“If you do not cooperate, doctor, we will have no choice but to label you as being ‘disruptive’ and take whatever steps are necessary to remedy the situation.”
What physician does not dread hearing these words? Over the past several years, the term “disruptive” has been increasingly used to characterize and intimidate a physician who is perceived as not being a “team player.” With hospitals increasing the difficulty in navigating a constantly changing health care landscape, it is no accident that there is tremendous pressure on physicians to just cooperate. Up to now, it has worked (given physicians’ weak resistance to the ill-conceived health care reform). Granted, there are some behaviors that clearly are wrong and should not be tolerated, but is there any doubt physician frustration has grown as they often find themselves in conflict with what they know is right for both themselves and their patients and poorly thought out health reform. Burnout is just one consequence.
Things are changing. As more and more physicians come to realize that being a “team player” has not worked as planned, they are finding that being “disruptive” may not be as bad or threatening as once thought.
So how does a physician know it is time to be “disruptive.” It’s not always easy, especially since more and more physicians are in employed positions, but it is possible. Here are my guidelines, learned through trial, error and experience. May they help you as much as they have helped me.
Fully understand what your obligations are. Carefully read and understand what the federal, state and local laws actually require you to do, as well as your institution’s own by-laws. The Emergency Medical Treatment and Labor Act (EMTALA) is a classic example of a law that has been misunderstood. Don’t accept what anyone is telling you at face value — find out for yourself. At times, it’s amazing how little a hospital knows about its own by-laws. It is a riot when you can use a hospital’s own by-laws against them. It is also a good idea to understand the by-laws before applying for privileges.
Be aware when your institution is considering changing the by-laws. Not responding to a by-laws change indicates passive acceptance on your part. You may not be able to stop the change, but you may be able to protect yourself by requesting grandfather status. It worked for me twice.
Make sure your requests are clearly understood. Put them in writing. Send a registered letter to both the administration and the department in question. If there is any problem, you can prove that the institution did not follow your request or you were aware of a problem that administration has ignored.
Do not do anything obviously wrong or indefensible. Do not make any sexual advances on hospital personal. Do not throw objects. Do not refuse to answer hospital calls. Don’t do anything you cannot defend!
Always put patient safety and welfare first. If you can defend what you did as a patient safety issue or threaten your institution with putting patient safety or welfare at risk, it’s amazing how rapidly the “disruptive” charge against you goes away. Telling administration that the patient is also “not satisfied” with what’s going on also works well these days.
If you are going to yell at a subordinate, make sure what they did was so egregious that they cannot defend it, especially if the patient is at immediate risk. This is the only time direct confrontation can be justified and work.
Ally with the patient. If a problem occurs, inform the patient that you are just as frustrated as they are. Remember, patients are not happy with the direction health reform is taking and they have a lot less understanding of the reasons why than you do. Use that.
Stay as independent as possible. Make yourself invaluable, Always have an escape plan. Always applicable to any situation.
Follow these rules and you can wear the term “disruptive” with pride, and maybe have a little fun at the real “disruptors” expense. Remember, while physicians may be under pressure to be a “team player” it is the “captain” that will down with the ship. And there are a lot more icebergs out there than there used to be.
Thomas D. Guastavino is an orthopedic surgeon.
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