As a hospitalist, caring for critically ill or injured patients can be stressful and demanding. Working with difficult doctors, those who exhibit intimidating and disruptive behaviors such as verbal outbursts and physical threats as well as passive activities such as refusing to perform assigned tasks, can make the work environment even more challenging.1 Some docs are routinely reluctant—or refuse—to answer questions or return phone calls or pages. Some communicate in condescending language or voice intonation; some are brutally impatient.1
The most difficult doctors to work with are those who are not aligned with the hospital’s or treatment team’s goals and those who aren’t open to feedback and coaching, says Rob Zipper, MD, MMM, SFHM, regional chief medical officer of Sound Physicians, based in Tacoma, Wash.
“If physicians are aware of a practice’s guidelines and goals but simply won’t comply with them, it makes it harder on everyone else who is pulling the ship in the same direction,” he says.
- foster medical errors;
- contribute to poor patient satisfaction;
- contribute to preventable adverse outcomes;
- increase the cost of care;
- undermine team effectiveness; and
- cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.1
“These issues are all connected,” says Stephen R. Nichols, MD, chief of clinical operations performance at the Schumacher Group in Brownwood, Texas. “Disruptive behaviors create mitigated communications and dissatisfaction among staff, which bleeds over into other aspects that are involved secondarily.”
Stephen M. Paskoff, Esq., president and CEO of ELI in Atlanta, can attest to the most severe consequences of bad behavior on patient care.
At one institution, a surgeon’s disruptive behavior lead to a coworker forgetting to perform a procedure and a patient dying.2 In another incident, the emergency department stopped calling on a medical subspecialist who was predictably abusive. The subspecialist knew how to treat a specific patient with an unusual intervention. Since the specialist was not consulted initially, the patient ended up in the intensive care unit.2
One bad hospitalist can bring down the reputation of an entire team.
“Many programs are incentivized based on medical staff and primary-care physicians’ perceptions of their care, so there are direct and indirect consequences,” Dr. Zipper says.
The bottom line, says Felix Aguirre, MD, SFHM, vice president of medical affairs at IPC Healthcare in North Hollywood, Calif., is that it only takes one bad experience to tarnish a group, but it takes many positive experiences to erase the damage.
The Roots of Evil
Intimidating and disruptive behavior stems from both individual and systemic factors. Care providers who exhibit characteristics such as self-centeredness, immaturity, or defensiveness can be more prone to unprofessional behavior. They can lack interpersonal, coping, or conflict-management skills.1
Systemic factors are marked by pressures related to increased productivity demands, cost-containment requirements, embedded hierarchies, and fear of litigation in the healthcare environment. These pressures can be further exacerbated by changes to or differences in the authority, autonomy, empowerment, and roles or values of professionals on the healthcare team as well as by the continual daily changes in shifts, rotations, and interdepartmental support staff. This dynamic creates challenges for interprofessional communication and development of trust among team members.1
According to The Joint Commission, intimidating and disruptive behaviors are often manifested by healthcare professionals in positions of power.1 But other members of the care team can be problematic as well.
“In my experience, conflicts usually revolve around different perspectives and objectives, even if both parties are acting respectfully,” Dr. Zipper says. “Sometimes, however, providers or other care team members are tired or stressed and don’t behave professionally.”
Paskoff, who has more than 40 years of experience in healthcare-related workplace issues, including serving as an investigator for the U.S. Equal Employment Opportunity Commission, says some doctors learn bad behaviors from their mentors and that behaviors can be passed down through generations because they are tolerated.
“When I asked one physician who had outstanding training and an outstanding technical reputation how he became abusive, he said, ‘I learned from the best.’” Paskoff was actually able to track the doctor’s training to the late 1800s and physicians who were known for similar behaviors.
Confronting Those Who Misbehave
Dr. Zipper says physicians should confront behavioral issues directly.
“I will typically discuss a complaint with a doctor privately, and ask him or her what happened without being accusatory,” he says. “I try to provide as much concrete and objective information as I can. The doctor needs to know that you are trying to help him or her succeed. That said, if something is clearly bad behavior, feedback should be direct and include a statement such as, ‘This is not how we behave in this practice.’”
