1. Physicians Behaving Badly: Dealing with the Disruptive Physician Sanford R. Kimmel, M.D. Professor of Family Medicine University of Toledo College of Medicine Chief of Staff University of Toledo Medical Center

2. Objectives: Why are disruptive physicians a problem? Why are disruptive physicians a problem? How common are disruptive physicians & how frequent is their behavior? How common are disruptive physicians & how frequent is their behavior? Who are disruptive physicians i.e. what behaviors do they display? Who are disruptive physicians i.e. what behaviors do they display? How do you assess and manage the disruptive physician? How do you assess and manage the disruptive physician?

3. The Joint Commission states that intimidating & disruptive behaviors: Foster medical errors Foster medical errors Contribute to poor patient satisfaction Contribute to poor patient satisfaction Contribute to preventable adverse outcomes Contribute to preventable adverse outcomes Increase the cost of care Increase the cost of care Contribute to a hostile work environment Contribute to a hostile work environment Cause qualified clinicians, staff, & administrators to seek new positions Cause qualified clinicians, staff, & administrators to seek new positions The Joint Commission Sentinel Event Alert, July 09, 2008.

4. How common is disruptive behavior? Less than 5% of clinicians are thought to demonstrate disruptive behavior.* Less than 5% of clinicians are thought to demonstrate disruptive behavior.* 70% nearly always involve the same physicians. ‡ 70% nearly always involve the same physicians. ‡ 56.5% usually involved conflict between physician & nurse or other staff member. ‡ 56.5% usually involved conflict between physician & nurse or other staff member. ‡ 86% (n=675) of nurses & 49% (n=245) physicians witnessed disruptive physician behavior in a separate study. # 86% (n=675) of nurses & 49% (n=245) physicians witnessed disruptive physician behavior in a separate study. # 72% (n=664) nurses & 47% (n=245) physicians witnessed disruptive nurse behavior. # 72% (n=664) nurses & 47% (n=245) physicians witnessed disruptive nurse behavior. # *Porto G, Lauve R. Patient Safety & Quality Healthcare, July/August 2006 ‡ Weber DO. The Physician Executive, September/October 2004:6-14 # Rosenstein AH, O’Daniel M. American Journal Nursing 2005;105:54-64

5. Estimates of Frequency of Occurrence of Physician & Nurse Disruptive Behavior % of respondents n  1400 Rosenstein AH, O’Daniel M. American Journal Nursing 2005;105:54-64, Figure 3

6. Adverse Effects of Disruptive Behavior > 90% (n=962) respondents think disruptive behavior has a potentially negative effect on patient outcomes. > 90% (n=962) respondents think disruptive behavior has a potentially negative effect on patient outcomes. 60% (n=1,487) were aware of any potential adverse events (AEs) that could occur from disruptive behavior. 60% (n=1,487) were aware of any potential adverse events (AEs) that could occur from disruptive behavior. 17% (n=1441) were aware of a specific AE that resulted from disruptive behavior. 17% (n=1441) were aware of a specific AE that resulted from disruptive behavior. 78% (n=249) believe that the AE could have been prevented. 78% (n=249) believe that the AE could have been prevented. Rosenstein AH, O’Daniel M. American Journal Nursing 2005;105:54-64

7. Psychological Effects of Disruptive Behavior Reported by Nurses & Physicians Stress Stress Frustration Frustration Loss of concentration Loss of concentration Reduced team collaboration Reduced team collaboration Reduced information transfer Reduced information transfer Reduced communication Reduced communication Impaired RN—MD relationship Impaired RN—MD relationship Rosenstein AH, O’Daniel M. American Journal Nursing 2005;105:54-64

8. Examples of Disruptive Behavior--1 Profane or disrespectful language Profane or disrespectful language Demeaning behavior e.g. name-calling Demeaning behavior e.g. name-calling Sexual comments or innuendo Sexual comments or innuendo Inappropriate touching, sexual or otherwise Inappropriate touching, sexual or otherwise Racial or ethnic jokes Racial or ethnic jokes Anger outbursts (Temper Tantrums!) Anger outbursts (Temper Tantrums!) Throwing instruments, charts, etc. Throwing instruments, charts, etc. Porto G, Lauve R. Patient Safety & Quality Healthcare, July/August 2006

