Constructive Responses to Difficult Doctors: A Practical Guide

1. Difficult DoctorsA Process for Responding Constructively When Doctors Behave Badly1,2A Presentation for Nursing Students Kendall L. Stewart, MD, MBA, DFAPA May 19, 2009 1My aim is to offer a practical process you can put to use in your personal and professional lives right away. 2Please let me know whether I have succeeded when you complete your evaluation form.

2. Doctors can be difficult. When they are, they create real problems in the workplace. Because of their status or power, bigwigs regularly indulge in destructive behavior with no significant adverse consequence. Temper tantrums are overlooked. Intimidation is accepted, even reinforced. Verbal abuse is tolerated and tyrants are lionized. Even physical abuse and destruction of property are more common than we would like to admit. But tolerating and thereby encouraging such behavior exacts an awful price. Disruptive behavior wounds others and leaves lasting organizational scars. After masteringthe information in this presentation, you will be able to Define the scope of the “difficult doctor” problem, Describe exactly how difficult doctors behave, Explain how difficult doctors “make” you feel, Describe how your feelings “make” you behave, Detail some effective organizational strategies for dealing with difficult physician behavior, Identify a process for dealing more effectively with difficult physician behavior, Explain why this process will help, and Explain how to it. All kinds of bigwigs regularly misbehave, but we bystanders are not as powerless as we sometimes feel.1,2 Why is this important? 1Even junior medical students, the lowest form of human life, are not totally powerless. 2A thoracic surgeon berated me during a case and later nicked his glove.

3. Preparing to Deal with Difficult Doctors Preparing yourself1,2 Preparing physician leaders Preparing executives Preparing trustees Preparing managers Preparing employees Annoying Doctors Negative doctors Selfish doctors Unreasonable doctors Whining doctors Disorganized doctors Immature doctors Disruptive Doctors Angry doctors Abusive doctors Dishonest doctors Arrogant doctors Felonious doctors Dangerous Doctors Marginal doctors Incompetent doctors Impaired doctors Distracted doctors Careless doctors Overwhelmed doctors What is the scope of this challenge? 1I began my career as an orderly’s assistant, and I immediately began learning how to cope with difficult doctors. 2A rogue EM physician offered to treat my bronchitis.

4. How exactly to difficult doctors behave? • They are disrespectful. • They berate colleagues publicly. • They use abusive language. • They indulge in condescending behaviors. • They throw temper tantrums. • They intimidate and threaten. • They engage in sexual harassment. • They lie, cheat and steal. • They are insulting. • They are upsetting to patients. • They throw things. • They slam doors and hit walls. • They may even physically assault others.1,2 1One of my professors in medical school delighted in intimidating women; he was elected teacher of the year. 2A senior surgery resident told me, “You incompetent SOB, you’ve killed the patient.”

5. How do difficult physicians’ behaviors “make” us feel? • Hopeless • Resentful • Angry • Hurt • Discouraged • Frustrated • Helpless • Enraged • Unappreciated1,2 • Rejected 1Some people just cannot be pleased. 2An orthopedist spent time going over x-rays with me as a orderly. A surgeon asked me to serve as his first assistant.

6. How do our feelings “make” us behave? • Withdraw • Nag • Argue • Give up • Explain • Talk behind others’ backs • Ruminate • Gossip • Try harder to please • Plot revenge1,2 1Sometimes it’s best to be quiet and wait for the right opportunity. 2Claude wanted to fly, but Maude thought it was too expensive.

7. Acknowledge the problem. Make a commitment to manage the problem. Clarify your behavioral expectations. Require physicians to agree to behave. Field the best possible executive team. Recruit a strong physician executive.1,2 Initiate a culture change. Delegate with care. Investigate and document allegations promptly, dispassionately and thoroughly. Insist on fairness. Confront physicians effectively. Consider all options and choose the best one. Propose a reasonable solution and force dissenters to appear unreasonable. Inform medical staff leaders; do not consult or seek consent. Follow up promptly with staff members. Send resolution letters immediately. Dismiss nuisance complaints quickly. Give your stars the star treatment. What are some organizational strategies for dealing with difficult doctors? 1This is a brutal job, but I love it. Most physician leaders don’t love their jobs. 2A physician who complained about “Kendall letters” during a focus group made my day.

