Dealing with the Disruptive Doctor

Urgent message: When a physician is dubbed “Tom the Terror,” turning a blind eye can send patients and staff heading for the exit, wreck your reputation, and spark a lawsuit. Here’s what to do instead.
LEONARD D. GOODSTEIN, PHD, ABPP, and JOHN SHUFELDT, MD, JD, MBA, FACEP

Tom P. is a competent, board-certified emergency physician. He is liked and respected by his patients. But Tom‘s relationships with staffers at the urgent care center where he still works used to be another matter entirely. His medical colleagues were treated with haughty disdain. With office staff, nurses, and techs, he was demanding, caustic, and dismissive. At the least provocation,

he would fly off the handle. One time, he opened the supply cabinet, found his favorite pens out of stock, and threw a tantrum in the back office, excoriating the office manager in front of her shocked and appalled staff.
Some staffers complained to Phil R., the center medical director. However, like many physicians in supervisory positions, Phil was reluctant to intervene. When he finally did mention the complaints, Tom brushed them off—and Phil let him, naively hoping that Tom would come to his senses on his own.

Instead, Tom’s relationships at the clinic continued to deteriorate. Staffers dubbed him “The Terror” and tried to arrange their work schedules so as not to over- lap with his. After Tom exploded at a physician assis- tant, a group of staffers confronted Phil: unless Tom’s behavior changed, they would resign en masse.

Phil then confronted Tom. Tom dismissed the com- plaints. Except for a few malcontents, he insisted, his relations with the staff were fine. Now it was Phil’s turn to insist that Tom needed to get help. Tom was referred for psychological evaluation and possible intervention.

When Is a Physician “Officially” Disruptive?
There is no universally accepted definition of a disruptive physician. Over a decade ago, the AMA defined a disruptive physician as a doctor whose behavior “interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care.”1,2 Note that this definition focuses on the overt behavior of the physician and the impact of this behavior on patients and the health system in which the physician works. Given the simplicity, clarity, and broadness of this definition, identifying physicians who meet these criteria should be relatively easy.

Among the categories of behavior that could result in disruptiveness are overt psychosis, clinical depression, drug or alcohol abuse or addiction, personality disorders, excessive stress and burnout, and behavioral changes due to aging. Within these categories, examples of disruptive behavior include disrespectful and profane language; angry outbursts; threats; inappropriate criticism of care given by other professionals; sexual harassment; drunkenness; throwing objects (eg, scalpels, clamps, clipboards) at staffers; failure to observe patient/physician boundaries; failure to respond to calls while on duty; failure to show up punctually for work; unauthorized absences during the workday (eg, long lunches, habitually leaving early); and unkempt, disheveled, or otherwise unprofessional appearance.

By displaying inappropriate emotions and uncollaborative behavior in the workplace, disruptive physicians jeopardize the provision of quality healthcare. The Joint Commission (formerly the Joint Commission on Accreditation of Healthcare Organizations, or JCAHO) mandates that each healthcare delivery system must “have a code of conduct that defines acceptable, disruptive, and inappropriate behavior.” In addition, each system must “create and implement a process for managing disruptive and inappropriate behaviors.”3 We will consider this process in a moment.

How Common Are Unruly Doctors?
Sound, research-based data on the incidence of disruptive physicians does not exist. Based on a survey of the extant literature, Leape and Fromson conclude that 3%-5% of all physicians evince problematic disruptive behavior.4 In another literature review, Williams arrives at a significantly higher estimate: 6%-12% of physicians are “dyscompetent” that is, not performing at an acceptable standard for providing patient care.5

Unfortunately, Williams’ analysis does not differentiate disruptive behavior arising from psychological problems and disruptive behavior resulting from lack of necessary knowledge and skill. A relatively large-scale study of physicians, nurses, and administrators at 102 Veteran’s Administration hospitals concluded that 1%-3% of physicians display serious disruptive behavior.6

These estimates do not suggest an epidemic, so it is easy to conclude that the problem of disruptive physicians is a tempest in a teapot. Not so. According to the Bureau of Labor Statistics, physicians and surgeons held approximately 661,400 jobs in in 2008 (the latest year for which statistics are available).7 If only 3% of those doctors are disruptive, that means 19,842 physicians in the United States are behaving like Tom or worse.

The Ripple Effects of Disruptive Behavior
The ripple effects of their unruly behavior adversely impact a far wider circle of people than the doctors in question. More than two-thirds of the respondents in the VA hospitals study, for example, had witnessed physicians engaging in disruptive behavior and reported that such behavior led to medical errors in 71% of the cases and patient mortality in 27%.6

A 2011 survey of a group of hospital emergency departments found that more than half the respondents (57%) had observed disruptive behavior in physicians.8 One-third of the respondents felt that disruptive behavior could be linked to the occurrence of adverse events, 34.5% to medical errors, 24.7% to compromises in patient safety, 35.8% to poor quality, and 12.3% to patient mortality. Disruptive behaviors “have a significant impact on team dynamics, communication efficiency, information flow, and task accountability,” the authors write, “all of which can adversely impact patient care.”

