Knowledge Expansion Dealing with disruptive physicians Insight Article Performance Management Sign in to save Judith Holmes ESQ. Leigh Olson Effective practice administrators accomplish a great deal without blinking but many struggle with how to deal with disruptive physicians, a topic of conversation for at least 30 years, according to a Journal of the American Medical Association (JAMA) article. When disruptive physicians cause problems, everyone comes to the administrator expecting a perfect resolution to the problem. Here are four common situations that illustrate that point: A young female physician says that a physician in the group made degrading, insulting comments to her and regularly calls her “Ms.” instead of “Doctor.” A staff member threatens to quit because a physician has harassed her for months, telling inappropriate jokes, making suggestive sexual comments and touching her inappropriately. A nurse practitioner reports that a physician has repeatedly yelled at her, thrown a chart at her and frequently berates her in front of patients. A physician refuses to attend mandatory practice group meetings and argues with other physicians. She is chronically late, which leads to waiting room backups and angry patients. The American Medical Association (AMA) defines disruptive behavior as personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care. This includes but is not limited to conduct that interferes with one’s ability to work with other members of the healthcare team. However, criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior. These situations all involve inappropriate, disruptive behavior as well as a power disparity, especially if the practice administrator works for the physician, which makes it difficult to resolve the problem. Even seasoned administrators find it difficult to resolve situations involving powerful, influential physicians whose behavior adversely affects the practice. These individuals are often intimidating and not accustomed to being questioned. They are rarely open to accepting criticism about their conduct and less receptive to requests for behavior modification. As a result, bad behavior might have been tolerated for years, which has caused low morale and high staff turnover. Tolerating inappropriate behavior can increase the likelihood your practice will be sued or that a charge will be filed with the Equal Employment Opportunity Commission (EEOC). In 2015, the EEOC reported more than 89,000 claims had been filed against employers by employees for allegations of harassment, discrimination and retaliation. Protecting the practice If bad behavior goes unchecked, it can jeopardize the future of a practice. Here are some steps administrative leaders can take to protect their practices before disruptive physicians cause significant or irreparable damage to the practice: Confront the problem. Dr. Disruptive (Dr. D) just berated a staff member in front of a patient and several employees. This is the third instance of his uncontrolled anger in the past month. Two valued employees have now threatened to quit if they are the target of one more outburst. What should you do? Ignoring complaints, which might be tempting, will likely lead to more bad behavior and potential legal liability. A head-in-the-sand approach is particularly damaging when a physician or staff member reports behavior to you and expects a response or some type of change. If there is no improvement in a physician’s behavior, you might lose good staff members and the culture of bad behavior will become more entrenched. Your first step should be to assure your valued staff members that you take the complaint seriously, that you will investigate the concerns and, if appropriate, you will take steps to ensure remedial measures are taken to prevent recurrence of the conduct. Take comprehensive factual notes regarding the complaints or ask the employee to submit the complaint in writing. Offer to keep the complaint as confidential as possible, assure the employee that there will be no retaliation for reporting the incidents and request that the employee advise you immediately if he or she believes there have been retaliatory actions by Dr. D or anyone else. Your second step is to determine the most effective way to confront Dr. D about his behavior. You can discuss the problem but this alone will likely not solve the problem, and the confrontation might have a lasting adverse effect on your relationship with the physician. Frequently disruptive physicians become defensive when confronted and believe they are not responsible for the outburst or other offensive conduct. Many times, a disruptive physician isn’t aware of the effect he or she has on colleagues and staff members, and might resent you for pointing out a personal fault he or she doesn’t want to recognize. If Dr. D is defensive or unaware of his effect on others, he will simply reject what you say and add you to his list of adversaries. You will have gained little and jeopardized your ability to communicate effectively with Dr. D in the future. Enlist help. Once you recognize the necessity of confronting Dr. D about his disruptive behavior, seek assistance. If your group does not have an executive committee with an established procedure in place for addressing disruptive physicians, you will need to partner with at least one other influential physician in the group who shares your concerns and is willing to support your efforts to confront the issue and act as a liaison between Dr. D and the group. That individual should be able to be objective, so he or she should not be a personal friend of Dr. D and should not be an individual Dr. D perceives as an adversary. Once the physician/liaison has been selected, convey the facts, discuss the likely outcome of failing to alleviate the problem and suggest ways the two of you can approach Dr. D to maximize the chance of a positive outcome. Although every situation is