Slamming a portable X-ray machine into a wall in front of a patient. Screaming at a nurse. Throwing instruments. Death threats.
All of these infractions are reasons physicians have been referred by hospitals, medical boards, and even their own attorneys to programs that assess their behavior and work with them to correct it.
However, even less-dramatic behavior seen by a coworker as passive-aggressive, manipulative, or threatening can result in a referral as well, leaders of the programs say.
"Perfect Storm" of Developments
Betsy Williams, PhD, MPH, clinical director of the Professional Renewal Center in Lawrence, Kansas, describes a "perfect storm" of changes that are sending physicians to programs such as hers.
Laws have gotten more strict, a Joint Commission alert has warned hospitals of the dangers of disruptive behaviors, more physicians have gone from being self-employed to being hospital employees, and team-based core competencies and Internet-savvy patients demand more collaboration from physicians.
Experts say only a small number of physicians (between 3% and 5%) exhibit disruptive behaviors, but more than 70% of physicians polled in a 2011 survey said disruptive physician behavior — from profanity to outright assault — occurs at least once a month at their organizations. More than 10% said such incidents occur daily.
Ultimately, these actions can have serious consequences for patient care and hospital finances, and the pressure is on to stop it from poisoning care environments.
"There may be more referrals [for treatment] because there's simply more risk in not making the referral," said Ari Novick, PhD, a psychotherapist with AJ Novick Group in Laguna Beach, California, which offers a program specifically for physicians.
"Twenty years ago, physicians could sort of behave the way they wanted to, and there really wasn't a protocol to stop that. We're seeing the trend move toward more equality in the workplace, regardless of whether you're a physician or a scrub tech," Dr. Novick said.
Program Types Vary Widely
Some of the best known programs are those for distressed physicians at Vanderbilt and the University of Virginia, as well as the Physician Assessment and Clinical Education (PACE) program at the University of California, San Diego. But programs are available all over the country and range from one-on-one sessions once a week to group coaching to communal living in apartments so that interactions with others can be observed.
The referred physicians are more often men than women, but they come from all disciplines, program directors say. Giovanna Zerbi, PsyD, who teaches University of California, San Diego, anger management courses for physicians, said the more stressful their practice area — obstetrics-gynecology, surgery, emergency medicine, for example — the more likely physicians are to wind up in her program.
Dr. Zerbi said a large part of her workshop is teaching leadership skills. Many of the physicians she sees describe a loss of power from being the captain of the ship to having to work collaboratively as healthcare models evolve.
"They don't really know how to make things happen, and so yelling is a way to get people to do what they want in the moment," she said.
The first step is often getting physicians to take responsibility for their actions, program leaders note.
"I usually have a room full of innocent lambs who say the system is completely messed up," she said. "That's where we start, and then in the course of 3 days people start taking some responsibility."
Other Reasons for Actions
Dr. Williams, from the Kansas program, said it is important to find the right program for a particular physician, because the reasons for referral vary widely. For instance, sometimes a change in an underlying medical condition is fueling unacceptable behavior, so the treatment options are different.
She approaches treatment as a way to fill in the collaborative and communication skills that may not have been stressed when physicians were in medical school.
That has changed, she said: Medical schools now are being more attentive to these issues early on and have even sent students whom they see as having potential for disruptive behavior to her program and others. Early intervention is important to stop what has become a culture of acceptance at hospitals, said Glenn Siegel, MD, who, with Mary Pittman, MS, RN, developed a model for treating disruptive physicians that is used in hospitals and state physician assistance programs nationwide.
"Often we see a long history of a physician being verbally abusive in the workplace and the hospital doing nothing about it because they don't want to tamper with the revenue production of that physician," Dr. Siegel said. That reinforces behavior and ultimately affects the patient. It also can undermine teamwork when colleagues feel they cannot approach the physician or know that he or she will not return pages or telephone calls.
When physicians come to Dr. Siegel and Pittman for treatment at Professionals at Risk Treatment Services in Elmhurst, Illinois, they have sessions between 9 am and 5 pm Mondays through Fridays. Physicians stay in apartments or "therapeutic residences" with other physicians so that professionals can observe during day sessions and after hours how they interact with people outside their clinical environments. Programs start with the recognition that a physician's anger is quite often paired with a belief that they are championing quality healthcare and a fierce sense of responsibility to patients.
"It's all these other contaminating parts of themselves that they've never really looked at or understood. They need some awareness of themselves and have a better relationship with themselves to function without so much anger," Dr. Siegel said. At the extreme end of the training for disruptive physicians are long-term engagements during which experts are called to a hospital to interview staff, set limits, and restore order. William Norcross, MD, executive director of the University of California, San Diego, program, said PACE experts were once retained by a hospital for a year and a half to work with a staff dealing with disruptive physician behavior.
"For hospitals, this can be a multimillion-dollar problem...if 1 or 2 of their high-earning physicians are disruptive. There are patient safety issues, there are lawsuit issues, there are nurse retention issues," Dr. Norcross said. "It is often in a hospital's best interest to fix the problem, rather than just get rid of it."
Reprinted with permission from Medscape (http://www.medscape.com/), 2013, available at http://www/,medscape.com/view article/ 782504