Dealing with Difficult Physicians

Joni Brodie, CPMSM, CPCSMat-Su Regional Medical Center

Difficult – or disruptive?

» Difficult – has a personality that is excessive but generally doesn’t cross boundaries. Tends not to have ‘trends’ of issues. Generally behavior does not directly effect patient care.

» Disruptive – actions and/or words have a detrimental effect on the staff, and therefore on the patient.

» Is there a real difference? Yes, according to the AMA…

AMA definition of terms

» Inappropriate behavior means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive and subject to treatment as “disruptive behavior”.

» Disruptive behavior means any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.

» Appropriate behavior means any reasonable conduct to advocate for patients, to recommend improvements in patient care, to participate in the operations, leadership or activities of the organized medical staff, or to engage in professional practice, including practice that may be in competition with the hospital. Appropriate behavior is not subject to discipline…

» Cohen B, Snelson E. Model Medical Staff Code of Conduct. American Medical Association. 2009

Behaviors to watch for…

AGGRESSIVE: yelling; foul and abusive language; threatening gestures; public criticism of co-workers/health care team; insults and shaming others; intimidation; invading one’s space; slamming down objects; physically aggressive or assaultive behavior

PASSIVE/AGGRESSIVE: hostile avoidance (cold shoulder treatment); intentional miscommunication; unavailability for professional matters (not answering pages or cell phone or delays in doing so); speaking in a low or muffled voice; condescending language or tone; impatience with questions; malicious gossip; racial, gender, sexual or religious slurs or “jokes”; “jokes” about a person’s personal appearance (fat, skinny, short, ugly etc.); sarcasm; implied threats, especially retribution for making complaints.

Reynolds, N. T., MD, Journal of Medical Regulation Vol 98, No. 1

But if it’s just one of those wonderful folks with an interesting and challenging personality…..

» Questions to ask yourself˃ Are people afraid to talk to this doctor? Do they hate calling him in?˃ What do other providers say about him/her?˃ Is the behavior/issue escalating?˃ Are there patient complaints or staff complaints?˃ ARE THE ANSWERS THINGS THAT CAN AFFECT THE PATIENT’S CARE?

– You may need to move this one up the chain.

The Martyr

• No one has EVER taken this much call!

• Why are you picking on me???!!!

• No matter what I do, it’s just never enough for you people! I do more than any other doctor!!!

• Why are there so many rules?! How am I supposed to take care of patients?!

The Intimidator

• Do I intimidate you??? Do I scare you???

• Who do you think you are, questioning ME?

• If you don’t stop questioning me about my orders, I’m going to have your job!

• What are you going to do, tell on me? Fine, do that. I’ll call my attorney now.

The Deflector

• The anesthesiologist wasn’t watching close enough – he should have seen that the sponge was still in there!!!

• The nurses didn’t tell me that the patientspiked a fever – isn’t that their job?

• Well I don’t care what the government says –that’s a stupid rule & I don’t thinkI should have to do this!!!

• I want you to know that this is a QUALITY issue – I’m not pointing fingers at anyone else!!! I’m concerned aboutpatient safety!!!

The Deity

• Well of course she recovered – I did the surgery!

• Please don’t question my bedside manner – I bring millions into this facility!

• And you would be…? Oh. A nurse.• If the President of the Medical Staff

would like to try and come and do MY job, I’d be happy to attend his little meeting.

• I am the best at what I do. That’s why I have so many patients.

• But my patients are sicker than everyone else’s – that’s why there’s so many problems! No one else will take care of them!

The Perpetual Adolescent

• Aw, c’mon – it’ll be fun! Just take this gurney and I’ll push…..

• Hey honey – want to come over here and see my trocar?

• What? It’s not “inappropriate”…it’s humor! You guys have way too many hang ups! Lighten up!

• We do better surgery if the music is loud and the staff is having fun.

• Yeah, I guess I should be more sensitive to the patients – but they seem to like me okay. After all, they keep coming back!

Let’s look at some personality types

Extrovert - Introvert

Sensing – Intuitive

Thinking – Feeling

Judging – Perceptive

*Myers-Briggs Personality Types

Myers-Briggs Type Indicator (MBTI)

» In the six Core Competencies of the ACGME, TWO OF THEM are:

Interpersonal/Communication SkillsANDProfessionalism

Among them are:» Patient care that is compassionate, appropriate, and effective for the treatment of health

problems and the promotion of health.» Interpersonal and communication skills that result in the effective exchange of information and

collaboration with patients, their families, and other health professionals.» Professionalism, as manifested through a commitment to carrying out professional

responsibilities, adherence to ethical principles, and sensitivity to patients of diverse backgrounds.

» Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.

How many of your “difficult” providers would get through residency today??? ACGME Core Competencies

Addressing the issue….

» Remember which type of difficult provider you are interacting with. The Martyr (who needs nurturing) is very different from the Deity (who absolutely needs NOTHING from ANYONE).

