“Problem physicians” are easily recognizable, but often difficult to address. At the 2012 AAOS Fall Meeting of the Board of Councilors and Board of Specialty Societies, five speakers discussed physician behaviors that undermine patient safety and outlined ways that physician colleagues could support changes in those behaviors.
Moderator Frank B. Kelly, MD, first established the prevalence of the problem, asking whether anyone in the audience had ever needed to confront a colleague who was seen as being disruptive or impaired. Nearly two-thirds had—and most agreed that the situation improved as a result. But confronting a colleague is difficult, as Gerald B. Hickson, MD, assistant vice chancellor for health affairs and associate dean for faculty affairs at Vanderbilt University School of Medicine (VUSM), noted.
“Doctors are eager to talk about each other and do so routinely,” he said, “but the notion of sitting down and having adult conversation with each other is something that we’re very uncomfortable with and is one of the greatest problems we have in setting the stage for dealing with what I call these ‘special colleagues.’”
Undermining a culture of safety
Behaviors that undermine a culture of safety, said Dr. Hickson, include, but are not limited to, words or actions that:
- Prevent or interfere with an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (such as intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution)
- Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (such as verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating)
- Threaten personal or group safety, aggressive or violent physical actions
- Violate the institution’s or group’s policies, including conflicts of interest and compliance policies
“When you encounter colleagues whose behavior threatens what you intend to do,” he said, “whether you realize it or not, you weigh the pros and cons of taking action. The biggest issue is that people don’t believe that they will be supported if they act.”
Dr. Hickson identified the following eight essential elements for addressing disruptive behaviors:
- Leadership commitment
- Goals, a credo, and supportive policies
- Surveillance tools to capture observations/data
- A process to guide graduated interventions
- Processes for reviewing observations/data
- Multilevel professional and leadership training
- Resources to address unnecessary variations
- Resources to help affected staff and patients
Dr. Hickson reviewed a program established at VUSM to identify and address physicians at high risk for incurring medical liability claims. “In our experience,” he said, “most of our challenging colleagues respond to a nonjudgmental, respectful, and tiered intervention process. The biggest problem is not measuring the percentage of colleagues who are disruptive, but finding the leadership to address them.”
Using group governance
According to Will Latham, of the Latham Consulting Group, although institutions may have the policies and resources to deal with disruptive behaviors, most individual and group practices do not.
“Toxic personalities survive because we tolerate them,” he said. “In my experience, most physicians are conflict avoiders. Dealing with disruptive physicians involves conflict, so there’s a clear incentive not to confront it—and that’s a huge mistake.
“When group members stop holding each other accountable, what ultimately happens is that they lose respect for each other. It creates a feeling of resentment among those members who feel like they’re being held to a different standard of performance.”
Mr. Latham noted that groups need to have a clear decision-making process that also addresses expectations for group members after a decision has been made and options for groups members who don’t agree with the decision. He encouraged the establishment of a “code of conduct,” which can help remove the issue of personalities from a discussion of behaviors.
A code of conduct addresses questions such as the following:
- What behaviors do we, as members of the group, expect of each other? What is acceptable to us? What is inappropriate?
- What are some of the unwritten rules that guide our behavior?
- What are the rights and responsibilities of each physician?
Once group members have outlined their expectations for each other, several techniques can be used to foster compliance. For example, the recruiting process can focus on behaviors as well as clinical skill, and new members of the practice can be assigned mentors who can help communicate values and expectations.
Addressing the behavior
Martha E. Brown, MD, assistant medical director and associate professor of psychiatry in the addiction medicine division of the University of Florida, outlined a protocol for addressing problematic behaviors.
“First, you must confirm the facts,” she said. “Immediately talk with the physician, point out that what happened was inappropriate, and obtain assurances that the behavior will not recur. Complete a record of the incident and your conversation for the physician’s personnel file. Closely follow up and monitor the physician’s behavior, but don’t be intimidated by threats of legal action.”