9. Examples of Disruptive Behavior--2 Comments undermining a patient’s trust in other caregivers. Comments undermining a patient’s trust in other caregivers. Comments undermining a caregiver’s self- confidence in caring for patients. Comments undermining a caregiver’s self- confidence in caring for patients. Failure to adequately address safety concerns. Failure to adequately address safety concerns. Intimidating behavior that discourages input by other healthcare professionals. Intimidating behavior that discourages input by other healthcare professionals. Failure to adhere to organization policies without adequate reason. Failure to adhere to organization policies without adequate reason. Retaliation against any person who reports or investigates violation of the code of conduct. Retaliation against any person who reports or investigates violation of the code of conduct. Porto G, Lauve R. Patient Safety & Quality Healthcare, July/August 2006

10. The Joint Commission Requirements EP 4: “The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.” EP 4: “The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.” EP 5: “Leaders create and implement a process for managing disruptive and inappropriate behavior.” EP 5: “Leaders create and implement a process for managing disruptive and inappropriate behavior.”

11. Policy on Disruptive Behavior Involving Members of the Medical Staff “Disruptive behavior” means any conduct or behavior including, without limitation, sexual harassment or other forms of inappropriate behavior, which: “Disruptive behavior” means any conduct or behavior including, without limitation, sexual harassment or other forms of inappropriate behavior, which: Jeopardizes or is inconsistent with quality patient care or with the ability of others to provide quality patient care at the hospital; Jeopardizes or is inconsistent with quality patient care or with the ability of others to provide quality patient care at the hospital; Is unethical; or Is unethical; or Constitutes the physical, written, or verbal abuse of others involved with providing patient care including written criticism of care or verbal criticism of care in public places by other providers. Constitutes the physical, written, or verbal abuse of others involved with providing patient care including written criticism of care or verbal criticism of care in public places by other providers. Policy number 3364-87-10. University of Toledo Medical Center, effective 07/14/99

12. Policy on Disruptive Behavior Involving Members of the Medical Staff “Sexual harassment” is defined as: “Sexual harassment” is defined as: unwelcome sexual advances, requests for sexual favors, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome sexual advances, requests for sexual favors, or verbal or physical activity through which submission to sexual advances is made an explicit or implicit condition of employment or future employment-related decisions; unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with the employee’s work performance or which creates an offensive, intimidating or otherwise hostile work environment. unwelcome conduct of a sexual nature which has the purpose or effect of unreasonably interfering with the employee’s work performance or which creates an offensive, intimidating or otherwise hostile work environment. Policy number 3364-87-10. University of Toledo Medical Center, effective 07/14/99

13. The Joint Commission Suggestions Educate all team members—physicians & non- physicians—on appropriate professional behavior. Educate all team members—physicians & non- physicians—on appropriate professional behavior. Hold all team members accountable for desirable behaviors, & enforce codes consistently & equitably. Hold all team members accountable for desirable behaviors, & enforce codes consistently & equitably. Develop/implement policies & procedures/processes: Develop/implement policies & procedures/processes: “Zero tolerance” for intimidating/disruptive behaviors. “Zero tolerance” for intimidating/disruptive behaviors. Medical staff policies should complement & support organizational policies for non-physician staff. Medical staff policies should complement & support organizational policies for non-physician staff. Include non-retaliatory clauses in all policy statements that address disruptive behaviors. Include non-retaliatory clauses in all policy statements that address disruptive behaviors. Describe how & when to begin disciplinary actions. Describe how & when to begin disciplinary actions. The Joint Commission Sentinel Event Alert, July 09, 2008.

14. Personality Profiles of Problem Physicians Behaviorally disruptive (n=39) : uncontrolled anger or conduct demeaning to others Behaviorally disruptive (n=39) : uncontrolled anger or conduct demeaning to others More open to assessment & willing to admit personal short- comings. Rationalize that behavior justified by intolerance of substandard performance by staff. More open to assessment & willing to admit personal short- comings. Rationalize that behavior justified by intolerance of substandard performance by staff. Sexual boundary violators (n=25) : alleged sexual mis-conduct or provocative behavior with patients/staff Sexual boundary violators (n=25) : alleged sexual mis-conduct or provocative behavior with patients/staff ↓ Impulse regulation,  self-centered, ↓ empathy, ↓ self- responsibility for actions, ↓ influence of societal norms. ↓ Impulse regulation,  self-centered, ↓ empathy, ↓ self- responsibility for actions, ↓ influence of societal norms. Other misconduct (n=24) : substance abuse, emotional instability or professional irresponsibility. Other misconduct (n=24) : substance abuse, emotional instability or professional irresponsibility. Roback HB et al. Problematic physicians: a comparison of personality profiles by offence type. The Canadian Journal of Psychiatry, 2007;52:315-22

