Articles on Compliance Strategies

Featured Health Business Daily Story May 6, 2008

Disruptive Physicians Heighten Hospital Risks at a Time When Collaboration Is Key to Effective Compliance

Reprinted from REPORT ON MEDICARE COMPLIANCE, the nation's leading source of news and strategic information on false claims, overpayments, compliance programs, billing errors and other Medicare compliance issues.

By Nina Youngstrom, Managing Editor, (nyoungstrom@aispub.com)

Disruptive physicians — the kind who insult nurses, throw tantrums and toss scalpels around — have always been a problem for hospitals and their employees. But the threat is looming larger given new developments, such as mandates that call for greater physician-coder/nurse interaction on issues that aren't purely clinical (e.g., present on admission (POA) reporting, hospital-acquired conditions payment restrictions, Medicare-Severity DRGs) and the government's push to link quality and payment. It's hard for a coder to team with a physician to make decisions about POA indicators if that particular physician tells the coder she's incompetent. And the hospital may struggle to thrive under value-based purchasing if a physician's contemptuousness leads to high nurse turnover.

As hospitals grapple with disruptive physicians, a new trend has emerged, making a stubborn problem even more resistant to improvement, says Pittsburgh attorney Henry Casale. Some disruptive physicians are trying to evade consequences for their behavior by claiming that they are not disruptive at all. Rather, they are whistle-blowers exposing hospital noncompliance and poor quality, but the hospital is trying to retaliate against their complaints by branding them troublemakers, he says.

"We are seeing this more and more," says Casale, who is with the law firm of Horty, Springer & Mattern. "Disruptive physicians raise specious claims that have no validity in an attempt to justify their disruptive behavior. Hospitals want to know legitimate compliance concerns, but if there were never any underlying compliance concerns, then lodging fictitious complaints is just another act of disruptive behavior. It's a very difficult issue, being made more complex and being obfuscated by claims that the disruptive behavior is part of some whistle-blowing activity."

Notwithstanding the distraction, the urgency for a solution remains. The Joint Commission requires hospitals to manage disruptive physicians. The code of conduct that hospitals must adopt for Joint Commission accreditation includes a standard for providing a "culture of safety and quality." That means "leaders set expectations for behavior" in the workplace, according to its Web site.

"Safety and quality thrive in an environment that supports working in teams and respecting other people, regardless of their position in the organization. Undesirable behaviors that intimidate staff, decrease morale, or increase staff turnover can threaten the safety and quality of care," the Joint Commission says.

Given the stakes, hospitals should consider ways to help disruptive physicians change their behavior, experts say. One approach is to do what hospitals do for any other outlier: confront physicians with data. Physicians respond to concrete information, even if it is about their own behavior, says Miami psychologist Larry Harmon, Ph.D. He runs a teamwork improvement program for disruptive physicians around the country.

Disruptive physicians are the kind who make life miserable for the people with whom they work — their health care team — with belittling remarks (e.g., "Are you a moron?"), sarcasm (e.g., "It's hard to believe you even have a nursing degree!"), yelling and screaming when things don't go their way and throwing things around the room.

Some physicians behave this way partly because of the milieu in which physicians are trained and practice, Harmon says. "Learning medicine is not a team activity," he says. "They spend much of their time learning technical skills, not teamwork skills." Also, physicians are what Harmon calls "feedback starved." The more prestigious the specialty (e.g., surgeons), the less likely someone will call the physicians on their behavior, he says. As a result, disruptive physicians may be highly skilled and passionate advocates for their patients, but nightmares as colleagues.

Physicians Respond to Feedback

So Harmon developed an educational program designed to get disruptive physicians to stop mistreating the health care team by giving them feedback they lack and helping them see themselves through other peoples' eyes.

There are three phases. First, there is assessment. Harmon sends personal e-mail surveys to the people who work with the disruptive physician. They are asked to answer, anonymously, a series of motivating (positive) questions and discouraging questions.

Examples of positive questions: To what extent does the physician treat team members with respect? To what extent does the physician adapt to changing policies? To what extent does the physician respond to conflict by trying to work out solutions? To what extent does the physician handle difficult team members effectively? To what extent does the physician point out mistakes in a helpful way? To what extent does the physician communicate clear expectations?

Examples of discouraging questions: To what extent does the physician talk down to team members? Overreact when little things go wrong? Yell and swear? To what extent does the physician get sarcastic or angry when asked important questions?

Avoidance, Favorable Comments Most Effective

Harmon summarizes the responses from the physician's team members and prepares a summary report and recommendations for the physicians. "Most [physicians] are surprised how negative the feedback is," he says. However, hearing the truth about how they are perceived "is necessary to break through the denial and defensiveness and to help the physician understand that his or her behavior is having a negative impact on others."

Disruptive physicians are particularly responsive to two kinds of feedback: (1) avoidance comments, such as when nurses state on the surveys that "I call in sick to work when I know you are scheduled [to perform] surgery" and "I am trying to get a job in another part of the hospital so I don't have to work with you"; and (2) favorable comments, such as "You're a great surgeon (even though I can't stand working with you)" and "I would take my mother to you for surgery." In other words, they are deprived of the compliments because of their demeanor.

Once all the feedback is in, Harmon analyzes it to home in more specifically on the disruptive physician's problem behaviors. That way, education can be tailored to the physician. There are education modules on frustration management, conflict management, people management and time management. For example, a physician who yells and screams a lot probably has an anger management problem.

Physicians then watch a video tailored to the triggers of their disruptive behaviors. It's designed to help the physicians change their behavior and work better as part of the health care team. They have to take an online test afterward to ensure they understood and absorbed the content, Harmon says.

Finally, Harmon monitors physicians for a year or so after the training to ensure the changes are sticking and bad behavior doesn't re-emerge. "We do periodic surveys [of the health care team] until the physician had had a sustained period of improvement," he says.

Harmon says that over the next five to 10 years, hospitals will emphasize "getting professionalism back. It will become routine." In fact, medical schools are already are addressing the importance of giving behavioral feedback to doctors-in-training. Harmon provides his program to all the medical students at the University of Miami Miller School of Medicine. "Periodically giving and receiving feedback" is essential, he says. "You can't change what you don't know."

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