Dr. Brown also reviewed a continuing medical education program for distressed physicians originally developed by Andrew Spickard, MD, that is designed to address the specific needs of professionals whose workplace conduct has become problematic, but many times has not risen to the point of a formal referral or is at an early intervention. Repeated or egregious behavior, however, should be reported to the state Physician Health Program (www.fsphp.org).
“Physician health programs (PHPs) can help with early identification, intervention, and appropriate referral of physicians who are affected with an impairment,” noted Dr. Brown, who also pointed out that most PHPs cover a variety of impairments including those arising from physical conditions, mental/emotional problems, disruptive behavior, and chemical dependency/abuse.
“The good news is that studies have begun to demonstrate that addressing the behavior when it first appears can result in positive, dramatic changes in the workplace,” she concluded. “Even though not all can be helped or saved, dealing with disruptive behavior in the workplace results in better team communication, improved patient safety, increased quality of patient care, reduced litigation and malpractice claims, and increased staff morale.”
William J. Hopkinson, MD, a member of the AAOS Committee on Professionalism’s Judiciary Committee, noted that a recent survey found that 71 percent of respondents believed that disruptive behaviors were linked to medical errors; 18 percent of respondents were aware of specific adverse events that occurred because of the disruptive behavior.
Dr. Hopkinson discussed the “cup of coffee” conversation that can occur between two professionals at the early intervention stage. Such conversations, he said, should take place soon after the behavior is noted, in a safe, quiet place. They require a balance of empathy and objectivity, and the expectation is that the physician will self-correct his or her behavior.
“These are nonjudgmental conversations, focused on the behavior,” he said. If, however, the behavior continues, intervention by a local hospital task force or review by a committee of peers may be necessary. “We all need to be involved,” he concluded.
Another member of the AAOS Judiciary Committee, Edward V. Craig, MD, MPH, concluded the program with a discussion of the AAOS Compliance Program and Standards of Professionalism (SOPs). He covered the history and the basis for the SOPs and focused on the impact of the loss of a medical license by a physician who is subject to disciplinary action for disruptive behavior.
According to Dr. Craig, the most difficult cases deal with physicians who have substance abuse issues. The extent of the problem is significant, as the following figures show:
- At some point in their career, 8 percent to 12 percent of physicians will develop a substance abuse problem.
- At any given time, 3 percent to 7 percent of physicians are active substance abusers.
- If they are left untreated, physicians who are substance abusers have a 17 percent mortality rate.
“If the statistics are correct,” said Dr. Craig, “among current U.S. orthopaedic surgeons, 2,500 to 3,700 will develop alcohol or substance abuse problems at some point in their careers.” Although PHPs do have programs to deal with these issues, 17 percent of orthopaedic surgeons practice in states that do not have PHPs.
This fact leads to disparities in both treatment and professional compliance. Orthopaedic surgeons in states with PHPs have a confidential, nondisciplinary treatment option; those in states without PHPs may have to face a medical licensing board, with subsequent loss of licensure, public disclosure, and possible suspension under the AAOS Professional Compliance Program.
“Should the AAOS be doing more?” asked Dr. Craig, and answered his own question by proposing additional education on the SOPs at the AAOS Annual Meeting, through AAOS publications (including AAOS Now), and with online education modules for residents and candidate members.
To view these and other presentations from the AAOS 2012 Fall Meeting, visit www.aaos.org/fallmeetingpres
Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at firstname.lastname@example.org
The impact of disruptive conduct
According to Dr. Hickson, disruptive conduct by medical professionals threatens retention, increases the probability of burnout and promotes jousting (defined as one healthcare professional criticizing another or an institution).
“This is a classic example of ‘managing down,’” he explained. “If, for example, a nursing professional has no formal or safe way to report unprofessional behavior by a physician, he or she may choose a less formal and potentially destructive way to ‘report,’ including voicing subtle, but real, criticism of the doctor to (or in the presence of) the patient or patient’s family. In the face of an unexpected adverse outcome, many lawsuits may be traced back to medical professionals who have made it clear to a family why they think the bad outcome occurred.”