15. 6 Drivers of Disruptive Behavior Substance abuse, psychological issues Substance abuse, psychological issues Narcissism, perfectionism, selfishness Narcissism, perfectionism, selfishness Spillover of chronic/acute family/home problems Spillover of chronic/acute family/home problems Poorly controlled anger; especially under stress Poorly controlled anger; especially under stress Poor clinical/administrative systems support Poor clinical/administrative systems support Poor practice management skills Poor practice management skills Providers whose constant criticisms create poor practice environments. Providers whose constant criticisms create poor practice environments. Bad behavior gets results & is rewarded! Bad behavior gets results & is rewarded! Clinical administrative inertia Clinical administrative inertia No one does anything about it & the behavior is considered the individual’s “norm”. No one does anything about it & the behavior is considered the individual’s “norm”. Hickson GB et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine 2007;82:1040-48

16. Used with permission. Hickson GB, Pichert JW, Webb LE, Gabbe SG. et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine 2007;82:1040-48

17. Level 1 Intervention—nonpunitive Do nothing. Do nothing. Request further information. Request further information. Initiate intervention. Initiate intervention. Informal meeting (“Cup of coffee”) with physician to share complaint: Informal meeting (“Cup of coffee”) with physician to share complaint: Explain reason for visit. Explain reason for visit. Assure confidentiality. Assure confidentiality. Discuss colleague’s view & potential solutions. Discuss colleague’s view & potential solutions. Arrange for follow-up visit, usually 12 mos at Vanderbilt. Arrange for follow-up visit, usually 12 mos at Vanderbilt. Ask colleague to develop a plan. Ask colleague to develop a plan. Standard Intervention. The Center for Patient & Professional Advocacy. Vanderbilt Medical Center at www.mc.vanderbilt.edu/centers/cppa/intervention.htm accessed 02/15/10.www.mc.vanderbilt.edu/centers/cppa/intervention.htm

18. Principles for “Informal” Conversations Report the event i.e. it’s not a control contest. Report the event i.e. it’s not a control contest. Let the colleague know that the institution does have a surveillance system (informal or formal). Let the colleague know that the institution does have a surveillance system (informal or formal). Do not downplay the seriousness of the event. Do not downplay the seriousness of the event. Be empathetic but objective. Be empathetic but objective. Focus message on the event. Focus message on the event. Affirm value to institution but hold accountable. Affirm value to institution but hold accountable. Assure confidentiality & arrange followup. Assure confidentiality & arrange followup. Hickson GB. Discouraging Disruptive Behavior: It starts with a Cup of Coffee! Center for Patient and Professional Advocacy, Vanderbilt University Medical Center.2009.

19. Physician Grief Reactions ala Elisabeth Kübler Ross Denial: Refusal to accept facts—”I didn’t do it.” Denial: Refusal to accept facts—”I didn’t do it.” Anger: Against others e.g. “Who says that?” or the system e.g. “If we had more/better staff or equipment, this wouldn’t have happened.” Anger: Against others e.g. “Who says that?” or the system e.g. “If we had more/better staff or equipment, this wouldn’t have happened.” Bargaining: “How can I make this go away?” “Let me talk to the person who complained.” Bargaining: “How can I make this go away?” “Let me talk to the person who complained.” Depression: Realizes gravity of situation, feels hurt, may cry. Depression: Realizes gravity of situation, feels hurt, may cry. Acceptance: “What do I need to do now?” “What happens now?” Acceptance: “What do I need to do now?” “What happens now?”

20. Impaired & Disruptive Physician!

21. Case Presentation—Doctor X* During an operation in the O.R., Dr. X is unhappy over a missing instrument from the surgical tray. While the circulating nurse is retrieving the instrument, (s)he curses the team for not ensuring the instrument was present. During an operation in the O.R., Dr. X is unhappy over a missing instrument from the surgical tray. While the circulating nurse is retrieving the instrument, (s)he curses the team for not ensuring the instrument was present. Does this constitute disruptive behavior? Does this constitute disruptive behavior? If so, how would you deal with it? If so, how would you deal with it? Dr. X is a fictional character that represents a composite of disruptive behaviors. Any relationship to any real person, either living or dead, is purely coincidental.

