Use awareness intervention to improve physician behavior

Here’s a familiar story in America’s hospitals. An “old fashioned” surgeon decides that the protocols and procedures put in place by the medical executive committee or other governing body don’t apply to him. “I’ve done it this way for 30 years, and it works fine. I’m the busiest surgeon here, and no one is going to tell me how to do my job.”

People in the risk management field will advise you that such a person is a high risk. His attitude often carries over to treatment of people in the OR. At best, he is uncompromising and lacking empathy. At worse, he is psychologically or perhaps even physically abusive to lower level staff. He also tends to treat patients with a lack of respect. He has more patient complaints on file compared to his peers. When he finally makes a mistake that causes a patient harm, he is a likely candidate for a large malpractice lawsuit.

And yet, notwithstanding this behavior, the hospital leadership is unlikely to do much to correct the problem. The surgeon has a great reputation in the community and is the source for many referrals. So, at most, when an egregious incident is reported to his chief, the reaction might be, “Yeah, I guess I won’t give him his full bonus this year.”

Clearly, such an approach is inadequate and will not resolve the underlying problems. It fails because the message is not delivered at or near the time of the incident. Also, there is not always a nexus drawn between the financial penalty and the behavioral issue. Finally, financial penalties do not have a lasting impact on behavior, if they work at all.

Institutionally, we are advocates for greater adherence to clinical approaches that are safer and deliver higher quality care. We also seek behavior between doctors and colleagues — and doctors and families — that is mutually respectful and reflects a partnership in delivering care. When a doctor has been habitually misbehaving on any of these fronts, we need a way to persuade him to change his ways.

Authority vs. awareness intervention

An alternative and more effective approach is outlined in several articles by Gerald Hickson and others from the Vanderbilt University School of Medicine. One article presents a hypothetical example about an emergency room doctor who has misbehaved:

Dr. Trauma has high productivity. Nonetheless, you cannot offer excuses for his performance. Others in the department conduct themselves professionally. In addition, this is not the first time that Dr. Trauma has behaved this way. During the past two years, other team members submitted event reports that describe similar behaviors. Some of the coworker and patient complaints suggest that Dr. Trauma gets angry in pressured circumstances.

You previously spoke with Dr. Trauma about several complaints from coworkers and patients. You find it concerning that Dr. Trauma failed to self-correct after this feedback. Given the accumulation of patient and staff complaints and the current event analysis, you decide that what is right for Dr. Trauma and the organization is for you, as his chief, to … require Dr. Trauma to undergo a comprehensive mental health evaluation and, if indicated, a defined treatment plan. Failure to comply would subject the physician to a loss of privileges.

Certainly this kind of “authority intervention” would get someone’s attention, but hospitals are wary of this approach, in that it has the potential of knocking a high performer off the clinical rolls. Also, chiefs often have a personal relationship with the doctor in question, one that makes it difficult to suggest that his colleague is medically impaired.

But Hickson, et al., also point out that a preliminary step can be effective and help avoid the authority intervention. They term this an “awareness intervention” by a peer. Awareness intervention is based on the premise that “each professional has a responsibility that colleagues and systems do no harm” and that “concerted effort to remove systemic or behavioral threats to quality must include willingness to provide feedback to others observed to behave unprofessionally.” It relies on “sharing aggregated data that present the appearance of a pattern that sets the professional apart from his/her peers.”

The key element of awareness intervention is to have a trained peer “messenger” present the data (e.g., the high relative number of patient complaints) and encourage the physician to reflect on what might be behind that pattern, but not to provide directive or corrective advice. The reason? “If a messenger offers a plan that does not “work,” the high-risk doctor can blame the plan and the messenger. We therefore want messengers who promote ‘awareness’ and encourage self regulation.”

The Vanderbilt experience suggests that this form of intervention is often successful. When it is not, the organization moves up the ladder to the type of authority intervention mentioned above.

Some readers might be surprised that awareness intervention would achieve any result. But let’s look at the underlying psychology. First, doctors view themselves as scientists and can be persuaded by data. Second, the troubled physician is treated respectfully. Third, the remediation plan is not prescribed by another and therefore cannot be viewed as externally imposed. It is his own creation based on his understanding of his problems.

If we think about it more generally, though, the Vanderbilt approach is based on an old theory of persuasion, one put forth by St. Francis: “Grant that I may not so much … be understood as to understand.” Or as Steven Covey restated it, “Seek first to understand and then to be understood.”