At times, it may not be possible to discuss an emergent matter, such as during a code blue.
“However, I will often ask if anyone on the code team has any ideas or concerns before ending the code,” Dr. Nichols says. “Then after the critical time has passed, it is important to debrief and reconnect with the team, especially the less-experienced members who may have lingering concerns.”
For many employees, however, it is difficult to report disruptive behaviors. This is due to a fear of retaliation and the stigma associated with “blowing the whistle” on a colleague as well as a general reluctance to confront an intimidator.1
If an employee cannot muster the courage to confront a disruptive coworker or if the issue isn’t resolved by talking with the difficult individual, an employee should be a good citizen and report bad behavior to the appropriate hospital authority in a timely manner, says A. Kevin Troutman, Esq., a partner at Fisher Phillips in Houston and a former healthcare human resources executive.
Hospitals accredited by The Joint Commission are required to create a code of conduct that defines disruptive and inappropriate behaviors. In addition, leaders must create and implement a process for managing these behaviors.1
Helping Difficult Doctors
After a physician or another employee has been called out for bad behavior, steps need to be taken to correct the problem. Robert Fuller, Esq., an attorney with Nelson Hardiman, LLP, in Los Angeles, has found a positive-oriented intervention called “the 3-Ds”—which stands for diagnose, design, and do—that has been a successful tool for achieving positive change. The strategy involves a supervisor and employee mutually developing a worksheet to diagnose the problem. Next, they design a remediation and improvement plan. Finally, they implement the plan and specify dates to achieve certain milestones. Coworkers should be informed of the plan and be urged to support it.
“Make it clear that the positive aspect of this plan turns to progressive discipline, including termination, if the employee doesn’t improve or abandons the plan of action,” Fuller says. In most cases, troublemakers will make a sincere effort to control disruptive tendencies.
Troutman suggests enlisting the assistance of a respected peer.
“Have a senior-level doctor help the noncompliant physician understand why his or her behavior creates problems for everyone, including the doctor himself,” he says. “Also, consider connecting compensation and other rewards to job performance, which encompasses good behavior and good citizenship within the organization. Make expectations and consequences clear.”
If an employee has a recent change in behavior, ask if there is a reason.
“It is my experience that sudden changes in behaviors are often the result of a personal or clinical issue, so it is important and humane to make certain that there is not some other cause for the change before assuming someone is simply being disruptive or difficult,” Dr. Nichols says.
Many healthcare institutions are now setting up centers of professionalism. Paskoff reports that The Center for Professionalism and Peer Support (CPPS) was created in 2008 at Brigham and Women’s Hospital in Boston to educate the hospital community regarding professionalism and manage unprofessional behavior.3 CPPS has established standards of behavior and a framework to deal with difficult behaviors.
“An employee is told what he or she is doing wrong, receives counseling, and is given resources to improve,” he explains. “If an employee doesn’t improve, he or she is told that the behavior won’t be tolerated.”
Dismissing Bad Employees
After addressing the specifics of unacceptable behavior and explaining the consequences of repeating it, leadership should monitor subsequent conduct and provide feedback.
“If the employee commits other violations or behaves badly, promptly address the misconduct again and make it clear that further such actions will not be tolerated,” Troutman says. “Expect immediate and sustained improvement and compliance. Be consistent, and if bad conduct continues after an opportunity to improve, do not prolong anyone’s suffering. Instead, terminate the disruptive employee. When you do, make the reasons clear.”
Karen Appold is a medical writer in Pennsylvania.
- Behaviors that undermine a culture of safety. The Joint Commission website. Accessed April 17, 2015.
- Whittemore AD, New England Society for Vascular Surgery. The impact of professionalism on safe surgical care. J Vasc Surg. 2007;45(2):415-419.
- Shapiro J, Whittemore A, Tsen LC. Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Jt Comm J Qual Patient Saf. 2014;40(4):168-177.