» Always have the door closest to you. And always bring a friend – the appropriate medical staff leader.

» Document. Document. Document.

Tips & Tricks

» Don’t take it personally. Besides, it’s never about YOU. It’s all about THEM. So:˃ Try using “I” statements instead of “you” statements – it alleviates the

defensive posture that can come from “you” statements.˃ While you are involved in the situation, let the Medical Staff Leader run

the show. That’s why they are in that position.˃ Separate the issue from the person. Rather than say “this is a disruptive

physician”, say “this is a physician with disruptive behavior”. ˃ They will definitely take it personally. So let your medical staff leader

take the heat. Be Switzerland.˃ The Deflector will blame everyone, including you. Let it go. Don’t be

defensive. ˃ The Deity will not blame you. You are not important. Unless you make

trouble. Again, this is someone who needs a peer with a large stick.

The Martyr

» They are not happy about something. Or everything. Ask questions – ˃ Dr. Smith, is there something specific I can help with? ˃ Have you spoken to your Department Chair about your issue? I can help

facilitate that.

» Most of the time, there’s just a need to be heard.˃ Providers need to feel valued. Some don’t. And some have big inferiority issues.

Let them know that you value them as part of the medical staff.˃ Just because they’re doctors doesn’t mean they’re feeling appreciated.˃ Focus on helping them find a solution. It’s NOT your job to fix it, but you can

help them find a way to do it themselves.˃ Keep them focused on the concern. Unless it’s apparent that what they really

need to do is whine a little about little Tommy’s problems in day care. ˃ Be positive and compassionate. But if the behaviors continue, talk to a medical

staff leader. Could this provider be depressed? Having a bout of SADD?

The Intimidator

» NEVER go this alone. You have no authority, and they will let you know it. Always have a physician leader direct this interaction.

» If the Intimidator comes in your office, and intimidates you – document it and report it.

» Keep the provider on task – they can deflect, too. Use phrases like “we can talk about that at another time, or after this meeting. Right now we need to discuss your behavior during your patient rounding this morning”.

» Bring the evidence. If they haven’t rounded on a patient in two days – have a copy of the chart that shows that there was no documentation. They want proof – and so do you.

» Don’t let this become a screaming match. If the provider is obviously not going to listen, end the meeting and move this to dealing with disruptive behavior. Don’t allow the Intimidator to do what they do best!

The Deflector

» Passive/Aggressive does not begin to describe interactions with this provider. Always document interactions with them – because they will, if they feel it necessary, throw you under the bus.

» “Watch the shiny balls…” they will do anything to move the discussion to a place they are comfortable. They do not like to be confronted about their issues.

» If at all possible, it will be someone else’s fault. “I yelled at the nurse because she called at 2 am with a STUPID question! Wouldn’t you?!”

» These individuals are very defensive. Be prepared, but don’t be intimidated. Deflectors and Intimidators are often present in one delightful package.

» They can be narcissistic, paranoid (it’s a witch hunt!!!) – and very difficult to communicate with – because they do NOT want to hear it!!!

The Deity

» They believe MD stands for Major Deity. » This is the king or queen of de Nile. What, me, do this wrong? Surely you

jest.» Narcissistic – a pattern of grandiosity, a lack of empathy and a constant need

for admiration are the hallmarks of this individual. » They are justifiers – they justify an inappropriate behavior by evoking the

“I’m taking care of my very sick patient, and this so-called nurse didn’t call me when their temp rose .5 degrees!!! I’m sick of this incompetence!”

» They believe in mind reading – as in you should be able to read theirs. They feel many tasks are beneath them.

» The most effective way to communicate – focus on the issue at hand, not on them, their patients, their practice, their lab coat. Because Deities are also Deflectors.

» Get their attention: “you are a really valued member of the medical team here at You Bet Your Life Memorial Hospital, and we’re glad you are part of our staff. “ Start with a positive – then move slowly into the behavior issue.

The Perpetual Adolescent

» These folks have a pattern of instability – in self-image, interpersonal relationships, etc. – much like a teenager. They are still “finding out who they are”.

» They tend not to take things as seriously as they should. Communicating with them means a lot of banter – followed by a reality check.

» Use the things you learned raising your kids – cause and effect. If you do this again, this will happen to YOU. Then follow through.

» Sometimes it takes more than once. As you well know.» Turn the tables. Most of the adolescents really do think something is just humor.

Saying something derogatory (if that is the issue) to and about them usually gets their attention. And don’t be polite. You have to make a point here.

» Have them define “fun”. Because the first answer is always “we are here for hundreds of hours – we need to have some fun!”. While this may be true, there needs to be a well-defined line of what is appropriate, and what is NOT. Their definition is usually enlightening.

» HOLD THEM ACCOUNTABLE. Even if it means reminding them that they agreed to uphold the Code of Conduct. Give them a copy. TELL THEM TO READ IT!

