Cracking the problem of the disruptive physician

We have so far seen the various ways in which the disruptive physician may frustrate healthcare and wreak havoc on patient safety. To recap we have looked at:

In this post we will look at some of the remedies that have been proposed to mitigate the damage caused by badly behaved doctors.

The Screaming Man. Walt Jabsco on Flickr. https://www.flickr.com/photos/waltjabsco/232098623

The first step in resolving the problem is to recognise the factors that facilitate the emergence and persistence of disruptive behaviours. Lucian Leape and John Fromson in their paper titled, Problem doctors: is there a system-level solution? explored several of such factors such as:

    • The reticence of physicians to tackle the behavioural problems of their colleagues.
    • The deficient training and skills of department heads to manage poorly performing doctors.
    • The tendency for healthcare institutions to ignore the warning signs of disruptive behaviour which are often evident years before the behaviour results in a catastrophic event.
    • The reluctance of health institutions to challenge disruptive physicians who contribute significantly to their ‘revenue stream‘.
    • The unwillingness of the disruptive physician to accept help.
    • The tendency of the disruptive doctor to challenge disciplinary action with lawsuits.
Shouting in the storm. Raul Lieberwirth on Flickr. https://www.flickr.com/photos/lanier67/4394900117

To overcome these hurdles, and to tackle the problem systematically, Leape and Fromson suggested the following strategies which are now in place in many health institutions:

    • The routine monitoring of all doctors for bad behaviour
    • The prompt but constructive response to concerns about disruptive behaviour
    • Paying attention to red flags such as a high number of complaints
    • Annual physical examinations and random drug tests for all doctors – admittedly a controversial suggestion!

The most enduring solutions to disruptive behaviour however centre on creating an institutional culture that strikes at the roots of the problem. Exploring this concept in their paper titled Creating a culture of respect, Lucian Leape and colleagues asserted that creating a ‘culture of respect‘ is the ‘essential first step‘ for any health care organisation which seeks to provide safe care for its patients, and a ‘supportive and nurturing environment’ for its staff

Handshake. AK Rockefeller on Flickr. https://www.flickr.com/photos/akrockefeller/7208427782

To establish such a workplace atmosphere, Leape and colleagues made the following recommendations

    • The institution of cultural changes that prevent the occurrence of disrespectful behaviour.
    • The establishment of ‘effective methods for responding to episodes of disrespectful behaviour
    • The introduction of a code of conduct that explicitly outlines ‘the expectation that everyone is entitled to be treated with courtesy, honesty, respect, and dignity

By Роза Гиматдинова/Юлия Лепе, CC BY-SA 4.0, Link

The establishment of a code of conduct is indeed central to all approaches to managing disruptive behaviour, and other authors have expanded on this theme. For example Grena Porto and Richard Lauve, in their paper titled Disruptive clinician behavior: a persistent threat to patient safety, stressed that the code must not just be ‘aspirational in tone‘, but it should explicitly state the types of behaviours that are unacceptable. They went further to propose that

    • The code must be incorporated in hospital policy
    • Medical staff must formally adopt the code
    • Adherence to the code must be monitored
    • Training must be provided on the monitoring and reporting of disruptive behaviour.
CC BY 2.0, Link

The critical importance of staff members endorsing and accepting the code of conduct policy was also highlighted by Alan Rosenstein and Michelle O’Daniel in their paper titled Managing disruptive physician behavior: impact on staff relationships and patient care. They however also stressed the need to enforce the code by establishing multidisciplinary committees which have the powers to review all complaints and to make disciplinary recommendations. For the code of conduct to work successfully, there are several measures which must be put in place. For example:

    • Leape and colleagues stress that the implementation of the code must be fair, consistent, and transparent.
    • Rosenstein and O’Daniel pointed out that staff must be educated on the ‘significance and seriousness of the problem’.
    • Porto and Lauve stressed the importance of training staff to monitor and report disruptive behaviour.
CC BY 4.0, Link

In a paper titled Measuring and managing the economic impact of disruptive behaviors in the hospitalAlan Rosenstein, encapsulated the principles of managing disruptive physicians in what he called a ‘10-step process‘. This helps to focus the attention of organisations on the measures that are necessary to resolve the problem of disruptive physician behaviour. The first 9 steps are:

    • Organisational commitment
    • Disruptive behaviour policy
    • Project champion
    • Recognition and awareness
    • Staff education
    • Identifying areas with ‘potential opportunities for improvement‘.
    • Advanced communication training
    • Assertiveness training and team-building skills
    • Incident reporting

The 10th and final step is intervention, and Rosenstein classified this into three phases:

    • Pre-crisis phase: the identification of at-risk physicians such as those suffering from ‘increasing levels of stress, frustration, burnout, and depression
    • Acute crisis phase: the prevention of ‘potential and imminent patient harm
    • Post-crisis phase: conflict management and dispute resolution

***

We have now completed our review of the principles of managing disruptive physician behaviour. In the next post, we will look specifically at the professional etiquette conducive to patient safety.

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