Joni Brodie, CPMSM, CPCS
Mat-Su Regional Medical Center
» Difficult – has a personality that is excessive but
generally doesn’t cross boundaries. Tends not
to have ‘trends’ of issues. Generally behavior
does not directly effect patient care.
» Disruptive – actions and/or words have a
detrimental effect on the staff, and therefore on
the patient.
» Is there a real difference? Yes, according to the
AMA…
» Inappropriate behavior means conduct that is unwarranted and is
reasonably interpreted to be demeaning or offensive. Persistent,
repeated inappropriate behavior can become a form of harassment
and thereby become disruptive and subject to treatment as
“disruptive behavior”.
» Disruptive behavior means any abusive conduct, including sexual
or other forms of harassment, or other forms of verbal or nonverbal conduct that harms or intimidates others to the extent that
quality of care or patient safety could be compromised.
» Appropriate behavior means any reasonable conduct to advocate
for patients, to recommend improvements in patient care, to
participate in the operations, leadership or activities of the
organized medical staff, or to engage in professional practice,
including practice that may be in competition with the hospital.
Appropriate behavior is not subject to discipline…
»
Cohen B, Snelson E. Model Medical Staff Code of Conduct. American Medical Association. 2009
AGGRESSIVE: yelling; foul and abusive language; threatening
gestures; public criticism of co-workers/health care team;
insults and shaming others; intimidation; invading one’s space;
slamming down objects; physically aggressive or assaultive
behavior
PASSIVE/AGGRESSIVE: hostile avoidance (cold shoulder
treatment); intentional miscommunication; unavailability for
professional matters (not answering pages or cell phone or
delays in doing so); speaking in a low or muffled voice;
condescending language or tone; impatience with questions;
malicious gossip; racial, gender, sexual or religious slurs or
“jokes”; “jokes” about a person’s personal appearance (fat,
skinny, short, ugly etc.); sarcasm; implied threats, especially
retribution for making complaints.
Reynolds, N. T., MD, Journal of Medical Regulation Vol 98, No. 1
» Questions to ask yourself
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Are people afraid to talk to this doctor? Do they hate calling him in?
What do other providers say about him/her?
Is the behavior/issue escalating?
Are there patient complaints or staff complaints?
ARE THE ANSWERS THINGS THAT CAN AFFECT THE PATIENT’S CARE?
– You may need to move this one up the chain.
• No one has EVER taken this much call!
• Why are you picking on me???!!!
• No matter what I do, it’s just never enough
for you people! I do more than any other
doctor!!!
• Why are there so many rules?! How am I
supposed to take care of patients?!
• Do I intimidate you??? Do I scare you???
• Who do you think you are, questioning
ME?
• If you don’t stop questioning me about
my orders, I’m going to have your job!
• What are you going to do, tell on me?
Fine, do that. I’ll call my attorney now.
• The anesthesiologist wasn’t watching close
enough – he should have seen that
the sponge was still in there!!!
• The nurses didn’t tell me that the patient
spiked a fever – isn’t that their job?
• Well I don’t care what the government says –
that’s a stupid rule & I don’t think
I should have to do this!!!
• I want you to know that this is a QUALITY
issue – I’m not pointing fingers at
anyone else!!! I’m concerned about
patient safety!!!
• Well of course she recovered – I did
the surgery!
• Please don’t question my bedside
manner – I bring millions into this
facility!
• And you would be…? Oh. A nurse.
• If the President of the Medical Staff
would like to try and come and do MY
job, I’d be happy to attend his little
meeting.
• I am the best at what I do. That’s why
I have so many patients.
• But my patients are sicker than
everyone else’s – that’s why there’s so
many problems! No one else will take
care of them!
• Aw, c’mon – it’ll be fun! Just take this
gurney and I’ll push…..
• Hey honey – want to come over here
and see my trocar?
• What? It’s not “inappropriate”…it’s
humor! You guys have way too many
hang ups! Lighten up!
• We do better surgery if the music is loud
and the staff is having fun.
• Yeah, I guess I should be more sensitive
to the patients – but they seem to like
me okay. After all, they keep coming
back!
Extrovert - Introvert
Sensing – Intuitive
Thinking – Feeling
Judging – Perceptive
*Myers-Briggs Personality Types
»
In the six Core Competencies of the ACGME,
TWO OF THEM are:
Interpersonal/Communication Skills
AND
Professionalism
Among them are:
» Patient care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health.
» Interpersonal and communication skills that result in the effective exchange of
information and collaboration with patients, their families, and other health
professionals.
» Professionalism, as manifested through a commitment to carrying out professional
responsibilities, adherence to ethical principles, and sensitivity to patients of diverse
backgrounds.
» Systems-based practice, as manifested by actions that demonstrate an awareness of and
responsiveness to the larger context and system of health care, as well as the ability to
call effectively on other resources in the system to provide optimal health care.
How many of your “difficult” providers would get through residency today???