different and requires a unique approach, here are some suggestions for conducting a successful meeting: Empower your physician/liaison to speak on behalf of the practice. When the meeting with Dr. D is scheduled, it should be clear that the liaison has the authority to speak on behalf of the practice. Prepare an outline of points you want to cover. Stick to a script so you avoid getting pulled into an argument. Have copies of your code of conduct and any written policies and rules that apply to the situation. Conduct the meeting in a private, comfortable, professional setting. Reduce the tension as much as possible to encourage a positive dialogue. Do everything possible to make this a problem-solving experience. Explain the problem behavior to Dr. D in factual terms. Describe the sequence of events and discuss the effect Dr. D’s behavior had on staff and the potential adverse effects his actions had on his professional reputation and the reputation of the group. Refrain from using emotional terms such as bad behavior, tirade or childish tantrum to describe the conduct. These terms might describe the conduct but can polarize the situation and make Dr. D more defensive. Give Dr. D the opportunity to explain the situation in his own words. Chances are he will not take responsibility for his behavior or might blame staff incompetence for an outburst. He may attempt to change the subject and begin listing the ways the group is at fault for mistreating him. Don’t take the bait. Insist those grievances be taken up at a different time and remind Dr. D that the purpose of the meeting is to address his conduct on specific dates. Ask for Dr. D’s input on how past situations could have been handled differently to avoid the incidents that gave rise to complaints. Make it clear that there is never a valid reason for treating staff members disrespectfully. When discussing Dr. D’s conduct, consider whether the outbursts may be a result of a drug or alcohol problem or whether his conduct could be the result of mental illness, such as depression. If there is some indication that Dr. D’s conduct is a result of one of these issues, it might be appropriate to refrain from taking any action until you consult with the executive committee and act in accordance with your substance abuse policy. Advise Dr. D that you will be drafting a performance improvement plan (PIP) that will require him to make immediate, permanent changes in his behavior. Make it clear that failure to comply with the terms may result in discipline, up to and including termination. The PIP should include objective, measurable and achievable goals designed to prevent disruptive behavior in the future. Make it very clear to Dr. D that no retaliation of any kind will be tolerated. If you have a written retaliation policy, be prepared to give Dr. D a copy at the end of the meeting. Carefully document what occurred and what was discussed during the meeting. Follow through. If you put Dr. D on a PIP, monitor his behavior and respond quickly and appropriately if requirements are not met. This type of approach is not appropriate for every situation. Some situations require immediate action. For example, if disruptive behavior involves threats, violence or sexual harassment, the practice must act promptly to remedy the problem. Develop a prevention plan. If a group has tolerated disruptive behavior for years, you won’t change the culture overnight. However, you can implement policies and protocols that will help protect your practice in the long run. Those policies should be assembled in a physician handbook and include policies that: Prohibit unlawful harassment that includes a clear statement that your group strictly prohibits sexual harassment as well as harassment on the basis of race, color, gender, religion, disability and all other categories protected by federal and state law. The policy should define harassment and give examples of unacceptable behavior. Prohibit discrimination on the basis of any protected category. This is helpful when addressing a situation in which a disruptive physician refuses to work with a colleague because of gender, religion, ethnicity, etc. Define unacceptable behavior. This physician discipline policy should also include a step-by-step procedure the group will use to investigate complaints. Prohibit retaliation against any employee to ensure that when staff members or physicians make complaints about a disruptive physician, they are protected from any retaliatory conduct. Prohibit workplace violence that includes a description of prohibited conduct as well as a clear statement that violence or threats of violence must be reported. Address the issue of impaired physicians that will be used to assess and address this very complex issue. The procedure might include a multistep plan for board intervention, mandatory leave and/or referral to an appropriate rehabilitation or mental health program. It should also include clear consequences for failure to rectify impairment issues within a reasonable time period. Many practices take the time and effort to develop behavior standards but do not take the extra step to make the policies an integral part of their management and discipline strategies. Incorporate behavior standards into a comprehensive physician handbook. Once you have implemented behavior policies, be sure to train every physician on what those policies mean and how they will be enforced, and then apply those policies consistently. It is a time-consuming effort, but if the group is guided by the policies contained in your handbook, your practice management will get much easier. Coming in the August issue: Learn how to curb disruptive conduct, establish a code of conduct and use physician contract provisions to reward good behavior and discourage bad behavior. We will also examine conflict resolution techniques that will help you resolve personality disputes that lead to disruptive behavior.