Informal Approaches
- Approach physicians collegially
- Express care but demand change
- Offer outside help
- Follow up until resolved
People in conflict tend to complain to a third party, as opposed to dealing directly with each other. Resist the pull to participate in conflict-escalating communication triangles.
It is imperative that both firmness and compassion be used when confronting the disruptive physician. Have documentation of specific behaviors that are unacceptable and must change. Documentation is critical. Without documentation of the impact the behavior has had on others, it will be difficult to help the physician develop any insight into his or her effect on others.
Many physicians displaying patterns of disruptive behavior may regularly feel remorseful and ashamed of their behavior, and at some level they want help to change. Take time to listen, offer concrete suggestions for positive change, and close with compassion but firmly underscore that the disruptive behavior must change. Challenge the physician to make changes or face progressively serious consequences.
Offer outside help, if needed; e.g., TMA, CMS PHR committee, hospital-based PHR committee. There are facilities that conduct assessments for disruptive behavior – a list is available from the TMA PHR Committee. Follow up to ensure that positive change occurs.
Formal Approaches
- Review and refine a written code of conduct consistent with the Joint Commission Standard
- Review and revise policies for dealing with violations
- Ensure and participate in workplace training
The first step to address the problem of disruptive behavior is to be proactive: develop and implement a written code of conduct and a method for responding to inappropriate behavior. The medical profession has long subscribed to high standards of ethical conduct. As a member of the profession, a physician must recognize responsibility not only to patients but also to society, other health professionals, and himself. The AMA Principles of Medical Ethics are not laws, but standards of conduct which define the essentials of honorable behavior for the physician. The first principle requires physicians to be dedicated to providing competent medical care with compassion and respect for human dignity and rights.
Development of a clearly-stated code of conduct, as well as institutional policies and procedures for dealing with violations of these standards, are prerequisites to fostering positive relationships. Managing workplace conflict is one of the most important, but also perhaps most stressful and time-consuming, tasks faced by today’s physician leaders. The key is to be proactive and have written standards in place. A code of conduct that is adopted while in the midst of a complaint is likely to be perceived as a punitive, personal attack by the physician in question.
No code can specify every possible violation. However, it should be based on an entity’s mission statement, and it should specify both blatantly unacceptable behavior, as well as behavior that can subtly damage morale, productivity or reputation. (Subtle behaviors that undermine group cohesion include secretive decision-making, lack of or indirect communication and passive aggressive behavior.)
Establishing ground rules for professional conduct is essential. The formality of guidelines helps keep disruptive physicians in check without making them feel they are under attack. Professional codes of conduct also can be beneficial to screen out prospective physicians who are not team players.
Offer workplace training that fosters positive relationship skills. When a problem arises, pay attention to how complaints are handled.
Action Steps
- Investigate and validate
- Define the problem
- Intervene when indicated
- Refer for evaluation
- Obtain treatment recommendations
- Monitor
Once a case of disruptive behavior by a physician is reported, the next step is to address the problem, usually by a peer review process (such as a hospital wellness committee), always expressing concern for the individual. Privileges to practice in the facility may be used as leverage to convince the physician to agree to the requested evaluation. In situations where the facility does not have such a committee, the TMA PHR Hotline can be utilized, or concerned peers may contact the county medical society PHR committee directly.
Steps of a peer review process begin with a discreet investigation and, if the allegations are substantiated, an intervention and/or a referral for evaluation occur. Policies should be reviewed and followed.
Disruptive behavior does not occur in a vacuum. Unhealthy hospital systems contribute to this behavior and must be examined to correct unhealthy systems or cultures that contribute to frustrating clinical experiences for a physician.
Physical assault, conduct that violates state of federal law, and conduct that has an adverse effect on patient care are grounds for an immediate investigation to occur.
Intervention
- Establish a clear goal for the intervention
- Conduct intervention in a private neutral setting
- Assure privacy, confidentiality, and adequate time to address needs
- Present information in a clear, non-judgmental manner, including dates and times of situations
- If situation warrants, discuss need for an outside evaluation
- State expectations clearly regarding any future occurrences
- State consequences of non-compliance with expectations
- Document summary of meeting in peer review file
A clear goal should be established for each intervention (for example, to identify the physician’s disruptive behaviors and to expect him or her to stop these behaviors). A referral to a mental health professional for a formal assessment and evaluation may also be a goal of the intervention.
An intervention should never be done alone, as group confrontations are safer and more effective. A supporter of the physician, but not one who condones or minimizes the behavior, should be included. It is often most beneficial to let peers take the lead since physicians are generally more likely to accept criticism and recommendations from their peers than from someone with merely administrative authority. A neutral setting should be selected that allows for privacy and confidentiality to be maintained. Equally important is setting aside a sufficient amount of time to adequately address the matter.
Information should be presented in a clear, non-judgmental manner, focusing on the disruptive behaviors, including specific dates and times they occurred.
An effective intervention may result in a referral to a mental health professional for evaluation. The referring source and the physician are best served if there are clear limits and consequences enumerated and enforced.
When making a referral for an evaluation, a minimum of three mental health professionals or entities ideally should be offered to the physician. This will allow the physician some leeway in where he or she goes for evaluation/treatment, yet ensure that a reputable, non-biased source is utilized.
Expectations regarding any future occurrences and consequences of non-compliance with expectations should be clearly spelled out. A summary of the meeting should be documented in the peer review file.