8. What is a typical “difficult doctor” scenario? A nurse on the unit receives a call from the lab that his patient’s potassium is low. The lab is calling because the value is in the critical range and the lab believes the physician must be notified. The lab has already tried unsuccessfully to reach the physician directly, and concluded that the patient’s caregiver must know what is going on. The nurse immediately calls the physician’s office and explains the issue. “The doctor is telling a patient he has terminal cancer, but I will have her give you a call as soon as she comes out of the room.” About this time, another patient codes on the floor and the nurse forgets about the low potassium. The doctor never calls back. The next morning, the physician discovers the low potassium and begins yelling at the nursing station. “What F***ing moron didn’t call me back. If I didn’t respond, any idiot should have known to call me again to remind me of this low potassium.” Everyone lapses into stunned silence while the irate physician repeats herself, all the while growing redder and louder.

9. Getting into a yelling match on the spot Failing to attempt to contain the outburst Agreeing with the doctor that the outburst was justified Failing to document the outburst objectively Confronting without objective documentation Confronting inappropriately Confronting without prior senior management support. Failing to attach any unpleasant consequences Responding while still emotionally aroused Failing to accept the victims’ feelings Failing to point out that imperfections do not justify such outbursts Failing to confront disruptive behavioral patterns Being drawn into distracting arguments and away from the disruptive behavior1,2 What mistakes have you seen people make in such circumstances? 1When physicians are screaming at you, just agree that their conclusion is one explanation. 2A surgeon came in to tell me that the Director of Surgery would not speak with him.

10. Label difficult physicians as “difficult.” Recognize that disruptive behavior is an organizational crisis that must be managed promptly. Recognize and monitor your own emotional arousal. Employ appropriate mental distractions. Minimize the emotional contagion. Begin the documentation immediately. Hear people out. Accept everyone’s feelings. Do not permit feelings to contaminate the documentation. Encourage a cooling-off period. Set realistic expectations for the staff. Clarify your expectation that a follow-up discussion with the physician will occur. Accept the physician’s frustration but not her behavior. Attempt to resolve incidents at the lowest possible organizational level. Suggest an early apology for inappropriate behavior and language. Follow the SOMC progressive corrective action model. Prepare to confront. Follow your script. Follow through on your promises to elevate the issue to the appropriate level. Reinforce more appropriate subsequent behavior. What process, if followed, will most likely produce the best outcome?1,2 1Decide on the results you want and select a process that will produce those results. Then, follow that process. 2Let me demonstrate with my own data. Go to www.SparkPeople.com to learn how.

11. What have we learned? • More effective teamwork with physicians is essential to our organizational success. • Tolerating inappropriate behavior from physicians (or anyone else) will undermine our efforts. • Building effective relationships demands a considerable emotional investment. • We should focus on our own—not others’—attitudes and behaviors since we have less control over theirs. • Total success is not possible.1 • Incremental success is easily achievable. • This is a process, not an occasion. • But executing these strategies will result in some wonderful occasions too.2 1What’s the ultimate answer? Hire only nice physicians. How many of your physicians would you hire as managers? 2The best we can do is play the cards we’re dealt. My melanoma patient brought that truth home to me.

12. Where can you learn more?1 • View or download this presentation online on SOMC’s Web site, http://www.somc.org/NRSOMCPress/Clinical.htm • Stewart, Kendall L., et. al. A Portable Mentor for Organizational Leaders, SOMCPress, 2003 • Stewart, Kendall L., “Physician Traps: Some Practical Ways to Avoid Becoming a Miserable Doctor” A SOMCPress White Paper, SOMCPress, July 24, 2002 • Stewart, Kendall L. et. al, “On Being Successful at SOMC: Some Practical Guidelines for New Physicians” A SOMCPress White Paper, SOMCPress, January 2001 • Stewart, Kendall L., “Bigwigs Behaving Badly: Understanding and Coping with Notable Misbehavior” A SOMCPress White Paper, SOMCPress, March 11, 2002 • Stewart, Kendall L., “Relationships: Building and Sustaining the Interpersonal Foundations of Organizational Success” A SOMCPress White Paper, SOMCPress, March 11, 2002 • Rosenstein, Alan H., et. al., “Disruptive Physician Behavior Contributes to Nursing Shortage,” The Physician Executive, November-December, 2002 1Please visit www.KendallLStewart.comto download related White Papers and presentations.

13. How can you contact me?1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center President & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1All speaking and consultation fees benefit the SOMC Endowment Fund.

14. Are there other questions? www.somc.org SafetyQualityServiceRelationshipsPerformance 