ACGME Core Competencies
» Remember which type of difficult provider you
are interacting with. The Martyr (who needs
nurturing) is very different from the Deity (who
absolutely needs NOTHING from ANYONE).
» Always have the door closest to you. And
always bring a friend – the appropriate medical
staff leader.
» Document. Document. Document.
» Don’t take it personally. Besides, it’s never
about YOU. It’s all about THEM. So:
˃ Try using “I” statements instead of “you” statements – it alleviates the
defensive posture that can come from “you” statements.
˃ While you are involved in the situation, let the Medical Staff Leader
run the show. That’s why they are in that position.
˃ Separate the issue from the person. Rather than say “this is a
disruptive physician”, say “this is a physician with disruptive behavior”.
˃ They will definitely take it personally. So let your medical staff leader
take the heat. Be Switzerland.
˃ The Deflector will blame everyone, including you. Let it go. Don’t be
defensive.
˃ The Deity will not blame you. You are not important. Unless you make
trouble. Again, this is someone who needs a peer with a large stick.
» They are not happy about something. Or
everything. Ask questions –
˃ Dr. Smith, is there something specific I can help with?
˃ Have you spoken to your Department Chair about your issue? I can help
facilitate that.
» Most of the time, there’s just a need to be heard.
˃ Providers need to feel valued. Some don’t. And some have big inferiority
issues. Let them know that you value them as part of the medical staff.
˃ Just because they’re doctors doesn’t mean they’re feeling appreciated.
˃ Focus on helping them find a solution. It’s NOT your job to fix it, but you
can help them find a way to do it themselves.
˃ Keep them focused on the concern. Unless it’s apparent that what they
really need to do is whine a little about little Tommy’s problems in day
care.
˃ Be positive and compassionate. But if the behaviors continue, talk to a
medical staff leader. Could this provider be depressed? Having a bout of
SADD?
» NEVER go this alone. You have no authority, and they will let you
know it. Always have a physician leader direct this interaction.
» If the Intimidator comes in your office, and intimidates you –
document it and report it.
» Keep the provider on task – they can deflect, too. Use phrases like
“we can talk about that at another time, or after this meeting.
Right now we need to discuss your behavior during your patient
rounding this morning”.
» Bring the evidence. If they haven’t rounded on a patient in two
days – have a copy of the chart that shows that there was no
documentation. They want proof – and so do you.
» Don’t let this become a screaming match. If the provider is
obviously not going to listen, end the meeting and move this to
dealing with disruptive behavior. Don’t allow the Intimidator to do
what they do best!
» Passive/Aggressive does not begin to describe interactions with
this provider. Always document interactions with them – because
they will, if they feel it necessary, throw you under the bus.
» “Watch the shiny balls…” they will do anything to move the
discussion to a place they are comfortable. They do not like to be
confronted about their issues.
» If at all possible, it will be someone else’s fault. “I yelled at the
nurse because she called at 2 am with a STUPID question!
Wouldn’t you?!”
» These individuals are very defensive. Be prepared, but don’t be
intimidated. Deflectors and Intimidators are often present in one
delightful package.
» They can be narcissistic, paranoid (it’s a witch hunt!!!) – and very
difficult to communicate with – because they do NOT want to hear
it!!!
» They believe MD stands for Major Deity.
» This is the king or queen of de Nile. What, me, do this wrong? Surely you
jest.
» Narcissistic – a pattern of grandiosity, a lack of empathy and a constant
need for admiration are the hallmarks of this individual.
» They are justifiers – they justify an inappropriate behavior by evoking the
“I’m taking care of my very sick patient, and this so-called nurse didn’t call
me when their temp rose .5 degrees!!! I’m sick of this incompetence!”
» They believe in mind reading – as in you should be able to read theirs.
They feel many tasks are beneath them.
» The most effective way to communicate – focus on the issue at hand, not
on them, their patients, their practice, their lab coat. Because Deities are
also Deflectors.
» Get their attention: “you are a really valued member of the medical team
here at You Bet Your Life Memorial Hospital, and we’re glad you are part of
our staff. “ Start with a positive – then move slowly into the behavior
issue.
» These folks have a pattern of instability – in self-image, interpersonal
relationships, etc. – much like a teenager. They are still “finding out who
they are”.
» They tend not to take things as seriously as they should. Communicating
with them means a lot of banter – followed by a reality check.
» Use the things you learned raising your kids – cause and effect. If you do
this again, this will happen to YOU. Then follow through.
» Sometimes it takes more than once. As you well know.
» Turn the tables. Most of the adolescents really do think something is just
humor. Saying something derogatory (if that is the issue) to and about
them usually gets their attention. And don’t be polite. You have to make a
point here.
» Have them define “fun”. Because the first answer is always “we are here
for hundreds of hours – we need to have some fun!”. While this may be
true, there needs to be a well-defined line of what is appropriate, and
what is NOT. Their definition is usually enlightening.