Progressive Intervention
Informal
- Informal “cup of coffee”
- Awareness “come to my office
Formal
- Authority “chief meeting” (final warning)
- Disciplinary
- Summary suspension
- Fair hearing/due process
- Texas Medical Board
Level 1. Awareness Intervention. First inappropriate behavior; non-adversarial one-on-one discussion with chair/section chief; possible referral to health and well-being committee.
Level 2. Authority Intervention. Persistent inappropriate or first disruptive behavior; apology; letter of admonition; and referral for evaluation and rehabilitation plan. Further isolated incidents that do not constitute persistent repeated inappropriate behavior treated similarly.
Level 3. Disciplinary Intervention. Disruptive behavior continues; final warning before initiating corrective action. Disruptive behavior recurs; appropriate corrective action initiated per bylaws and due process rights. The use of summary suspension should be considered only when the disruptive behavior presents an imminent danger to the health of any individual. If no corrective action is taken, the file will be expunged after two years.
Ethical Principles for Conversations
Suggested approaches for informal conversations
- Your role is to report an event
- Approach as if delivering bad news to patients
- Beware of tendency to downplay seriousness
- Know message and “stay on message”
- Assure confidentiality
- Anticipate various reactions
Principles for “Informal” Conversations
- Your role is to report an event. It’s not a control contest (“I am coming to you as a colleague…”)
- Approach using same principles as for sharing bad news to patients
- You are letting the colleague know that the institution has eyes and ears (surveillance)
- Beware of tendency to downplay seriousness. Balance empathy and objectivity.
- Know message and “stay on message”
- Know your natural default
Opening the Conversation
- Offer appreciation (if you can): “You’re important. If you weren't, I wouldn't...”
- “I heard…,” “I saw…,” “I received…”
- Briefly review incident in as much detail as appropriate
- “Colleague's view” -- Wait/ask for colleague’s view …
- Respond to questions, concerns
Ending the Discussion
- Appreciation, affirmation
- Empathy: “Now I feel I understand...but…"
- Accountability: "But we've all got to respond professionally..."
- Reminder: “incident did not appear consistent with..."
- If asked, coach: "reflect on the issues, think about ways to prevent recurrence"
Assure: conversation confidential known only
- Confidential, to…. “Me and chair of the Wellness Committee only”
- Follow-up: “I am confident it won’t be necessary, but..."
Anticipate Various Reactions
- Rationalizations, explanations of behavior
- Acceptance, professionalism
- Denial, anger, narcissistic, hurt
- End-around the chain of command
- Requests for help with change
Ethical Principles for Conversations (cont’d)
What a “cup of coffee” is not:
- A control contest
- Therapy (for the individual or yourself)
- A hierarchical or enabling conversation
- An opportunity to address multiple other issues
What if behavior recurs?
Intervention escalates as does the behavior’s impact on safety. If a pattern of behavior is apparent, intervention becomes more formal and may require reeducation, training, and departmental awareness. If pattern persists, intervention becomes authoritative possibly involving department chair supervisor/peer review, final warning. If the behavior continues, follow bylaws for disciplinary procedures
(adapted from Hickson, GB. Discouraging Disruptive Behavior: It Starts with a Cup of Coffee! Center for Patient and Professional Advocacy, Vanderbilt University Medical Center, 2009)
What to Say to a Colleague
I am aware of your behavior and I am concerned
- I have faith in your ability to improve
- Help is available
- Seeking help may save your life and career
- Not seeking help can have serious consequences
The above list contains suggestions of how a physician might express concern to a colleague who may be impaired by a mental disorder.
Appropriate Focus
- Address problematic behaviors
- It’s not the person, it’s the behavior
- The “why” is not important at this point
“Why” inappropriate behavior has occurred should not be the primary focus; rather, concentrate on the behavior that is unacceptable or jeopardizing the operation of the practice, hospital or other entity. If efforts to facilitate behavioral changes are not successful and disciplinary action becomes necessary, it will be easier to prove that such action was based on the behavior and not on a disability.
Personality and bipolar disorders are protected under the Americans with Disabilities Act. Therefore, focusing on the behavior that is unacceptable is crucial.
Referral for Evaluation
- Physician agrees to participate in a comprehensive evaluation (physical, neurological, psychological)
- An agreement is entered into whereby the physician agrees to follow treatment recommendations
A comprehensive evaluation includes the following dimensions: physical, cognitive, psychological, neurological, and metabolic.
An evaluation may be conducted either on an outpatient or inpatient basis. An outpatient evaluation could often be accomplished by psychiatric physicians competent in issues of physician impairment, including Substance Use Disorders. Inpatient evaluations are often provided over a 72-96 hour timeframe. Evaluations should be paid for by the hospital. The physician should be given a choice of evaluators, and conflicts of interest should be avoided.
When a physician agrees to participate in an evaluation, it is often necessary that someone remain with the physician at all times, from the time of the intervention until the physician arrives at the place of the evaluation. This is especially important in the physician who is very depressed or who has been in significant denial and is experiencing a lot of shame regarding the intervention. The window of time after the intervention and before the physician arrives at the site of evaluation is a time of high risk for suicide.
An agreement with the physician should be entered whereby the physician agrees to follow any treatment recommendations made by the evaluating team. Such agreement should be undertaken within the peer review process. The physician should be requested to sign proper waiver forms for the referring facility and with the members of the mental health team who will be involved in the evaluation/treatment process. So that all involved parties have access to needed information. This agreement helps to ensure the best evaluation and establish a monitoring protocol.
The circumstances in which the counseled physician is uncooperative, or, if requested, refuses to agree to an evaluation is addressed in the next section.
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