by Mark N. Simon, MD
What can hospital medical staff leaders learn from University of Oregon football coach Chip Kelly? In the morning of September 4th, Kelly had an opportunity to review video tape from the conclusion of his team’s game with Boise State University the night before. What he saw was his senior running back LeGarrette Blount punch an opponent and then lose his cool with the fans in attendance. He also saw that it took a number of individuals to get Blount off the field and into the locker room.
Kelly was now faced with one of the most difficult decisions any leader will face. What was he to do with a valuable member of the team whose behavior was clearly unacceptable? Blount was beginning his senior season with the university. He had been named to the watch list for the Doak Walker Award (the best running back in college) and he was projected to be a 2nd round draft pick in next year’s NFL draft. Blount had set a University of Oregon record with 17 rushing touchdowns in 2008 and had rushed over 1,000 yards that year. Any punishment leveled by Kelly would likely have a significant impact on the team’s offensive production and possibly could result in fewer team wins. Not an easy decision for this first year coach.
Kelly pondered all of these facts, reviewed the evidence, and considered his previous interactions with Blount. Blount had been punished by the coaching staff earlier in the year for previous poor behavior. In the end, Kelly determined that the behavior displayed by Blount was inappropriate and Kelly suspended Blount for the remainder of his senior season. Kelly wants Blount to participate in other football related activities but he will not be allowed to play in any more games. Kelly said, “…he needs to pay for that mistake. But we’re not going to throw LeGarette Blount out on the street.”
How does this translate to the hospital setting? Not infrequently, medical staff leaders are faced with disruptive behavior by physicians. On many occasions, the physicians responsible for these behaviors represent a “great value” to the hospital, and people are reluctant to take significant action for fear of losing business. Kelly recognized that Blount represented a “great value” to the team, and he determined that Blount’s behavior did not meet those expected of member of the team. In addition, Blount had already been subjected to disciplinary action and had been once again reminded of what behaviors were expected. Blount was also aware of the potential consequences of poor behavior.
Hospital leaders should follow these same examples for all members of their teams regardless of perceived value.
* Expected behaviors should be clearly delineated.
* Consequences for divergence from these behaviors should also be delineated.
* The type of punishment should be in line with the severity of the infraction.
* Consequences should increase in a step-wise fashion for repetitive infractions.
* Clear communication should occur at each and every instance.
In the end, medical staff leadership like Chip Kelly must be willing work with disruptive providers while being firm when it comes to expectations. They must not be afraid to suspend or dismiss providers who unable or unwilling to conform to codes of conduct. Medical staff leaders are not only responsible to monitoring the skills of their providers. They are responsible for making sure that the providers adhere to team norms in order to cultivate the best environment for providing quality care to the patients they serve.
Mark N. Simon is an OB-GYN hospitalist.
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Well, first, doctors are not football players.
IMHO, this is a one-sided article that feeds the notion that doctors are always the problem (as opposed to the hospitals themselves – or their management):
http://drjshousecalls.blogspot.com/2009/04/medscape-lays-rotten-egg-offering.html
Dr. Simon needs to come on over to Housecalls and spend some time reading – paying particular attention to the exhibits in the sidebar.
“Disruptive physician” is, more often than not, a bogus “diagnosis” assigned by corporate types (you know, those leaders adhering to “team norms”) to physicians whose troublesome behavior includes blowing-the-whistle on some of the very things Dr. Simon laments.
It’s been used to destroy careers, and the AMA has been blissfully asleep-at-the-wheel.
Moreover, “whistle-blower” protection in the medical arena is little more than a myth. Hospitals and their accreditation-racket-known-as-JCAHO don’t want it to be anything more than that.
Mark,
Could you please be more specific about ‘disruptive’ physician behavior? I am as concerned about poor behavior on the part of physicians as anyone – but my concern is that certain ethical behavior has been classified as ‘disruptive behavior’ by hospital administrators in an effort to control them. For example, physicians who want patients to stay longer in the hospital because they don’t think it is in the patient’s best interests to leave to sooner, or physicians who believe that hospital practices, in a certain manner, are dangerous and call the administration’s attention to this fact. I could see how such physicians might be viewed as a ‘thorn in the side’ of the hospital, but that is a far cry from being unethical. At least with respect to these types of issues, hospitals should simply be more honest and state that length of stay issues are an important part of the way Medicare pays them, and therefore, they will be enforcing certain rules with respect to that variable. Or that certain safety issues, while addressable in the long run, are not important enough in the current fiscal environment to address. This avoids the use of misleading labels for ethical physicians yet makes the hospital’s position clear.
“Disruptive” increasingly means “anything the hospital doesn’t like” and ESPECIALLY “anything bad for the hospital’s $$$”. Naturally, well meaning but stupid legislators and bureaucrats have given hospital boards the ability to turn these disputes between provider and hospital into something that can affect the doctor’s permanent record and thus are useful as a cudgel. Nice national database record you got here, shame if not wanting to take extra ED call were to make something happen to it… This is why I look forward to the day that I drop admitting privileges.
So long, suckers. Last one out turn off the lights.
I agree with the other comments and I disagree with the analogy between the college football player and physician privileges. What is a “disruptive physician”? The definition of those terms is a potential mine field for the practitioner. If a physician acts beyond the hospital’s expectations, then he/she is labled “disruptive”. If a physician doesn’t dictate his notes within a specified period of time, he/she is a “disruptive” physician. If a physician raises his/her voice to staff during a tense moment, he/she is a “disruptive” physician. It is quite easy to fall into the category of “disruptive” physician, especially if the hospital administration already has you on its hit list. So, a “disruptive” physician is a definition at the whim of the hospital administration. It doesn’t matter how good you are, when the administration is against you, you better act with caution. Another caveat, once you get on the administration hit list and your privileges are called into question, do not resign or take a leave of absence, demand your hearing on the matter before the ethics committee, and get attorney representation because it may be the only way your side of the story will get heard in a timely manner.
