Treating Disruptive Physicians on Tampa Bay Medical News

Treating Disruptive Physicians

By: LYNNE JETER

Professionals Resource Network Focuses on Hospital Rogues

Did you hear the one about the doctor who got into a fistfight with another doctor in the hospital cafeteria?

The Face of the Disruptive Physician

Most disruptive physicians are male surgeons representing neurology, trauma and cardiovascular specialties who are typically overworked and stressed.

They have family issues because they’re rarely home and harbor poor nutritional, sleep and fitness habits.

Despite the perception that the typical disruptive physician is middle-aged or nearing retirement, there’s no concentration in a particular age group, according to Professionals Resource Network.

At the Professionals Resource Network (PRN) annual conference held in late September, psychologists were buzzing about treating disruptive physicians who verbally abuse nurses and colleagues and engage in other unacceptable behaviors. Disruptive behavior represents a new emphasis area for the Florida Department of Health-contracted program responsible for evaluating and treating physicians and other healthcare professionals who have substance abuse issues or other impairments that affect their performance and jeopardize patient safety. (See related stories below.)

Among the more interesting cases discussed:
• When two nurses didn’t comply quickly enough after a doctor gave them an order, he quipped, “Are you too fat or stupid to do what I asked you to do?”
• A surgeon entering an operating room pointed to a nurse assigned to the case and said: “This woman is unacceptable. If you put her in my room, I won’t do the surgery.”
• Another surgeon told a nurse: “I’ll get your license taken if you come into my room again.”
• A doctor filling in for a primary care physician scrawled a sarcastic comment on a patient’s chart: “Thanks for the proper management.”
• After losing patience with an unreasonable patient, one doctor told him, “I’ll come back when you decide to cooperate,” and walked out of the room.
• Others told dirty jokes, made inappropriate gestures, kicked or threw objects, or used profanity. One female physician “swore like a sailor.”

Some of these incidents may seem amusing, but it’s no laughing matter, since problems tend to escalate. Hospital administrators usually refer disruptive physicians to PRN treatment, which begins after evaluation with an intense two-week session at one of three facilities—Acumen Institute in Kansas, University of Florida School of Medicine in Tallahassee, and Physicians Development Program in Miami. The one-year program costs between $3,000 and $5,000 at the participant’s expense.

“When they enter the program, they’re typically in denial and argue with PRN staffers,” said PRN spokesperson John Van Gieson. “They spend a lot of time saying that they’re not disruptive when in reality they’re acting just like they’re disruptive. The treatment providers delve into their backgrounds to see if they can determine why the doctors are disruptive and deal with those issues. They go over why the behavior is unacceptable and discuss ways in which the doctors should’ve responded.”

In his conference presentation, “Treatment of Disruptive Professionals,” Michael J. Herkov, PhD, associate professor at the University of Florida, said the philosophy behind the learning model is that most behavior is state dependent and not trait-based.
“Everyone can improve their interaction skills,” he said. “Change isn’t about masking undesirable behaviors in the workplace, but learning a new, better way to be.”

During the intense initial session, participants learn about themselves through self-exploration and discovery, about others through emotional intelligence, and what to do through skills development. Treatment modules include anger management, stress management, physician wellness, spiritual development, relationship enrichment, and communication skills.

At the end of the initial term, participants sign a behavioral contract, or the equivalent of a relapse plan, specifying expectations and requiring them to join support groups either via weekly conference calls or mental health group meetings in Miami, Orlando, Tampa or Jacksonville.

“In those groups, they’re encouraged to discuss their reactions to stressful situations with other doctors in the program,” said Van Gieson. “The feedback from peers is very important in changing behavior. If three other doctors look at you and say you’re being a jerk, you say, ‘Oh,’ and change your behavior.”

The facilitation of accountability via the program results in positive internal changes for the participant, said Acumen Institute co-director Scott C. Stacy, PsyD. Among them: internationalization of change; recognition of coercion as the presenting problem and not the means of behavior change; prompting the client to grapple with ethics, character and self-regulation; and moving from personal conviction to intentional professional identity. Another benefit of completing the program: Rogue doctors “grow up professionally,” said Stacy.

Related Stories

Joint Commission Takes Action

Even though the problem has been discussed mostly in hushed tones behind administrative doors since the advent of modern medicine, disruptive behavior has been elevated to the forefront in recent years as social and economic factors have shed light on problems related to it that impact the bottom line and patient care.

According to a 2002 survey on the adverse impact of disruptive physicians to nurse retention conducted by VHA, a large network of community-owned healthcare organizations, 90 percent of 2,562 respondents reported witnessing disruptive physician behavior and one in three reportedly knew a nurse who had quit her job because of a physician’s behavior.

Hospital administrators previously reluctant to refer disruptive physicians to programs for treatment became more motivated after the Joint Commission implemented new standards for all accreditation programs on Jan. 1, 2009: The hospital/organization must have a code of conduct that defines acceptable, disruptive and inappropriate behaviors (EP 4), and leaders must create and implement a process for managing disruptive and inappropriate behaviors (EP 5).

Defining Disruptive Behavior

In their presentation at the 2010 Professionals Resource Network (PRN), “Professionalism and the Behavior Problems: Emerging Standard of Care in Evaluation, Treatment, and Monitoring,” Acumen Institute co-directors Peter Graham, PhD, and Scott C. Stacy, PsyD, defined disruptive behavior as “aberrant behavior manifested through personal interaction with physicians, hospital personnel, healthcare professionals, patients, family members or others, which interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care.” It has “the presence of coercion and control, and the absence of persuasion, empathy, and a feedback loop.”

Even though coercive (active) conduct is more obvious—threatening, interrupting, manipulating others to take sides, shouting, making hostile gestures, sexualized interaction, and finger-pointing—the other face of disruptive conduct may be more difficult to discern. Inaction involves avoidance, withdrawal, withholding information, giving coworkers “the silent treatment,” making unilateral decisions, being tardy and procrastinating tasks.

When discussing disruptive behavior trends in 2007, Graham and Stacy acknowledged it wasn’t a new challenge in medicine. They described it as a symptom of organizational conflict and distress at various levels, and pointed out that all physicians, nurses and administrators have a DP, or disruptive potential.

“Each professional,” Graham emphasized, “has his own disruptive threshold.”

Graham said it’s vital to stay focused on the “contagious disease” because of its downside: medical errors, poor patient satisfaction, preventable adverse outcomes, increased cost of care, and personnel issues. For example, when faced with intimidating or disruptive behavior, qualified professionals often seek other jobs, and when they leave, clinical services are disrupted because new teams have to form.