22. Level III Disruptive Behavior Verbal Abuse which is directed at-large, but has been reasonably perceived by a witness to be disruptive behavior as defined previously. Verbal Abuse which is directed at-large, but has been reasonably perceived by a witness to be disruptive behavior as defined previously. UTMC Policy Number 3364-87-10. Disruptive Behavior Involving Members of the Medical Staff.

23. The Continuing Saga of Doctor X Because it is a long case, the scrub nurse is relieved by another nurse who does not usually scrub in on this type of case. The nurse does not prepare the instruments in as expedient manner as demanded by Doctor X and (s)he becomes more frustrated cursing and stating, “If you can’t do things right, you shouldn’t be in the O.R.” Because it is a long case, the scrub nurse is relieved by another nurse who does not usually scrub in on this type of case. The nurse does not prepare the instruments in as expedient manner as demanded by Doctor X and (s)he becomes more frustrated cursing and stating, “If you can’t do things right, you shouldn’t be in the O.R.” Does this constitute disruptive behavior? Does this constitute disruptive behavior? If so, how would you deal with this situation? If so, how would you deal with this situation?

24. Level II Disruptive Behavior Verbal abuse such as unwarranted yelling, swearing or cursing; threatening, humiliating, sexual or otherwise inappropriate comments directed at a person, or persons, or physical violence or abuse directed in anger at an inanimate object. Verbal abuse such as unwarranted yelling, swearing or cursing; threatening, humiliating, sexual or otherwise inappropriate comments directed at a person, or persons, or physical violence or abuse directed in anger at an inanimate object. UTMC Policy Number 3364-87-10. Disruptive Behavior Involving Members of the Medical Staff.

25. Doctor X Escalates Increasingly frustrated at the perceived inefficiency and ineptness, Doctor X tells the scrub nurse to leave the table, and as she is doing so, throws an instrument at her. Increasingly frustrated at the perceived inefficiency and ineptness, Doctor X tells the scrub nurse to leave the table, and as she is doing so, throws an instrument at her. As is her right, the nurse files a complaint with the medical staff office. As is her right, the nurse files a complaint with the medical staff office. How will you respond to this situation? How will you respond to this situation?

26. Level I Disruptive Behavior Physical violence or other physical abuse which is directed at people. Sexual harassment involving physical contact. Physical violence or other physical abuse which is directed at people. Sexual harassment involving physical contact. UTMC Policy Number 3364-87-10. Disruptive Behavior Involving Members of the Medical Staff.

27. Chief of Staff (COS) Actions Interview the complainant and, if possible, any witnesses promptly after receiving the complaint. The COS & a 2 nd med. staff member shall interview the medical staff member. Interview the complainant and, if possible, any witnesses promptly after receiving the complaint. The COS & a 2 nd med. staff member shall interview the medical staff member. The med. staff member may respond in writing. The med. staff member may respond in writing. The Chief of Staff shall do one or more: The Chief of Staff shall do one or more: Determine that no action is warranted Determine that no action is warranted Issue a warning or reprimand Issue a warning or reprimand Require a written apology to the complainant Require a written apology to the complainant Refer member to the Medical Staff Impaired Physician Advisory Group Refer member to the Medical Staff Impaired Physician Advisory Group Initiate corrective action pursuant to the medical staff bylaws. Initiate corrective action pursuant to the medical staff bylaws. UTMC Policy Number 3364-87-10. Disruptive Behavior Involving Members of the Medical Staff

28. Benefits of Dealing with Unprofessional Behavior Improve patient safety so that staff are more likely to report problems in patient care. Improve patient safety so that staff are more likely to report problems in patient care. Reduce liability exposure & risk-management. Reduce liability exposure & risk-management. Improve staff satisfaction & retention. Improve staff satisfaction & retention. Enhance reputation for the medical center. Enhance reputation for the medical center. Create professionals who are role models for students, residents, staff, & each other. Create professionals who are role models for students, residents, staff, & each other. Produce more productive, civil & desirable work environment. Produce more productive, civil & desirable work environment. Hickson GB et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine 2007;82:1040-48

29. Good Teamwork Provides Effective and Efficient Patient Care