TFME 2013 Organizational Professionalism Conference

1. Understanding & ManagingUnderstanding & Managing
Physicians with DisruptivePhysicians with Disruptive
BehaviorBehavior
--
TFME Kent E. Neff, MD, FAPATFME Kent E. Neff, MD, FAPA
Organizational ProfessionalismOrganizational Professionalism kentneff@gmail.comkentneff@gmail.com
October 19, 2012 (541) 719-0036October 19, 2012 (541) 719-0036

2. The Big FourThe Big Four
• Physicians / staff with disruptive behavior
• Physician leaders who deal with them
• Administrators & system officers above
• Culture

3. Health Care CultureHealth Care Culture
• Highly dysfunctional in predictable ways
– “Enabling” is rampant
– Disruptive outliers not dealt with
• We tolerate behavior other industries don’t
– High revenue producers protected
– Staff tolerant of dysfunctional behavior
– Lateral violence (esp. RN to RN)
– Culture often fear-based
• Creates high vulnerability for errors

4. Health Care CultureHealth Care Culture IIII
• Wonderful Mission Statements & values
– But often don’t “walk their talk.”
• Staff & physicians become disillusioned, lose trust
• Afraid to speak up
• Don’t collaborate, etc.
• Five Dysfunctions of a Team
• Lencioni

5. Inattention to
RESULTS
Avoidance of
ACCOUNTABILITY
Lack of
COMMITMENT
Fear of
CONFLICT
Absence of
TRUST
*Lencioni: Five Dysfunctions of a Team

6. Building Trust is KeyBuilding Trust is Key
• Done in the trenches; build up, not down
• Managing behavioral outliers is critical
– This begins the trust-building process
• Cannot have safe culture if disruptive
behavior is tolerated
• Org. professionalism is key to safe culture

7. I. BEHAVIOR = SAFETYI. BEHAVIOR = SAFETY
A New ParadigmA New Paradigm
Paradigm shift involvedParadigm shift involved

8. Disruptive BehaviorDisruptive Behavior
• “An aberrant style of behavior or personal
interaction with physicians, hospital
personnel, patients, family members, or
others that interferes with, or could
reasonably be expected to interfere with,
patient care.”
• Modified from D.A. Lang, M.D.

9. Characteristics ofCharacteristics of
Disruptive BehaviorDisruptive Behavior (1/2)(1/2)
• Disrespectful
• Demeaning
• Harsh and/ or intimidating
• Inappropriate touching, violates boundaries
• Sexual advances or innuendos
• Racial, cultural, gender-biased behavior
• Includes all behavior: verbal & non-verbal

10. Characteristics of DisruptiveCharacteristics of Disruptive
BehaviorBehavior (2/2)(2/2)
• Inappropriate chart notes or email
• Destructive gossip
• Publicly criticizing staff or physicians
• Inappropriate treatment of patient, family
• Not communicating w/ doctors, staff
• Not following safety policies/ procedures
– Hand washing, surgical pause, check lists, etc

11. Disruptive behavior is aboutDisruptive behavior is about
howhow a physician responds toa physician responds to
distress or frustration,distress or frustration,
not what the stressor is.not what the stressor is.
Harsh, disrespectful behavior isHarsh, disrespectful behavior is
unacceptable, regardless.unacceptable, regardless.

12. What correlates with disruptiveWhat correlates with disruptive
behavior?behavior?
• Disruptive behavior often occurs when:
– Anxiety, fear (Looks like frustration, anger)
– Perfectionism… to a fault
– Striving for good patient care
• Highly-skilled physicians may be
disruptive
• You can’t be disruptive & be considered a
a good doctor

13. WhatWhat’s behind disruptive’s behind disruptive
behavior?behavior?
In order to change seriousIn order to change serious
disruptive behavior, one mustdisruptive behavior, one must
identify & address the root causes.identify & address the root causes.

14. I. The Making of a Physician:I. The Making of a Physician:
Doctors not normally socializedDoctors not normally socialized

15. Medical School & ResidencyMedical School & Residency (1/2)(1/2)
• Select for intellectual, technical skills
• Intellect
• Emotional development
• Increases anxiety, self doubt
• Lowers self esteem

16. Medical School & ResidencyMedical School & Residency (2/2)(2/2)
• Further delays gratification
• Insists on perfection, absence of error
– Instills faulty error paradigm
• “Good doctors don’t make mistakes.”
• May increase shame
• What we should teach:
– All physicians make mistakes
– Real surgeons do use checklists/ wash hands

17. Medical School AbuseMedical School Abuse
• 12 U.S. Medical Schools (10% US students)
– Verbal insults, harassment, physical attack
– Abuse= 46% of all students; 80% of 4th
yr students

18. Delayed social development=Delayed social development=
occupational hazard for docsoccupational hazard for docs
Episodes ofEpisodes of “childish behavior” in an“childish behavior” in an
otherwise excellent physician mayotherwise excellent physician may
reflect this.reflect this.