How do you find out if behavior is continuing on to that “disruptive” phase?

» Talk to the staff – at staff meetings, in orientations, in physician orientation – about your policy regarding behavior. Tell them how to report it. Tell them a provider didn’t hire them, and they cannot have them fired. New, young employees find this the most intimidating.

» Zero tolerance for retaliation – enforce it, communicate it!» Let them know the difference between a behavior happening once that is out of

character – and consistent behavior. » Communicate to them that – in spite of everything they may have heard – providers

are human. They go through divorces, sick children, dying or aging parents, financial issues. Just like you and I. It’s not an excuse for acting out, but maybe a peer needs to have chat and help their colleague find some resources to help their situation. Not everything is as it seems.

» Tell them how to find you. Tell them who the leaders are and how to find them. Have a process to report. Then follow up.

» Reinforce your message every single time you can. The staff on the floor, the cafeteria staff, the housekeepers – they all see and hear a lot. Don’t leave them out of the circle.

» Have a policy that determines when the line gets crossed. And then ACT.

Disruptive Behavior-Cause and Effect

» Consistent offenders need to be dealt with – this sends a message and reinforces behavioral expectations.

» Look at the provider – are there gender, ethnicity, cultural, religious or social factors that may be effecting their behavior?

» Look at the outcomes – if the provider is not answering pages quickly, or if they are not returning calls – how is that effecting patient care and safety? How much risk does that put the patient and the hospital in? Look at the big picture. Sometimes it’s really, really scary.

What does disruptive look like????

Positive Traits

» Highly skilled Well-read» Intelligent Articulate» Hard-working Heavy Admitters» Confident Persevering» High Achievers

Not so positive traits

» Arrogant» Intimidating» Controlling – their way or the highway» Inflexible, uncompromising» Self-centered – exaggerated sense of self-importance» Entitlement» Un-empathetic» Rationalizing to justify their behavior» Blames others» Creates upset & distress in others; viewed as “difficult”» Denial – lacks self awareness; inaccurate self-appraisal» Lacking in remorse – can’t genuinely apologize» Failure to self-correct behavior» Resists help» Vindictive» Litigious

Reynolds, N. T., MD, Journal of Medical Regulation Vol 98, No. 1

Next steps

» Have a well-defined policy on Disruptive Behavior˃ Definitions of what is NOT disruptive behavior˃ Definition of what IS disruptive behavior˃ Clearly outlined steps – including collegial interventions – that are

followed meticulously. Remember – these folks are litigious.˃ Have options in the policy – Performance Improvement Plan?

Psychological evaluations? Anger Management? How about a physical – can illness be a contributing factor? All this should be included in the FIRST step in dealing with this.

˃ Outline the process after that – up to and including revocation of privileges and medical staff membership.

˃ ENFORCE IT EQUALLY. This is the hardest part. There can be NO DIFFERENCE in how any incident is handled, whether it’s a no/low provider, or a $65 million per year neurosurgeon.

» Outline who will handle these issues – and how. Department Chair, CEO and Medical Staff President? CMO? Who should be involved – before the crisis happens.

» EDUCATE YOUR LEADERS – they must document – even if it is a collegial thing. Even if it is a one time event. You have to document that the conversation occurred.

» Include Legal Counsel as you are developing this process. You need to know what’s reportable to the State, and whether you can restrict a Fair Hearing to whether or not the PIP was violated – a handy item to know! And you want to stay protected.

» Always provide reassurance to the participants – both the perpetrator and the colleagues – that they are protected. Then remind them that going into the doctor’s lounge and railing about the unfairness of it all could put that protection in jeopardy.

AMA Code of Ethics & Codes of Conduct

» Do you have this? Is it part of your Bylaws? » Do you educate new providers during

orientation on expected behavior?» Do they have to sign an acknowledgement that

they have read and understood the expectations?

» All of this can help you in the future should that person prove to be, shall we say, a challenge?

» Situations are fluid – arguing and yelling in a closed medical staff meeting is very different then the same behavior being exhibited on a nursing unit or in the cafeteria.

» Doctors are very opinionated. They are also frustrated by the many changes in health care that require more paperwork, have more regulations and more consequences.

» Have we mentioned Electronic Medical Records?» They need to vent – but it must be done in an appropriate

location and circumstance.» The Cone of Silence…

• Once it is understood that your Medical Staff Leaders mean business – please don’t expect harmony and peace. That’s not a realistic expectation when dealing with large numbers of human beings. But you can expect that you will have greater levels of expected behaviors based on fairness, a good process and policy, and open communication with all of your colleagues. And that can NOT be a bad thing!!!

Thank you again!

You are the bridge between what’s going on, and the leaders of your hospital and medical staff. You have a critical role. You have their trust, and you have their ear. If you don’t tell them what’s going on, maybe no one will – and that patient needs you. That patient could be you or a loved one.

Now if you just had Prozac mist, and Haldol in the water…..