When a physician exhibits behavior that is out of line, it may be a sign of a larger problem.
Medicine is a stressful profession. The hours are long, the work is demanding, and a wrong decision can have deadly consequences. In recent years, changes in the medical environment—cutbacks and staffing shortages, increased scrutiny and accountability, and a constant influx of new technologies—have compounded the problem. Add to that the everyday stressors of modern life—marital troubles, aging parents, or financial strain—and you have an environment that can overwhelm even the most dedicated professional. How physicians handle stress can have a significant effect on the workplace and on patient safety. Although most physicians find appropriate ways to cope, a small percentage turn to drugs or alcohol; some act out, blowing up at colleagues, storming out of meetings, and berating subordinates.
Such disruptive behavior gets in the way of collaboration and cuts off communication; a bullying physician can intimidate colleagues and co-workers to the point that patient care suffers. Many physicians aren’t even aware their behavior is disruptive, and even those who might see their behavior as a problem have a difficult time reaching out for help. Some might be convinced they can manage the problem on their own, while others fear seeking help could jeopardize their medical license and professional relationships.
“It’s the old thing of ‘doctor heal thyself,’” says Doug Adamek, founder and CEO of Physician Wellness Services, one of several organizations in Minnesota that specialize in helping physicians cope with personal problems, stress, mental illness, and addiction. “You get in that mindset, and it can be really self-destructive.”
Recognizing the Problem
Just as there is no single cause, there is no single definition of disruptive behavior, says Alan Rosenstein, M.D., a San Francisco internist and medical director for Physician Wellness Services, who has studied disruptive behavior in physicians for more than a decade. A general description, he says, is any interaction in which a physician intimidates another individual to the point where it compromises the quality of care and patient safety.
Disruptive behavior can be subtle: a physician who doesn’t return calls, ignores charts, or refuses to follow best practices because the guidelines “don’t apply to them,” for example. It also can be overt: a physician screaming at a nurse who is trying to draw attention to a potential mistake, such as cutting on the wrong side, or responding belligerently when someone calls with a question. The cumulative effect of disruptive behavior, Rosenstein says, is that co-workers become so intimidated they begin to avoid the physician.
Although organizations once might have turned a blind eye to bad behavior from high-performing physicians, Rosenstein says, increasingly they’re calling physicians on it. Research shows that bad behavior translates into bad patient care. In 2009, a Joint Commission review of sentinel events found the safety and quality of patient care depends on teamwork, communication, and a collaborative work environment. Further, the commission found that intimidating and disruptive physician behavior can foster medical errors and contribute to preventable adverse outcomes. Disruptive behavior also reduces patient satisfaction and increases costs and staff turnover.
The Joint Commission now mandates that all accredited hospitals and health care organizations have a code of conduct that defines unacceptable, disruptive, and inappropriate behaviors and a process for managing such behaviors.
Often, the first step for hospital and health care administrators who encounter a disruptive doctor is letting that person know his or her behavior is unacceptable, says Rosenstein. The next is to determine the cause of the problem. “The issue we see on the surface probably isn’t the issue,” Adamek says. Although the presenting symptom might be an angry outburst at a nurse, the underlying issue might be concern about an adolescent child, depression, or stress about the financial health of the practice. “The core is what we’re looking for,” he says.
The next challenge is to convince the physician to seek help. The type of help depends on the extent of the problem. Some physicians just need assistance managing the details of life and work. In those cases, Physician Wellness Services offers concierge-style services that help mitigate day-to-day stress such as finding appropriate child or elder care, making travel reservations, or contracting a lawn service. Others need to talk with someone. The organization can connect physicians to a physician peer coach or mental health professional for individual counseling and support for issues such as stress, depression, dealing with grief or loss, or conflicts with colleagues or family members. The services are designed specifically for physicians and the organizations that employ them.
Another organization, Physicians Serving Physicians, provides confidential intervention and counseling services to doctors struggling with drug and alcohol addiction. It tries to pair clients with recovering physicians in the same medical specialty. “It’s been effective to have somebody present who has been there, done that, and is in recovery and who can say that life doesn’t end, the medical practice isn’t affected,” says Diane Naas, executive director of the Edina-based organization.
In June, Hazelden opened a new treatment program specifically for addicted health care professionals at its Center City campus in Minnesota. “Although addiction affects the brain in the same way whether you’re a neurosurgeon or a longshoreman, physicians face some unique issues,” says Omar Manejwala, M.D., medical director at Center City.
“First and foremost, it’s really, really hard for people who spend their lives treating patients to themselves be patients,” he says. “When you remove alcohol or the drug, the individual can often feel a tremendous sense of shame,” he says. Because health care professionals’ self-esteem often comes from helping others, he explains, they can end up trying to help everybody else in treatment rather than focusing on their own issues. To break that pattern, Hazelden houses health professionals together during treatment so that they interact with each other as part of their recovery process.
“So a doctor who has been sober two or three months can talk to the new guy, the new neurosurgeon who walks in the door,” Manejwala says. “Being able to share their experience with each other is very powerful and can make a physician who comes into treatment feel a real sense of connectedness.”
It can also help physicians deal with some of the unique issues they face upon re-entering the workforce, such as what to tell patients and colleagues, how to manage stress, how to handle the availability of intoxicants, how monitoring works, and what they can do to protect their license.
The state licensing form physicians are required to fill out every year asks applicants to disclose whether they have a mental, emotional, or substance abuse problem that impairs or limits their ability to practice medicine with reasonable skill and safety. Answering yes could result in disciplinary action or jeopardize a physician’s license. The state-run Health Professionals Services Program (HPSP) offers physicians and other medical professionals with addiction and mental health issues a nondisciplinary alternative to reporting such problems to the Board of Medical Practice.
Physicians can come to the HPSP either through self-referral, referral from a colleague, an employee health program, or some other third party. Or the Minnesota Board of Medical Practice can refer physicians to the program with or without discipline. The HPSP evaluates the physician, and, when warranted, sets up a monitoring program to track how he or she manages the illness over time, says Monica Feider, HPSP program manager.
Participants are required to seek treatment from an approved provider such as Hazelden, and both the physician and the provider must provide the HPSP with regular progress updates. The physician must also be accountable to a worksite manager or supervisor. If the problem is addiction, they may be asked to attend a support group and undergo toxicology screening. Monitoring lasts an average of three years but could continue for as long as five years.
Feider says physicians are highly motivated to complete the program, and most do. Last year, 83 percent successfully met the conditions of their monitoring plan. “When physicians complete monitoring, their file is closed. If they were self-reported or reported by a third party, and if they have been compliant with monitoring, the board never knows of their involvement in the program,” she says.
A Pound of Prevention
Increasingly, health care organizations are realizing that the easiest way to deal with disruptive behavior may be to prevent it. That means talking about the effects that stress can have on a work and personal life as early as medical school and providing targeted employee assistance programs or other services to help physicians cope with the issues that can affect not just their lives but the lives of their patients.
“Our goal is to make physicians happier and more satisfied,” Rosenstein says. “If you’re more satisfied, you are more well-adjusted, more productive, and there’s less likelihood of a disruptive event later on, either at home or at the workplace.”—J. Trout Lowen