19. II. Background ofII. Background of
emotional neglect oremotional neglect or
abuse or traumaabuse or trauma

20. Professional Assessment ProgramProfessional Assessment Program
Abbott Northwestern HospitalAbbott Northwestern Hospital
• 202 physicians; 91% male, 9% female
• History of emotional neglect or abuse = 66%
• Physical abuse, including sexual abuse= 21%
• Often traced behavior to earlier life experience

21. III. High Incidence of Axis IIII. High Incidence of Axis I
Psychiatric DisordersPsychiatric Disorders
• Axis I Diagnosis: 78 %
• Major Depression: 40 %
• Alcoholism/ Chemical Depend: 27%
• Sexual Disorder: 6%
• Bipolar Illness: 6%
• Obsessive-Compulsive Disorder: 2%

22. Unresolved grief, loss, &Unresolved grief, loss, &
depression are commondepression are common
““The most important thing we canThe most important thing we can
do for physicians is help them withdo for physicians is help them with
their grief.”their grief.”
-Leonard Boche, MN BMP-Leonard Boche, MN BMP

23. IV. Alcoholism & drugIV. Alcoholism & drug
dependencydependency
• Common in physicians
• Occupational hazard (access to drugs)
• Very good prognosis when identified & get
into recovery

24. Axis II: Personality Disorders &Axis II: Personality Disorders &
TraitsTraits
Prof. Assmnt. Program: 27%Prof. Assmnt. Program: 27%
Most were compatible withMost were compatible with
practice if treated & monitoredpractice if treated & monitored

25. V. Medical conditions may beV. Medical conditions may be
associated with disruptiveassociated with disruptive
behaviorbehavior
Often unrecognizedOften unrecognized
and/or under-treatedand/or under-treated

26. VI. Limited social skills & lowVI. Limited social skills & low
Emotional Intelligence (“EQ”)Emotional Intelligence (“EQ”)
are commonare common
Many physicians do not have theMany physicians do not have the
tools to deal with their currenttools to deal with their current
problems.problems.

27. VIII. Excessive workVIII. Excessive work
patterns are oftenpatterns are often
problematic.problematic.
Success often depends uponSuccess often depends upon
modulating the workload of themodulating the workload of the
distressed physician.distressed physician.

28. IX. Higher Incidence of PoorIX. Higher Incidence of Poor
Clinical Performance??Clinical Performance??
• Psychiatric profile +++
• Longitudinal experience: +++
• Similar traits in excellence, disruptive behav.
– “Down side of up side”
• Disregarding policies = disruptive, unsafe
• Clinical competence vs. performance
• Clinical skills, productivity mask performance

29. These physicians do notThese physicians do not
see the impact of theirsee the impact of their
behavior on othersbehavior on others
Getting them to take ownership ofGetting them to take ownership of
the problem is essential.the problem is essential.

30. ManyMany physicians madephysicians made
substantial positive practice &substantial positive practice &
life changeslife changes
““Despite the pain, this is the bestDespite the pain, this is the best
thing that has happened to me… “thing that has happened to me… “

31. Management StrategiesManagement Strategies
Check List of StepsCheck List of Steps

32. Guiding PrinciplesGuiding Principles
• Respectful at all times
• Completely confidential
• Based on objective, nonjudgmental data
• Focused on rehabilitation of physicians
• Timely & prompt: Must report back
• Safe for everyone
– Protect anonymity of staff

33. Use appropriate consequencesUse appropriate consequences
• Consequences promote behavior change
– Good intentions, insight alone don’t work
• Frequently no previous consequences
– Even for bullying

34. Steps in DevelopmentSteps in Development II
• Get buy-in by physician & admin. leaders
– Good alignment is essential
• Determine scope of program(s)
– Evaluate MS By-laws, policies, procedures
• Draft policies & procedures for identifying
& managing these physicians
• Review personnel policies for staff

35. Steps in DevelopmentSteps in Development IIII
• Develop Behavior Code
– Principles of Partnership
• Announce commitment to culture of safety
– Bold; utilize crisis if available
– Keep procedures in draft form to involve docs
– Frame as safety issue, healthy workplace
– Include staff in process

36. Steps in DevelopmentSteps in Development IIIIII
• Establish & train Physicians Health
Comm.
– Non-punitive option
– Physician to physician
• Get approval of Principles by Med. Staff
– Develop compatible Principles for staff
• Continually educate physicians, staff
• Begin holding everyone accountable