Prevention Strategy

Many problems in life can be avoided by using a variety of preventive measures. Just as helmets help reduce the frequency and severity of head injuries, an effective credentialing process can head off the hiring or appointment of a disruptive physician. The credentialing process should have mechanisms in place to ‘sniff out’ or uncover disruptive physicians with the goal of preventing them from joining the organization. Ideally, it is best to stop them at the door!

Proactive Intervention:

If for some reason your organization is compelled to hire a physician with a history of disruptive behavior (e.g. you live in a small rural community and they are the only cardiologist within 200 miles; he/she is a mega star that you can’t live without, although this is rarely the case!; or you are looking to create more drama in your life!), be prepared to confront his/her pattern of disruptive conduct BEFORE they come on board and begin seeing patients.

1. Set and communicate clear expectations. As part of their orientation, have them sign and agree to follow your new policy regarding a zero tolerance for disruptive behavior.
2. Place them on a contract that includes a 3 and 6 month probationary period, where their performance and history of complaints are reviewed. Do not give them full partnership and privileges until you are confident he/she will not engage or continue a pattern of disruptive conduct.
3. If there are complaints, extend the probationary period and develop a Performance Improvement Plan that includes referring them to a remediation course to learn coping and communication skills. Make it their job and responsibility to change their conduct!

If the organization is pro-active with an immediate and powerful response to disruptive or unprofessional conduct, the disruptive physician will often times leave voluntarily. Being proactive also means actively creating a culture of professionalism, where unprofessional, rude, hostile, disruptive behavior is simply unacceptable and not tolerated, not only because it is against policy, but also because it violates the culture of the workplace!

The-Horse-Has-Already-Left-Barn Strategy:

This strategy means your organization already has somebody on board who has been identified as ‘disruptive’, and has not dealt with them effectively. Here are a few observations I’ve made over the years working with many different types of organizations and many physicians identified as ‘disruptive’:
1. Most organizations have several employees/physicians who engage in unprofessional or disruptive behavior;
2. These individuals take up an extraordinary amount of the organization’s resources and create a high percentage of the staffing problems, including low staff morale, nursing turn-over, poor communication, patient safety issues, and a greater risk of medical errors.
3. These individuals, for the most part, are smart, clinically competent people who lack a certain skill set, and are sometimes developmentally immature (it is rarely a matter of psychopathology or character!). They are usually very committed to patient care.
4. These ‘disruptive’ individuals are often times accurate or correct in their observation or identification of problems, either individual or system based. (e.g. inadequately trained nursing staff.)
5. They often become scapegoats, even when their behavior has improved or ceases to be disruptive. This is because they created a culture where others have a conditioned response to them regardless of how they are actually behaving; or their reputation becomes their legend. This becomes a system’s issue that cannot be addressed by the changes in one person’s behavior.
6. Disruptive people usually look for the slightest element of ‘truth’ in what they are saying to justify their behavior, and it often has to do with quality of care issues. “I’m just advocating for my patient!” “If it wasn’t for me, the nurses would have killed my patient!” Sound familiar?
7. Disruptive physicians have high expectations of others, and even higher expectations of themselves! They find it difficult to live with a lack of perfection.
8. They often have high levels of anxiety, fear, and symptoms of depression.

This is not a justification for their disruptive and unprofessional conduct!

While dealing with disruptive or hostile behavior is never easy, allowing your own emotions to get out of hand only exacerbates the situation and further enflames a hostile person. They always use the conduct or response of others to justify their behavior. Do not give them that opportunity. Thus,
Rule #1: No matter how difficult, infuriating or absurd the conduct of the other person, make every effort to maintain control over your own emotions and impulses. In a war of words, you may end up slitting your own throat! Step back and allow the hostile, disruptive person to reveal themselves through their public display. They will often back down if they begin to feel foolish in their tirade. Remove yourself from the situation as soon as possible.
Rule #2: When the person is calm, address their behavior directly by setting clear expectations, tell them the negative consequences of their conduct, and let them know what will happen if the unprofessional conduct continues. Tell them specifically what the situation was and outline what behavior was unacceptable. DO NOT debate the situation or merit of their position, as they will try to explain why they are ‘right’ and how others are ‘wrong’.
Rule #3: Avoid having conversations about their conduct in a public venue, but also avoid the parking lot, hallway, cafeteria style ‘casual’ conversations where their misconduct is addressed informally, and ‘in passing’. Make it formal and assert your authority the first time and every time! Call the person to your office. If you need to speak with the person in your office more than twice, have another person of authority present (e.g. an MEC member) to support you.
Rule #4: Document all incidents and complaints, and all conversations you have about the disruptive conduct with all parties involved (e.g. witnesses, attorneys, MEC, etc.). Make it part of their medical staff file.
Rule#5: Don’t tolerate — don’t wait! Intervene early and often! Develop a Performance Improvement Plan (PIP) and set measures of expectations.
Rule#6: Provide regular feedback that includes the positive. All people like to hear when they are also doing well. An adversarial relationship will worsen if the only time they hear from you is when there is a problem.
Rule#7: Set realistic expectations for them and for yourself. If your organization has been tolerating disruptive and unprofessional conduct from somebody for many years, you cannot decide in 2009 to enforce a zero tolerance policy and expect his/her complaint rate to go from 10 to 0 per month just because you decide to get tough! Set high expectations and insist on progress without expecting perfection. If not, he/she will certainly fail.
Rule #8: Provide them with an appropriate place or venue to vent their frustrations or concerns. Listen to their concerns or observations and try to channel them into a positive direction. But they can’t just become a complainer; suggest they get involved in teaching the nurses new procedures, orienting the new staff, or sitting on a QA committee.
Rule#9: DO NOT mix the conversations and topics! Say to them: “Let’s set up a separate time to meet regarding your concerns about nursing matters. I would like to hear what you have to say, and brainstorm with you ways to improve the quality of our nursing care, but right now we are only going to talk about your conduct.” Stay on topic. Do not let him/her roll over you. If they start to become agitated or disrespectful, end the conversation. This may mean that you need to stand up, open your office door and leave.
Rule #10: Manage poor performance by getting him/her help or support. Sometimes physicians are disruptive because they have problems (verses simply being a jerk!). Most physicians want to be and do better, if given the opportunity. Offer supervision or mentoring as a way of providing feedback. Refer to the Well-Being committee or for Executive Coaching if he/she complains about stress or personal problems. Incorporate referrals into a PIP.
Rule#11: Take corrective action if the disruptive behavior continues and the physician has refused to cooperate with all voluntary PIP efforts. Corrective action must include the willingness to terminate physician’s privileges and all the consequences that go along with that decision (e.g. 805 report).
I’ve noticed that there are no PIP’s or remedial education programs for the ‘disruptive’ LVN, the rude IT guy, or the screaming social worker. When an organization tolerates disruptive and unprofessional conduct from any physician, they are telling the other employees that such behavior is tolerable if you are special, talented, or generate enough revenue for the organization.
Finally, remember that culture eats strategy for lunch! The best way to eliminate disruptive behavior is to create a culture of excellence, professionalism and respect, irrespective of role, education, or status.