Winning Together with the Destructive Physician Will Latham Latham Consulting Group

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What is a Disruptive Physician? … Disruptive physician behavior consists of a practice pattern of personality traits that interferes with the physician’s effective clinical performance. Norman T. Reynolds, MD Journal of Medical Regulation, Vol 98, No 1

What is a Disruptive Physician? …one whose actions are contrary to the best interests of the practice, or jeopardizes the morale or even tenure of the group and its radiologists members. Larry Muroff, MD

What Does It Look Like? Degrading comments or insults Discriminatory behavior Inappropriate joking Incompetence Physical assault Profanity Refusal to cooperate with others Refusal to follow established protocols Retaliation Spreading malicious rumors Substance abuse Throwing objects Yelling

Why Do We Have Disruptive Behavior?

Workload Learned behavior (medical school) Other members of the healthcare team Non-work related causes Policy or procedure related Other root causes

Why Do We Have Disruptive Behavior? Because We Tolerate It

Why Do We Tolerate It? Because We Are Conflict Avoiders

Conflict Style Competing Collaborating Avoiding Accommodating Compromising Assertive Passive Uncooperative Cooperative Conflict Style

Conflict Continuum Mean-Spirited Personal Attacks Artificial Harmony Constructive Destructive Ideal Conflict Point

We Focus Here

We Should Focus Here

Disruptive Behavior Occurs at least Once a Month > 70% Disruptive Behavior Occurs at least Once a Month

Disruptive Behavior Occurs at least Once a Week > 37% Disruptive Behavior Occurs at least Once a Week

Disruptive Behavior Occurs on a Daily Basis > 10% Disruptive Behavior Occurs on a Daily Basis

If men were angels, no governance would be necessary. - James Madison 

What Do We Do? Prepare for Problems

Employment Contract Protective Clauses Termination without cause (2/3rd vote). Non-compete. Automatic resignation from all group’s hospitals at the end of employment. All medical employment work with group. Protection against sale/repossession of stock to/by an outside entity.

What Do We Do? Careful Hiring

Careful Hiring Consider factors beyond clinical competence. Can they play well in the “sandbox?” Explain group “norms” and specifically ask if they are willing to adhere to them. Rehabilitation is unlikely.

What Do We Do? Mentoring

Strengthen Our Ability to Deal With Disruptive Behavior What Do We Do? Strengthen Our Ability to Deal With Disruptive Behavior

Disruptive Physicians x x x x x x x x x

Disruptive Physicians x x x x x x x x x

Disruptive Physicians Normative Behaviors x x x x x x x x x

If I didn’t vote for it,

If I didn’t vote for it, or I don’t agree with it,

I don’t have to do it. If I didn’t vote for it, or I don’t agree with it, I don’t have to do it.

The Foundation: Decision-Making How will the group make decisions?

The Foundation: Decision-Making How will the group make decisions? Talk and vote?

The Foundation: Decision-Making How will the group make decisions? Talk and vote? What is expected of each physician once a decision is made?

The Foundation: Decision-Making How will the group make decisions? Talk and vote? What is expected of each physician once a decision is made? What you want to hear is “support it,” “do it,” “not sabotage it,” etc.

The Foundation: Decision-Making How will the group make decisions? Talk and vote? What is expected of each physician once a decision is made? What you want to hear is “support it,” “do it,” “not sabotage it,” etc. What are a physician’s options if he or she doesn’t like the decision?

The Foundation: Decision-Making How will the group make decisions? Talk and vote? What is expected of each physician once a decision is made? What you want to hear is “support it,” “do it,” “not sabotage it,” etc. What are a physician’s options if he or she doesn’t like the decision? Do it anyway – that’s group practice Try to get it change, in the appropriate forum. Self-select yourself out of the group.

Code of Conduct Questions: Set expectations for: What behaviors do we expect of each other? What is acceptable to us? What is inappropriate? What are some of the unwritten rules that guide our behavior? What are the rights and responsibilities of each physician? Set expectations for: Interactions between physicians. Interactions with employees. Interactions with those outside the group. Practice management responsibilities. Support of group decisions, established goals and policies.

Establish Group Policies Impairment (substance abuse, eroded skills, psychological Sexual harassment/creation of a hostile work environment. Disability. Nepotism. Leave. Notes: Work with your attorney – these policies can be governed by state and federal requirements. Set them before you need them.

Establish a System to Deal with Disruptive Physicians What Do We Do? Establish a System to Deal with Disruptive Physicians

Consequences There must be a consequence for disruptive behavior. These consequences must apply to all.

Disciplinary Enforcement Process Options Rulebook. General System. Rules Based System.

Rulebook If you do “X”, then “Y” happens. BTW – it’s up to the manager to implement “Y” Problems: “I didn’t get into medicine to have to follow a rule book” “We can’t think of everything.”

General System President of group tries to fix. “Physician Affairs Committee” tries to fix. Board fixes. Problems: Typically no authority for consequence until the Board. Conflict avoidance at its best!

Rules Based System Similar to General System, but guidelines for dealing with infractions.

Type of Offense Category 2 First Offense $1,000 and outside counseling paid for by physician. Second Offense $3,000 and outside counseling paid for by physician. Third Offense $5,000 and outside counseling paid for by physician. Example Category 2 Offense: Harassment. Reporting to work under the influence. Gambling or fighting.

Meaningful Consequences Re-education or training. Documented verbal warnings. Written warnings. Withhold bonus money. Penalty per violation. Self-payment for additional education. Self payment for additional staff. Losing priority status for scheduling vacation. Assigned extra call. Loss of voting privileges (A to B Shareholder) Probation. Temporary suspension. Demotion. Termination. Restitution for damages. Referral for criminal prosecution.

Confronting the Disruptive Physician (Gulp) What Do We Do? Confronting the Disruptive Physician (Gulp)

Confronting Problem Behavior Focus on behavior, not personality. Describe the specific situation that illustrates the behavior you are concerned about. Explain why it concerns you and express your desire for change. Seek out and listen to the individual’s reasons for this behavior. Inform the individual how improved behavior will improve his/her relationship with the group. Ask for the individual’s ideas and commitment to solving the problem. Offer your encouragement and support. Agree on an action plan and set a date to discuss it.

Pain is inevitable. Suffering is optional.