Hickson and colleagues have designed a program that achieves advocacy through inquiry. We stimulate the troubled doctor to consider the reasons for his behavior and the results that stem from it. We ask him to reveal his understanding of those reasons by designing and acting on a plan to remediate them. We learn things about that doctor that can be very helpful in our dealings with him but may also be useful more broadly in our institution. Ultimately, through this process, he understands, too, where we are coming from and adopts behaviors consistent with the greater good. Our advocacy has succeeded.

Paul Levy is the former president and CEO, Beth Israel Deaconess Medical Center and blogs at Not Running a Hospital. He is the author of Goal Play!: Leadership Lessons from the Soccer Field and How a Blog Held Off the Most Powerful Union in America. This article originally appeared in athenahealth’s Health Care Leadership Forum.

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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I’m not sure I understand this, Paul.
    The guy has been doing this for 30 years (I’m certain he is not doing it exactly like he did it in 1980). After 30 years and high volumes, he is yet to make a mistake or be sued for anything (perfect outcomes). He has a great reputation (so people do want him to operate on them, regardless of his personality).
    Now he refuses to comply with some administrative directive, and he is not the friendliest chap on the block. Why exactly is this a problem? Personally, I’d much rather see this guy, than a malleable and friendly team player trained to sincerely apologize twice a day for his frequent mistakes.

    • PoliticallyIncorrectMD

      Hit it right on the nail once again!

    • ninguem

      And the hospital will use certificate of need laws to prevent that surgeon from opening his own surgicenter. The surgeon could just peacefully do things his own way. The hospital would be rid of a troublesome surgeon. And if he’s really so bad, his enterprise will flop and the hospital is better off.

      The greatest fear, of course, if the surgeon will succeed, prosper, and make it clear that, in the dispite between the surgeon and the hospital, the surgeon was right. The bad player was the hospital.

      I think, in childhood, the hospital administrator was the kid that would take his ball and go home when things didn’t go his way.

  • guest

    So, to recap: we are very happy to have a high-volume, high performance doctor on our staff. But, unlike in the business world, it is somehow not all right for him to ruffle feathers occasionally in the course of doing his job well (think Steve Jobs). So we would prefer (we think) to have doctors on staff who never offend anyone, and if in the course of avoiding doing that, they frequently don’t do an excellent job, it’s fine. Most patients won’t know the difference unless a really egregious error gets made.

    What we really want is mediocre doctors who are good at getting along with everyone and jumping through every little administrative hoop without a fuss. Anyone else is “disruptive.”

  • FEDUP MD

    So he doesn’t follow protocols, and he quite rightly points out his patients do well, and he has yet to make a major mistake in 30 years? And perhaps he is a bit prickly (“uncompromising”) but the referrals and patients keep coming? So basically everything he says is right, but since he doesn’t fall into lockstep with Corpmed, he is now an issue. Since when did not complying with rules handed down from on above as opposed to one’s own proven medical judgment (rules often made without one’s input) to do what is best for the individual patient make one a terrible doctor? Welcome the future of medicine, where Corpmed wants to ensure all physicians know who is ultimately in charge and no dissent from the party line is allowed.

  • buzzkillerjsmith

    Dr. Levy would likely be happier with his physician staff, at least the troublesome male portion thereof, if they were put on anti-androgen therapy as a condition of employment. Psychosurgery on the frontal lobes is perhaps another option for irksome physicians of both sexes, sparing of course the team player regions of the brain.

  • LordElrond09

    Yeah sorry Paul but I’ll take the Maverick doing it right. Most of these administrative edicts are issued by those who aren’t doctors or if they are, they haven’t seen a real patient in 10 years. Their degree is there to give the hospital a thin veneer of credibility to help them understand medically what may or may not happened in a given instance. They are a prime example of ‘those who can’t teach’ It’s also why our ‘happy, no one should feel bad society’ approach in medicine doesn’t work. Lives are on the line and if you can’t grasp that, you don’t belong in the field.

  • rbthe4th2

    Maybe the complainers were the only ones brave enough to say, hey you need to look out for this issue because patients are worth speaking up for. Maybe others have left because of it. When a program doesn’t look out for patients, but doctors, would you want to be under the knife of that person?

  • Gregory Fritz

    Why on earth is it ok for a physician to behave and treat people badly because they are a good clinician? Why can’t they be a decent person and clinician? Is it too much to ask? What about the behavior of others like police officers, firemen, bankers, mechanics, etc.? Based on the comments by those posting, I gather that it would be alright if a police officer or fireman went on a rant, pushed people or treated them like dirt, just so long as they were great at their job. The same for the mechanic who just worked on your car. It’s all good if he’s beligerant so long as he’s top in his field.
    I’m a great engineer. But that doesn’t give me the right to treat a coworker or customer with indifference or disdain. We need to expect more from one another and be exceptional. Not below ordinary or unacceptable.

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