief or a stress reaction. In more serious situations, disruptive behavior may stem from a personality disorder that requires long-term attention.

In all of these cases, the physician leader will initiate an evaluation to determine whether the behavior is amenable to therapy and whether recovery is possible. While it is important to be optimistic about the truly troubled's recovery, optimism should never be a substitute for adherence to an organization's code of conduct and deliberate intervention according to an established policy.

The physician leaders challenge will be to lead an intervention in a nonjudgmental manner, and also to ensure that a code of conduct actually serves the healthcare organization as intended.

Be aware of physician uniqueness

The wise physician leader realizes that high-functioning teams are those where everyone brings their talents, ideas and quirks to the table. To be open to diverse opinions means accepting personalities that may not be like yours.

If your goals are results and innovation, keep your judgment in check. Deal with difficult people by managing yourself, withholding judgment and guiding physicians to participate in a way that leverages their uniqueness.

--Francine R. Gaillour, MD, MBA, FACPE

Francine R. Gaillour, MD, MBA, CPE, FACPE is president of the Gaillour Group and founder of Creative Strategies in Physician Leadership, an executive coaching resource for physicians who want to develop their potential as leaders, entrepreneurs and business professionals. She is a nationally-recognized speaker on health care' leadership, technology and cultural change. She may be reached at 425-885-5753 or [e-mail]