~DocbLawg
http://www.post-gazette.com/pg/03299/234499-84.stm
“The Cost of Courage” a series by Steve Twedt of the Pittsburgh Post-Gazette. Abuse of the label “disruptive physician” and the peer-review laws, has been going on for some time.
Read the series if you have not seen it before.
Thanks to all that have taken the time to read and comment on this piece. I would certainly agree that there is the potential for the misuse of the label “disruptive” physician. I am by no means trying to say that keeping someone in the hospital for an extra day is an example of disruptive behavior.
What I was trying to illustrate is that there are physicians, and we all know these people, who display truly disruptive behavior in the hospital or in the office. These people verbally abuse (or worse) nurses, staff, or other physicians. Sometimes medical staff leadership (not hospital administration) is unwilling to address this behavior because of the stature of the physician involved. My piece tried to illustrate how in a different arena (in this case college football), a leader acted with more courage than is sometimes encountered in our profession.
I hope that our profession can do a better job of policing truly abusive and distruptive physician behavior. If we don’t, someone will do it for us.
Dr. Simon, respectfully, I’ve been preaching “physicians police your own” for six years in this blogosphere.
And I’m eleven years beyond “potential”.
Likewise, the doctors featured in the P-PG “Cost of Courage” (excellent link, ninguem) series are way beyond “potentially” destroyed.
The AMA and JCAHO (and USDHHS for that matter) have known that administrative abuse of the “disruptive physician” diagnosis (I hesitate to call it that) by hospitals has been a problem FOR YEARS. Yet these so-called advocacy and regulaotry bodies have turned their noses up (and their backs on) the problem.
For instance, my own situation, as long-standing as it is, could be resolved and cleaned-up – RIGHT NOW – with a few well-placed phone calls from the Federal agencies with jurisdiction. It hasn’t happened because our government (for all of the “hope & change” being preached by Obama) just doesn’t care.
I note you are an OB – a hospitalist. I could tell you a couple of really ugly tales about two OB-Gyns I used to know.
In the first story, the hospital adored the guy (a fine clinician) – execs winked and nodded at everything he did – no matter how destructive to morale. But it wasn’t about “stature” (part of the story is that his stature – by virtue of his behavior – was on the downswing – his head was just too inflated to realize it). It was about the MONEY he brought into their coffers. Ultimately, he was brought low by the Medical Board (for a heinous ethical lapse that I won’t describe here). Once that happened, it was amazing how quickly he got dumped.
In the second story (involving another OB), the little/rural hospital KNEW that there were BIG behavioral and clinical problems – but had to face/kick down every roadblock known to man in order to stop him – because our legal and medical systems are so screwed up. It took two years and more very bad medical badness to get the Medical Board to move.
Meanwhile, there’s what happened to me (visit Dr. J’s Housecalls) – for the act of intervening and reporting badness.
There does not seem to be a happy medium in any of this.
The problem we have right now is that previous sweeping “reforms”, in the form of HCQIA and HIPAA . . . where no one was paying attention to the details – or giving serious thought to the “unforseen consequnces” such inattention might bring to bear . . . have made it impossible for physician discipline to be applied evenly and fairly.
You’re right that someone is going to do it for us. But my gut is telling me they will do it with no more foresight or thought than those who came before.
If you ask a nurse the definition of a disruptive physician,
it would be verbal or physical abuse directed toward the nursing staff or trainees, usually behind the closed doors of the OR. Some actions I have witnessed would be no less than battery in any other arena. But in a medical setting, it is tolerated, ignored or swept under the rug. If there is a wistleblower, you can bet their days are numbered. And any witnesses asked to verify the incident would be reluctant to do so for fear of losing their job. It’s just part of the culture.
“Disruptive physician” can be used as code for “troublesome whistleblower.”
When we speak of genuinely disruptive physicians (not those who disrupts the hospital owners attempt to make more money by neglecting quality of care), we are talking about bullies.
Bullies have to be stood up to and held accountable not just by the authorities, but by the victims who need to be supported in that. The teacher can’t be the final solution. I have seen nurse bullies, clerical bullies, and administrative bullies in hospitals as well.
Dr. Simon, as a nurse, I feel like I should be praising your article, but I cannot, and the reason that I cannot is, in part, because of the football player illustration with which you begin your article. In the example you site, the individual punches someone in the face, a potentially dangerous assault (especially when carried out by a young, fit athlete). You then argue for sanctions against such things as verbal abuse, which though always regrettable, is hardly comparable. In fairness, you do acknowledge this in your call for “clearly delineated standards,” “punishment reflective of the severity of the offense,” and “stepwise consequences.” You are obviously a fair-minded individual. My concern is that, in the real world of hospital life, less reasonable heads might not do as admirable a job of parsing out the details in cases where the accusation is as vague as “being disruptive.” The vague nature of the charge will tend to do what might be implied in your choice of allegory: homogenization of all misbehavior to the point that too little distinction will be made between rudeness (a sad but universal human vice) and throwing a scalpel (a potentially dangerous attack of a sort that few physician will ever commit). I also cannot ignore the absence of any mention of an effort to assist to a physician who may be presenting with the initial signs of physical or mental illness, or simply being briefly overwhelmed and in need of collegial support. Now I might not be being fair in that last observation, as you were emphasizing a different point, and may have simply decided not to mention that as a way to keep your article brief, which is understandable. However, this is, I think, an important consideration.
Best wishes, sir.
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