While studies of disruptive physicians have primarily been conducted in hospital settings, problem doctors pose significant risks to any healthcare organization— including urgent cares—in patient safety, quality of care, staff morale, and community confidence and sup- port, not to mention the potential for lawsuits brought by patients or even members of a clinic’s staff. Failure to deal promptly and effectively with an unruly doctor undermines staff confidence in the center’s leadership and sends a tacit message: “No one here seems to care about how we treat patients, so why should I?” Once allowed to take root, such permissiveness can quickly permeate and undermine a clinic’s culture.

Problem doctors severely reduce the job satisfaction of nursing and ancillary staff, further lowering morale and increasing staff turnover.6 Williams and Williams found that a disruptive team member leads not only to decreased morale of other team members but also their reduces their commitment to the profession and to the workplace.9 This is something that no healthcare facility in a competitive market environment can afford.

Lawsuits Waiting to Happen
The financial risks posed by disruptive physicians are
substantial. Medical errors caused by problem doctors that have direct adverse consequences for patients open the door to malpractice litigation and negative financial impact on an urgent care. When those consequences cause patient morbidity and mortality, the potential negative financial impact is even greater.

In many cases, insurance coverage may defray most, if not all, of a financial settlement. However, the costs in staff time, energy, and stress in preparing for and defending against such litigation will not be mitigated. And when the litigation results in a large settlement against a center, the negative publicity hurts its reputation in the community.

An urgent care also faces substantial financial risks when such behavior is directed at staff members. Imagine if a doctor like Tom had verbally attacked a nurse while absentmindedly holding a scalpel, frightening but not actually physically injuring her, and she subsequently sued the center and scalpel-wielding doctor for damages, citing post-traumatic stress disorder.

While it is difficult to predict how a judge or jury would respond in such a case, how the center had dealt with previous complaints about the disruptive physician would be critical to its defense. If such complaints had been ignored or handled with a perfunctory wrist slap, the center would likely be seen as complicit in tolerating such behavior and could be liable for a portion of the damages, which typically are not covered by malpractice insurance.

If, on the other hand, the problem doctor had been warned about the seriousness of his behavior, had been urged to begin a remedial course of action, and a record of this feedback was carefully recorded and maintained, the outcome would likely be very different.

Evaluation and Remediation of Problem Doctors
A number of organizations exist to assess disruptive physicians and offer coaching, counseling, workshops, seminars, and psychotherapy with the goal of behavior modification and reintegration into the workplace (see Where to Seek Help on page 20). Some are private consulting firms. Others are universities and hospitals. Still others are state-funded entities.

At Phil’s behest, for example, Tom contacted a private firm specializing in the assessment and remediation of disruptive physicians. Three well-validated personality assessment tests, plus an in-depth clinical interview, were then used to develop a comprehensive psychological profile of Tom and clarify the nature of his problems (see The Evaluation Process on page 22). Tom took two of the tests online in a monitored setting. Monitoring was about to become a big part of his life.

Tom was initially resistant to the evaluation process. But it slowly began to sink in that his career was on the line. He could participate or not, but he would have to live with the consequences of non-participation. That would very likely mean he would, yet again, need to find another job. Once he understood the seriousness of his situation, he quickly became engaged in the process. The clinical interview was revealing. Tom had always excelled in school and at sports. He did everything well.

His parents were supportive; he was never criticized by them, even though he was criticized by others.
Breezing through medical school, Tom encountered his first problems during his residency. He found it difficult to follow the rules, preferring to do it “my way,” raising serious questions in the eyes of others about his fitness for a medical career.

He took a year off to find himself, traveling and doing locums work. There were fewer rules. He experienced greater freedom from supervision. Ultimately, though, he returned and finished his residency. Finding a job was never a challenge. Tom was articulate, initially personable, and clearly bright. He had worked in several different emergency departments and urgent care centers before moving to his present job, always leaving when he found himself at odds with management.

As part of his evaluation, Tom was asked to choose six coworkers to offer feedback on his behavior. Phil was also asked to choose six respondents who knew Tom. The purpose was to let Tom see himself through the eyes of others. Naturally, he chose people he believed under- stood and empathized with him.

No matter. The results were unanimous. All 12 respondents found much of Tom’s behavior unacceptable, and there was an enormous gap between Tom’s self-ratings, all highly positive, and those of the respondents, whose comments were not only quite negative, there was no discernable difference among them. Everyone felt that Tom was a bully and jerk!

Tom was shocked. Tom was also given a comprehensive psychological test designed to assess psychopathology. The results showed no evidence of serious mental illness, although there was a strong suggestion of anti-social attitudes and behaviors. A self-report survey was also revealing. Tom’s scores indicated that he had a narcissistic personality with a high degree of suppressed anger.

