If you’ve been a hospitalist leader for a few years, you likely are familiar with the specter of the disruptive physician. Most group leaders dread dealing with a hospitalist who exhibits behavior that upsets the group or the hospital staff; fewer meet the task head-on and try to change that behavior; and fewer still enjoy the challenge.
If you fall into one of the first two categories, take comfort in knowing you aren’t alone. But if you know that problem hospitalists are a management challenge, you should seek counsel or training to address such issues when they arise.
—Aaron Gottesman, MD, FACP, Staten Island (N.Y.) University Hospital
Managers are responsible for maintaining equilibrium in their HM groups, so it’s important to understand what constitutes disruptive behavior. “What it really comes down to is behavior which can impair patient care, collegiality, and the overall work in the hospital,” says Aaron Gottesman, MD, FACP, director of hospitalist services at Staten Island University Hospital in New York. “If a specific physician or other staff member acts in a way that hampers staff satisfaction, patient satisfaction, and obviously care, then that is disruptive.”
Disruptive behavior in the hospital can come from any staff member, not just physicians. Disruptive physicians receive greater attention because their bad behavior is more likely to be noticed and reported. And they do tend to get angry. “Physicians are time-sensitive, and they’re perfectionists,” says Timothy J. Keogh, PhD, assistant professor at the Citadel School of Business Administration in Charleston, S.C., who has researched physicians’ personality traits. “When they’re put in a stressful situation—such as an ED or ICU, where the outcomes may be uncertain and they’re operating on insufficient sleep or under stress—you may see this behavior.”
Although HM is a stressful career path with challenges of its own, Dr. Gottesman says he rarely notices the same level of disruptive behavior as can be found in the ED, OR, or ICU. “I don’t think it occurs among hospitalists any more than among the general physician population,” he says. “Hospitalists are not under the same time constraints; they don’t have as much stress or pressure—or at least they have a different kind.”
So who is responsible for dealing with a physician who behaves badly? In all cases, it should be the individual’s immediate supervisor.
The crucial component in dealing with a disruptive employee is to have an official behavior policy that is shared with everyone in your organization. The Joint Commission recently required hospitals to employ a code of conduct that outlines acceptable and unacceptable behavior, and it sets a process for addressing problematic behavior.
“You can bet physicians and nurses know it, including the disruptive individuals,” Dr. Keogh says. “This will make it much easier for executives to enforce.”
Dr. Gottesman relies on his organization’s policy. “It’s absolutely critical to have a sense of direction, to know what’s appropriate and what’s inappropriate, to have a procedure to follow,” he says. “Having policies and protocol in place is also critical for legal protection if the situation escalates. It protects the physician, the staff, the patients, and the institution.”
Dr. Keogh, a faculty member of SHM’s Leadership Academy, recommends that all physician employees learn their code of conduct policy. “To prevent downstream behaviors, when you get a new hire, don’t just give them this statement—read that section to them out loud,” he advises. “This ensures that they notice it, and gives hospitalist executives a much stronger position when something happens.”
There are two proven methods to successfully deal with disruptive behavior: 1) React to it immediately, and 2) follow up to ensure it doesn’t happen again. When you receive a complaint about a disruptive hospitalist, gather all the information you can on the incident and schedule a meeting to discuss it with the party accused of poor behavior.
“The first occurrence should result in an informal conversation. ‘You stepped over the line here, and we have to make sure it doesn’t happen again,’ ” Dr. Keogh says. He recommends that a human resources staffer be present at this meeting, and supervisors should come prepared with documentation.
“You have to sit them down and go over a written document—don’t just talk about word-of-mouth. Go over the documented occurrence of the behavior,” Dr. Keogh explains. “Talk through what they did, and let them know that you both have to find a way to ensure that it doesn’t happen again. They’ll rationalize their behavior at first, but make sure they understand that it’s unacceptable.”
In the case of an allegation or a one-on-one dispute, Dr. Gottesman advises you “clarify both sides before taking any action. I hear both sides of the story, then we find some common ground and work toward a solution.” In his experience, he says, “by and large, most physicians tend to be responsive when spoken to in a constructive, positive fashion. Let them know that you’re here to support them, not prosecute them. You need to maintain a professional demeanor.”
Dr. Keogh says oftentimes the first disciplinary meeting will be enough to end the disruptive behavior. If the same individual has another incident, schedule a second meeting and emphasize the seriousness of the infraction and disciplinary measures. You might want to have a senior manager, such as your chief medical officer, join the discussion. Officially document the problem and identify the consequences if the employee is disruptive again.
Followup Is Key
Another key to quashing disruptive behavior is doing your part to ensure it doesn’t happen again. “The problem is that the impact is residual on the people around that individual, whether it’s the nurses or patients,” Dr. Keogh says. “The results are avoidance and silence.”
Supervisors should follow up on the disruptive behavior by placing themselves in the problem employee’s way; doing so will let you see how they work and how others react to them, and it will show that you’re keeping an eye on them. “The [manager] has to show ongoing oversight of that individual, with occasional walks in the [hospital halls] and ongoing verbal encouragement, to show that someone is paying attention,” Dr. Keogh says. “They can fall back into bad behaviors if they think no one is watching.” Positive recognition of good behavior and outcomes (i.e., improved patient satisfaction) also helps reinforce your followup.
Depending on the individual and the situation, dealing with a disruptive behavior can be a long-term, never-ending job. But it’s a necessary one.
“There has to be zero tolerance,” Dr. Gottesman says. “People should be comfortable and confident with reporting this behavior. It should not be accepted as a normal part of work to put up with it. And they should know that the situation will be looked at objectively, and both sides will be heard.” TH
Jane Jerrard is a freelance writer based in Chicago.