In the more than ten years that Paul Levine, MD, FACS, has served as chair of otolaryngology and head and neck surgery at the University of Virginia in Charlottesville, he has heard his share of complaints about high-powered surgeons who are difficult to work with. Although stories about doctors who throw instruments—or punches—make headlines, verbal abuse is more common, Dr. Levine said. “Many times, nurses and junior colleagues are the targets of the surgeon’s verbal attacks,” he added.
Explore This IssueFebruary 2010
In today’s hospitals and medical offices, you might hope that tales of abusive doctors would be rare. After all, the Accreditation Council for Graduate Medical Education’s six core competencies that training programs are expected to instill in new physicians include systems-based practice (basically, working in teams), interpersonal skills and communication and professionalism.
But despite efforts to instill a higher level of professionalism, disruptive doctors are still far more common than they should be. A 2004 survey by the American College of Physician Executives found that more than 95 percent of the more than 1,600 respondents observed problems with physician behavior on a regular basis. One survey respondent summed up the situation in this way: “Some people never reach adulthood. Unfortunately, many of them are physicians who, when under stress, behave as adolescents.”
Addressing the Problem
So what do you do when one of those overgrown adolescents is disrupting your team? All too often, senior leaders just ignore the behavior, hoping it will go away. “Often, these antics come from a very small group of individuals, usually senior-most individuals who have been rainmakers and have gotten into this position because we’ve tolerated it for ill-advised reasons,” said Anthony Whittemore, MD, chief medical officer at Brigham and Women’s Hospital in Boston, who was instrumental in creating the hospital’s professionalism program. “Some are generating huge revenue streams, so everyone says, ‘Oh, that’s just old George, he’s that way,’ and tolerates it. But it’s totally unacceptable.”
Gerald Healy, MD, FACS, past president of the American College of Surgeons, said the issue sometimes boils down to economics. “I think many hospitals in the country are making the mistake of heading in the direction of American business: What’s good for the bottom line? If that means a high-performing, very busy physician who happens to be a disruptive character who abuses people, yells and screams and throws instruments, we find a way to make an excuse for that behavior,” he said. “Even though most hospitals claim to have rules and regulations in place to inhibit that behavior, when you drill down under the surface, I think you’ll find that a lot don’t enforce them very well.”
—Anthony Whittemore, MD
A Multi-Step Response
Dr. Whittemore said that in the course of his 10 years as CMO at Brigham and Women’s Hospital, he’s come across “no more than a handful of truly disruptive individuals.” Dr. Healy noted that in the current high-pressure environment for physicians, however, disruptive behavior may be on the rise despite attempts to change the culture of medicine. “Doctors are under enormous stress these days. You need to see more patients, and reimbursements are going down,” he said.
Otolaryngology leaders interviewed by ENT Today recommended a multi-step process to deal with disruptive physicians:
- Establish a code of conduct. “You have to make clear what is acceptable and what is not, so no one can say they didn’t know,” Dr. Healy said. “Give examples of what you’re talking about, rather than some nebulous statement that ‘disruptive behavior will not be tolerated.’”
- Ensure that leadership is willing to take on problem physicians. “They have to be willing to bring the person in and say, ‘We have a problem here. You throw instruments in the operating room. This will not be tolerated,’” Dr. Healy said.Harold C. Pillsbury, MD, FACS, chair of the Department of Otolaryngology/Head and Neck Surgery at the University of North Carolina School of Medicine in Chapel Hill, said it’s important to let the physician know that others have noticed his or her disruptive behavior. “A lot of people will be nasty if they think no one’s watching,” Dr. Pillsbury said. “In such a case, senior staff must do a ‘360’ evaluation of that person, asking everybody in his world what they think of [the person’s] behavior. Then they provide that feedback to the individual.”
- Set up a process for responding. Warn the disruptive physician, and refer that person to sources of help; then follow up to make sure that the behavior is changing, Dr. Healy advised.
- Make finding help easy. Ensure that there are resources to help physicians in trouble without jeopardizing their careers. Dr. Whittemore pointed out that the Massachusetts Medical Society provides Physician Health Services, a program that was founded to deal with substance abuse but has more recently been successful in resolving behavior disorders. Physicians referred to the service aren’t required to be reported to the state licensing board. Dr. Whittemore also sometimes refers difficult physicians to an accredited life coach. “I’ve had two very successful turnarounds with successful senior rainmakers; with one, it wasn’t so successful,” he said.
- Highlight the consequences of bad behavior. Dr. Levine advised leaders to follow a no tolerance policy for disruptive behavior. “If an individual is unwilling or incapable of change, despite academic success, their continued unacceptable behavior would mandate their dismissal,” he said.
In the practice setting, response to such behavior must also come from the top, which can be more challenging depending on the size of the practice. Richard Waguespack, MD, FACS, who practices in Birmingham, Ala., can’t recall any egregious behaviors from colleagues in his specialty—“all otolaryngologists are very civilized,” he joked—but remembers a particularly ill-behaved orthopedist in his community.
“He actually left the OR at an outpatient facility, gowned and gloved, and walked out verbally abusing staff for not answering the phone appropriately,” Dr. Waguespack recalled. “The senior-most individual on site, the anesthesiologist, told this individual that he needed to go back and finish his caseload and that he would not be able to return to the facility until the incident had been fully investigated. Ultimately, he lost his privileges at the facility.”
In an outpatient surgi-center or a large, well-organized practice, Dr. Waguespack said, a chief of staff or compliance officer would be responsible for addressing a physician’s disruptive behavior. “In a smaller practice, it would need to be a senior surgeon, peer-to-peer counseling. You give the doctor the opportunity to change their behavior and offer counseling if it’s pretty egregious. If behavior doesn’t change, remedies can include monetary penalties, limiting the scope of their practice or ultimately removal from the practice.”
Dr. Healy believes that disruptive physicians are a threat to the heart of medical professionalism: “I told one surgeon, did you train for nine years to be a bully? Is that the legacy you want to leave—not the great surgeon who knew how to take out lung cancer, but the person who abused everybody and threw instruments? Your legacy depends on how you behave.” ENTtoday
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