Addressing Disruptive
Physician Behavior
Counseling Peers
William Hopkinson, MD
Orthopaedic Program Director, Loyola University Medical Center
AAOS Fall Meeting, October 19, 2012
XXX Disclosure XXX
Any opinions expressed in this presentation are
solely my own
Retired USA MC
Part-time VA
Full time academic faculty at private university
Member AAOS Committee on Professionalism
Judiciary Committee
No financial conflicts of interest
“SPECIAL BEHAVIOR”
Disruptive = Inappropriate
Interferes with function/flow of workplace
If unaddressed, usually escalates.
Disruptive Behavior Examples
Yelling
Profanity/Verbal abuse
Threatening body gestures
Failing to adhere to usual authority, such
as:
– Not providing ID
– Not participating in Time Out
– Not returning calls/pages
More Serious Behavior
Threatening
– Physical actions just short of contact
– Oral/ written /implied threats
Legally defined as assault
Violent
– Physical behavior or specific threats of
physical harm
– Harmful or offensive contact
Legally defined as battery
Is there a rationale for DB?
Surgical Stress/ Frustrations
-Increased complexity/ more regulations
- High volume
- Low margin
of error
Reason for DB
Substance abuse/psych issues
Narcissism/perfectionism
Personal issues
Reasons for Tolerating DB
None……but
– Majority of surgeons are non-confrontational
– Respect/tolerance of “rainmakers”
– Rationalizing behavior
– “Not my …..” problem /patient/ resident/ issue
– If I ignore, maybe the problem will go away
– ETC
What they think
they are
Perception is Reality
What others see
Why deal with disruptive behavior?
Easy
Directly linked to adverse events
Professionalism issue
Lawsuits
Poor morale
How to deal with disruptive behavior?
The Hard Part
Pyramid upside down
Level of action
Persons involved
One-on-one intervention
Fellow professional
Awareness meeting- self-improvement
plan
Fellow professional/ authority figure
Formal report/action plan
Institutional /Task Force
Disciplinary action
Institution
Reportable/appealable
My Experience
Department Vice-Chair
Residency Program Director
Professional Standards and Peer Review
Committee, Loyola
Loyola PARS Program
– Co-chair and mentor
AAOS Committee on Professionalism
My Experience in the trenches
One-on-one- peer interactions
Authority figure
Our local PARS activity
LUMC Professionalism Committee
AAOS COP and Judiciary Committee
Cup of coffee
conversation
Why – behavior noted
When – soon
Where – safe/quiet place
How – balance empathy and objectivity
stay on message
Expectations
Self-correction
Cup of coffee conversation
To be meaningful – stay on topic
Avoid the following tendencies
– Control contest
– “Curbside therapy”
– Enabling
– “Oh, by the way, now that we are here……”
Can an authority figure do this?
Can you do this to the boss?
Yes – with care
– Non-judgmental
– Empathy and objectivity
– Focus on the behavior
Perception is reality
Prepare for full range of
responses
When a lot of coffee doesn’t
work
Cre
Self-creating an
improvement plan
Local Hospital Task Force
Generating a report
Review by Committee of Peers
Actions taken can range from
– No action
– Fines
– Mandated activities – local/national programs
– Dismissal
The Loyola PARS Program
Using “unsolicited” patient complaints to
measure physician risk
At Loyola, 2 co-chairs and 20 mentors
Program started in 2003
– Mentor selection and training
– Assigning mentors
– Annual update
PARS: Reducing Malpractice Risk,
Professionalism and Self-Regulation
Conceptual Framework – Professionalism
 Professionals commit to:
 Technical and cognitive excellence
 Professionals also commit to:
 Clear and effective communication
 Modeling respect
 Being available
 Professionalism promotes teamwork
 Professionalism demands self-regulation
Loyola PARS Experience
2003-2011
2003-2007
2008
2009
2010
2011
Phys. Interventions
No.
First Interventions
28
First Interventions
9
First Interventions
7
First Interventions
7
Proposed First Year
6
(Excluding 1 Recidivist)
Total
57
Results to date - LUMC
Total # high complaint physicians
57
First follow-up in ’12
6
Departed After Initial Intervention
Total with follow-up results
47
Results for those with follow-up data:
Good – Intervention visits suspended
21
Good – Anticipate suspension in ’12
9
Some improvement -- Still need tracking 1
Subtotal 31
Unimproved/worse
14
Departed Unimproved
2
Total follow-up results
47
4
(45%)
(19%)
(2%)
(66%)
(30%)
(4%)
AAOS Standards of
Professionalism
6 SOPs establishing “minimum standards
of acceptable conduct for Orthopaedic
surgeons”
Each SOP has an aspirational statement
with one or more mandatory standards
AAOS SOPs
Covers a range of professional topics
One AAOS member files a grievance
against another
All other administrative actions should
have been completed
SOP on Professional
Relationships
Aspirational
– Good relationships among physicians, nurses,
and other health care professionals are
essential for good patient care
– The orthopaedic surgeon should promote the
development and utilization of an expert
health care team that will work together
harmoniously to provide optimal patient care.
SOP on Professional
Relationships
Mandatory standards:
An Orthopaedic surgeon:
– Shall maintain fairness, respect, and
appropriate confidentiality…
– Shall conduct themselves in a professional
manner in interactions…
– Shall work collaboratively with others to
reduce medical errors, increase patient
safety, and optimize outcomes …
Professional Compliance
Program
Actions to date (April 2012)
125 grievances submitted
47 COP Hearings
21 Appeals to Judiciary Committee
Results
– 18 No action
– 2 Letters of concern
Grievances Filed by SOP
Providing MS Services
3
Professional Relationships
9
Expert Witness Testimony
94
Expert Opinion
9
Research/academic
responsibility
0
Advertising
9
Conflicts of interest
1
AAOS Professionalism Program
30 Official Actions of AAOS BOD
7 Censures
23 Suspensions
Ranging from months to 3 years
0 Expulsions
Summary
Disruptive behavior is
disabling to health care
An organized process can be
effective
It starts with one-on-one
Elimination of DB requires an
organizational commitment
We all need to be involved