» HOLD THEM ACCOUNTABLE. Even if it means reminding them that they
agreed to uphold the Code of Conduct. Give them a copy. TELL THEM TO
READ IT!
» Talk to the staff – at staff meetings, in orientations, in physician orientation
– about your policy regarding behavior. Tell them how to report it. Tell
them a provider didn’t hire them, and they cannot have them fired. New,
young employees find this the most intimidating.
» Zero tolerance for retaliation – enforce it, communicate it!
» Let them know the difference between a behavior happening once that is
out of character – and consistent behavior.
» Communicate to them that – in spite of everything they may have heard –
providers are human. They go through divorces, sick children, dying or
aging parents, financial issues. Just like you and I. It’s not an excuse for
acting out, but maybe a peer needs to have chat and help their colleague
find some resources to help their situation. Not everything is as it seems.
» Tell them how to find you. Tell them who the leaders are and how to find
them. Have a process to report. Then follow up.
» Reinforce your message every single time you can. The staff on the floor,
the cafeteria staff, the housekeepers – they all see and hear a lot. Don’t
leave them out of the circle.
» Have a policy that determines when the line gets crossed. And then ACT.
» Consistent offenders need to be dealt with – this
sends a message and reinforces behavioral
expectations.
» Look at the provider – are there gender, ethnicity,
cultural, religious or social factors that may be
effecting their behavior?
» Look at the outcomes – if the provider is not
answering pages quickly, or if they are not
returning calls – how is that effecting patient care
and safety? How much risk does that put the
patient and the hospital in? Look at the big picture.
Sometimes it’s really, really scary.
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Highly skilled
Intelligent
Hard-working
Confident
High Achievers
Well-read
Articulate
Heavy Admitters
Persevering
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Arrogant
Intimidating
Controlling – their way or the highway
Inflexible, uncompromising
Self-centered – exaggerated sense of self-importance
Entitlement
Un-empathetic
Rationalizing to justify their behavior
Blames others
Creates upset & distress in others; viewed as “difficult”
Denial – lacks self awareness; inaccurate self-appraisal
Lacking in remorse – can’t genuinely apologize
Failure to self-correct behavior
Resists help
Vindictive
Litigious
Reynolds, N. T., MD, Journal of Medical Regulation Vol 98, No. 1
» Have a well-defined policy on Disruptive
Behavior
˃ Definitions of what is NOT disruptive behavior
˃ Definition of what IS disruptive behavior
˃ Clearly outlined steps – including collegial interventions – that are
followed meticulously. Remember – these folks are litigious.
˃ Have options in the policy – Performance Improvement Plan?
Psychological evaluations? Anger Management? How about a physical
– can illness be a contributing factor? All this should be included in
the FIRST step in dealing with this.
˃ Outline the process after that – up to and including revocation of
privileges and medical staff membership.
˃ ENFORCE IT EQUALLY. This is the hardest part. There can be NO
DIFFERENCE in how any incident is handled, whether it’s a no/low
provider, or a $65 million per year neurosurgeon.
» Outline who will handle these issues – and how. Department
Chair, CEO and Medical Staff President? CMO? Who should
be involved – before the crisis happens.
» EDUCATE YOUR LEADERS – they must document – even if it is
a collegial thing. Even if it is a one time event. You have to
document that the conversation occurred.
» Include Legal Counsel as you are developing this process.
You need to know what’s reportable to the State, and
whether you can restrict a Fair Hearing to whether or not the
PIP was violated – a handy item to know! And you want to
stay protected.
» Always provide reassurance to the participants – both the
perpetrator and the colleagues – that they are protected.
Then remind them that going into the doctor’s lounge and
railing about the unfairness of it all could put that protection
in jeopardy.
» Do you have this? Is it part of your Bylaws?
» Do you educate new providers during
orientation on expected behavior?
» Do they have to sign an acknowledgement that
they have read and understood the
expectations?
» All of this can help you in the future should that
person prove to be, shall we say, a challenge?
» Situations are fluid – arguing and yelling in a closed
medical staff meeting is very different then the
same behavior being exhibited on a nursing unit or
in the cafeteria.
» Doctors are very opinionated. They are also
frustrated by the many changes in health care that
require more paperwork, have more regulations
and more consequences.
» Have we mentioned Electronic Medical Records?
» They need to vent – but it must be done in an
appropriate location and circumstance.
» The Cone of Silence…
•
Once it is understood that
your Medical Staff Leaders
mean business – please
don’t expect harmony and
peace. That’s not a
realistic expectation when
dealing with large
numbers of human
beings. But you can
expect that you will have
greater levels of expected
behaviors based on
fairness, a good process
and policy, and open
communication with all of
your colleagues. And that
can NOT be a bad thing!!!
You are the bridge between what’s going on, and
the leaders of your hospital and medical staff. You
have a critical role. You have their trust, and you
have their ear. If you don’t tell them what’s going
on, maybe no one will – and that patient needs
you. That patient could be you or a loved one.
Now if you just had Prozac mist, and Haldol in the
water…..