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4/21/2015
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DEALING WITH DIFFICULT PHYSICIANS AND OTHER HEALTH CARE PROVIDERS FROM A PHYSICIAN’S PERSPECTIVELynn M. Myers MD, CPC, CHC
Special Thanks & Congratulationsto Dr. Bob Ossoff.
Objectives
Learn what drives physicians (and what drives us crazy)!
Structure an approach to physicians
Develop physician leaders in your organization
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The disruptive physician exhibits behavior that “interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care.”
Federation of State Medical Boards of the United States, Inc. Report of the Special Committee on Professional Conduct and Ethics. Dallas, TX: Federation of State Medical Boards; 2000.
WHAT DRIVES DOCTORSThe basic DNA
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Know Your Audience
• Used to a long trail of success, not failure
• Hard Working
• Highly educated & life-long learners
• Type A
• Competitive
• Respond best to an informed message
• Highly productive
• Don’t respond to threats
• Like to lead or be a part of a team
WHAT DRIVES DOCTORS CRAZYStories from the field
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Dr. MakemydayThe compliance opportunity
• Low audit score
The physician perspective
• A bazillion admits
• No role in scheduling
• Unmet salary expectations
What to do?
• Be prepared!
• Rethink the training
• Wish him well
Dr. CutfirstThe compliance opportunity
• Billing compliance during the global period
The physician perspective
• Eats system representatives for lunch
• Wife negotiating for both (he just found out!)
What to do?
• Be prepared
• Be concise
• Stick to the facts
• Follow up with leadership
Dr. NerviosoThe compliance opportunity
• Excessive open Encounters
The Physician Perspective
• Unmet expectations around EMR implementation
What to do?
• Stick to the facts
• Implement corrective action
• Discuss options for EMR implementation
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Dr. Nervioso(6 months later)
The compliance opportunity
• Excessive open Encounters
The Physician Perspective
• Unable to return to productivity after EMR implementation
What to do?
• Corrective action plan
• At the elbow EMR support
• Scribe
• Shadowing a colleague
Dr. PequenoThe compliance opportunity
• Salary outside FMV
The physician perspective
• Unsatisfactory EMR implementation
• Unable to return to previous productivity
What to do?
• Consider scribe
• Adjust RVU rate
Dr. EstomagoThe compliance opportunity
• Leveraging referrals for medical directorship
The physician perspective
• Being pressured to refer patients?
• Problems at home
What to do?
• Stick to the facts
• Mentoring
• Quick follow up
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Dr. CorazonThe compliance opportunity• Sexual harassment• Late to clinic• Undies on the desk
The physician perspective• Self prescribing of
testosterone• Failing marriage
What to do?• Stick to the facts• Follow early/often• Mentoring• Meet with staff
Dr. Olecranon
The compliance opportunity
• Patient concerns of recent weight loss
• Staff concerns of forgetfulness and ‘just not himself’
The physician perspective
• Recent health concern and trouble regulating meds
What to do?
• One on one mentoring
• Follow up with staff
• Close follow up with MD
• Fitness for duty eval?
Dr. IntegumentThe compliance opportunity:
• Berating staff in front of patients
• High patient volume
The physician perspective
• Staff not rooming patients timely, so he runs late from the start of the day
• Family upset with missing children’s activites
What to do?
• Address schedule with staff
• Counsel on core values of respect and integrity
• Close follow up
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Performance Issues• Symptoms of underlying disorders
• Mental & behavioral problems (drugs and alcohol)• Physical illness (age- and/or disease-related)• Failure to maintain knowledge or skills• Work-life balance • Burnout
• Contributing factors• Overwork• Family strife• Dysfunctional working environment• Pressure from leadership• Anxiety
Categories frequently overlap-declining procedural skill could be a due to alcohol dependence or age, both exacerbated by underlying illness such as severe depression or organic disease
Stressors • Stress, fatigue, isolation, easy access to drugs• Compounded by
• Large educational debt for new grads• Increasing malpractice premiums• Decreasing reimbursement• Pressure to see more patients • Changing practice paradigms: value-based reimbursement
• Leads to • Further isolation• Maladaptive coping strategies• Burnout
http://emedicine.medscape.com/article/806779-overview
A corrosive effect…
• Increased likelihood of error• Staff hesitates to ask for clarification
• Staff less likely to make treatment plan suggestions
• Negativism becomes infectious
• Undermines confidence of patients• In the physician
• In the institution
• In partnering in their own care
• Increased likelihood of litigation
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The last frontier
What keeps you up at night?
http://www.hcca-info.org/Portals/0/PDFs/Resources/Compliance_Today/0312/ct0312_Turteltaub.pdf
DEVELOPING PHYSICIAN LEADERSTools for successful relationships
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Key CompetenciesAccountability – Able to hold leaders and employees accountable for their actions;
be clear on what subordinates will be held accountable for; establish a culture of fair accountability allowing for mistakes when innovating; is personally accountable for own actions and commitments.
Adaptability – Able to adapt to changes in situations / direction / people; be flexible when considering options / opinions; adjust to needs of others without losing self; adjust approach when dealing with arrogant or inflexible people.
Motivate Others – Able to share knowledge and experience to help motivate others; motivate others by helping them see their contribution to the organization; motivate and excite others to raise the performance bar, demonstrate a clear willingness to address individual needs of employees.
Judgement – Able to make wise decisions (people, technical, business and creative) despite ambiguity; identify root causes and get beyond treating symptoms; separate what must be done well now and what can be improved later; think strategically and articulate what you are, and are not, trying to do.
http://www.medi-leadership.org/physician-leadership.html
http://www.physicianleaders.org
Due Diligence
• Network with colleagues to gather information
• Build consensus around the issue
• Build consensus around alternative solutions
• Propose pilot with metrics
Communication Pearls
Channel Columbo-’help me understand…’Describe the emotionAsk questions-start with how or whatAppeal to the highest value
quality of carepatient satisfaction
With high emotion, use caution with email or voice mail
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EXCELLENCE BY DESIGN
Ever feel like this?
How does this happen?
• Physicians more likely to develop left-brain fluency
• Inadequate identification of issues• Fitness for duty assessments
• Physical Exams?
• Drug testing
• Inconsistently managing opportunities• Warning signs ignored
• Physicians reluctant to confront each other
• The two-edged sword of independence
• The tension of friendship
• Lack of skills in physician leadership
• Influence of downstream revenue
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The Physician Compact
• Purpose-states the commitment of the organization and the physician to the patient, the community and to each other.
• Expectations of the Organization• Recruit and retain outstanding providers
• Support career development, operational efficiency and excellence in care
• Provide opportunities to dialogue regarding policies, procedures and strategy
• Acknowledge and reward superior performance
• Strive to make the organization a great place to work
The Physician Compact
• Expectation of the Provider to strive for:• Excellence in quality of care
• Excellence in quality of service
• Responsible resource management
• Respectful peer and co-worker relationships
• Acccountable Citizenship
Mentoring Program
• Colleague to colleague
• Emphasize the compact
• Understand stressors inside/outside the office
• Issues not surfaced by new business development
• Discover unmet expectations early in the relationship
• The cost of recruitment and retention vs the cost of a termed provider (jousting)
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Consistency
• Develop a plan and then work the plan!
Fitness for Duty
• Periodic physical exam
• Periodic drug testing
Presenting the flySet the hook:
“What ideas do you have for improving this…?”
Listen and take Notes
Make no promises, except to
Sleep on it
Follow up quickly
Then ask them to participate.
Potential for turning behavior from obstreperous to advocacy