This feedback,  interestingly,  did not come as news. “I’ve often wondered if I was a narcissist,” Tom reflected. “My wife certainly won’t be surprised to learn that she’s been right about me all along.”

The results of his evaluation were sobering. Tom enjoyed his clinical work and the lifestyle of an emergency and urgent care physician. The prospect of being forced to leave yet another job because of his anger management issues was disconcerting to him. He needed a reality check. He got one. Discussing a treatment regime was then no longer out of the question. Phil received a report summarizing the findings. It is standard practice to keep the medical director, lead physician, or whoever refers a disruptive doctor for evaluation in the loop. A doctor under evaluation consents to this at the outset of the process.

The firm that assessed Tom then assigned him an affiliated psychotherapist, who would work with him for a period of two years. The therapist would also monitor Tom and send the assessment firm regular reports on his progress, which in turn would be summarized for Phil. Tom agreed to all this.

By the end of the first year, however, Tom was no longer “The Terror.” He didn’t suddenly become warm and cuddly, but least he now was able to maintain a professional demeanor with his coworkers. The outbursts ceased. Continuing follow-up provided both the guidance and feedback he needed to develop the necessary auto-control system that led to a successful outcome.

The Role of the Physician Leader
Disruptive physicians are often about two problem doc- tors, not one. The first is Tom, or someone like him. Then there’s Phil. By putting off dealing with Tom, Phil was, in effect, his enabler. Why did he ignore repeated staff complaints? Why did people have to threaten to quit before he would act?

The Joint Commission’s mandate is explicit: disruptive physicians should be dealt with decisively and in a timely manner. Every healthcare executive knows this or should. Yet Phil’s procrastination seems to be the rule rather than the exception with doctors with supervisory oversight of other doctors.

By doing, eventually, what he should have done paying attention to staff complaints, then referring Tom for assessment and treatment Phil never had to deal with the question of what must be done. But what if a disruptive physician refuses treatment, or refuses to acknowledge the validity of his assessment, or refuses to be monitored? What if he agrees to everything but his behavior doesn’t change—or change enough?

In any of these events, there would be little or no alternative to terminating the doctor for cause. Not to do so would expose the center to litigation and potential serious financial risk. If the staffers who threatened to quit en masse had actually done so, it would have been disastrous for clinic, and morale among the staffers who remained would surely have been jeopardized. In addition, the center’s reputation in the community would likely be harmed as word unpreventably  spread.

Quality care, especially patient safety, necessitates that all caregivers behave in a professional manner, especially when engaged in direct patient care. This requirement is especially true for physicians, who tend to be viewed by non-physician staffers as team captains and setters of standards.

Healthcare organizations need to have unambiguous, clearly written policies and standards that clarify the meaning of “professional demeanor.” Explicit expectations about being on time, manner of dress, answering calls behaviors that in the “good old days” never needed to be mentioned—can no longer be assumed; they must be spelled out.

Physician executives with direct supervisory authority over other doctors must insist that these standards be met, and be ready to step in as enforcers of appropriate behavior before members of the center staff are driven to the point where they must threaten to quit. It may not be easy (see Medical Culture’s Feedback Problem on page 19), but to allow a problem doctor to go unchecked is a dereliction of duty to all concerned: patients, staff, and the center itself.

REFERENCES

1. American Medical Association. Opinion E-9.045—Physicians with disruptive Available at: www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical- ethics/opinion9045.page. Accessed June 9, 2011.
2. Federation of State Medical Boards of the United States. Report of the Special Commit- tee on Professional Conduct and Ethics. Available at: fsmb.org/pdf/2000_grpol_ Professional_Conducts_and_Ethics.pdf. Accessed June 9, 2011.
3. The Joint Sentinel Event Alert, Issue 43: Leadership committed to safety. Available at: www.jointcommission.org/sentinel_event_alert_ issue_43_leadership_committed_to_ safety. Accessed June 9, 2011.
4. Leape LL, Fromson Problem doctors: is there a system-level solution? Ann Intern Med. 2006:144(2):107-115.
5. Williams The prevalence and special educational requirements of dyscompetent physi- cians. J Contin Educ Health Prof. 2006;26(3):173-191.
6. Rosenstein AH, O’Daniel A survey of the impact of disruptive behavior and commu- nication defects on patient safety. Jt Com J Qual Patient Saf. 2008;34(8):464-471.
7. US Bureau of Labor Occupational Outlook Handbook, 2010-11 Edition. Available at: www.bls.gov/oco/ocos074.htm#emply. Accessed June 6, 2011.
8. Rosenstein AH, Naylor Incidence and impact of physician and nurse disruptive behav- iors in the emergency department. J Emerg Med. 2011;3:287-292.
9. Williams BW, Williams The disruptive physician: Conceptual organization. J Med Lic and Disc. 2008;94(3):12-20.