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The surgeon who curses and throws instruments. The cardiologist who insists that staff in the cath lab do things “her way”— or else. Attending physicians who seem to delight in publicly dressing down subordinates.

For decades, this kind of conduct was endured and ignored in many, if not most, hospitals and practice groups. That has changed over the last decade or so, with the emergence of professional codes of conduct such as the ACGME’s six core competencies and the Joint Commission’s adoption in 2009 of new standards that call on hospitals to crack down on “disruptive” behavior.

This package presents two perspectives on addressing disruptive conduct and teaching positive interpersonal skills.

Disruptive behavior: The NCPHP approach
Warren Pendergast, MD, NCPHP Medical Director

The NC Physicians Health Program (NCPHP) has been known for its work with physicians and PAs who suffer from alcohol or drug dependence, but we also assist individuals with a number of other problems that impact the ability to safely practice medicine.

Disruptive behavior is the primary concern in about 21 percent of all cases referred, up from about 15 percent in 2006. Here’s how NCPHP approaches interventions with individuals who exhibit disruptive behavior.

Approach to treatment
Physicians and PAs exhibiting problematic behavior are sometimes referred for individual psychotherapy, but increasingly NCPHP finds that a coaching approach is effective. There is often less stigma attached to coaching, which can give this approach an advantage over therapy. A second advantage is that a coach can focus on teaching positive skills to the physician or PA. This model works well for those who have spent many years in a classroom or other learning environment, and are adept in the didactic setting.

Psychotherapy and/or medication management is nonetheless indicated in some cases, especially for individuals who have suffered earlier trauma, or in cases where depression, bipolar disorder or substance-related issues are present. It is critical for professional coaches to be adept at recognizing these problems and making appropriate referrals when indicated.

Another important intervention in many cases involves helping the physician or PA deal with personal stress. Most individuals try to maintain a “firewall” between their personal and professional lives, but this only works up to a point. If a clinician has ongoing personal stress, it will likely spill over into the professional arena if it is not addressed.

Factors affecting outcomes
NCPHP is best able to help the clinician and the referring agency when all of the following are true. The more factors that exist, the better the anticipated outcome.

• A pattern of behavior has been established and documented Examples of behavior and consequences to the hospital or clinic should be clearly documented. Examples are useful to explore the problem with the physician or PA and may help identify underlying triggers and issues that can be addressed. Often, the clinician has little or no insight into the effect he or she has on others, or how often the behavior has been a problem. If NCPHP has no documentation of specific instances of disruptive behavior, it is difficult to help. NCPHP usually does not (and generally should not) receive referrals for an isolated incident or minor instances of disruptive behavior.

• There is a treatable condition, and/or no severe personality disorder “Disruptive behavior” is not a psychiatric diagnosis in and of itself. The prognosis for improvement is usually best for those with a well-defined Axis I diagnosis such as depression, bipolar disorder or chemical dependence. Axis II personality disorders, such as narcissistic or obsessive-compulsive, often require long-term treatment or intervention and the prognosis varies greatly. The prognosis for improvement in those simply prone to angry outbursts (“impulse-control disorders”) also varies and often depends largely on potential consequences.

• The physician/PA is willing to take some responsibility for his or her behavior The clinician must be willing to acknowledge that he or she is at least part of the problem. If, on the other hand, he or she is unwilling or unable to do this, no intervention is likely to be effective.

• The referral is presented and intended as assistance, not punishment Some physicians/PAs view a referral as punitive no matter how it is presented. Nonetheless, a referral that is made in a positive, cooperative way increases the chance of a good outcome.

• The referring entity is willing and able to impose consequences if the behavior does not change The needs of the referral source and the physician/PA are best served if there are clear limits and consequences established and enforced regarding disruptive behavior. It’s also important that expections are consistently communicated, and positive feedback is given when appropriate.

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Towards positive behavior change: A chat with John-Henry Pfifferling, PhD

John-Henry Pfifferling is an anthropologist who specializes in working with physicians and other health care professionals to address burnout, stress, communication issues and other problematic behaviors, such as disruptive conduct, that create problems in the professional medical workplace. He spoke to Forum editor Jean Fisher Brinkley about changing attitudes towards disruptive behavior and how his nonprofit, the Center for Professional Well-Being, works with professionals to address it.

How have attitudes towards disruptive behavior changed in the medical workplace in recent years? Hospitals and medical practices seem more willing to address this issue.
It has changed because there are more professionalism guidelines or what is called codes of conduct. There are now policies and processes to report allegedly disruptive conduct and a Joint Commission standard related to disruptive behavior, and none of that existed 10 years ago. I think the major cultural change though, anthropologically speaking, is that the “specialness” of the physician is no longer a barrier to confronting the uncivil behavior. Physicians and others at that level of power are down a notch and it’s now possible to address it. At the same time, the culture that says, “Don’t snitch,” is still very much alive and well.

Do you routinely come in contact with staff and others who do not feel comfortable reporting disruptive behavior?
Absolutely. It’s a huge barrier. When we work with allegedly disruptive physicians we try to get invited to the site and sometimes I have to beg to get people to talk to me. I just called someone in the OR and spent 20 minutes on the phone convincing her that it was confidential, that what she was sharing with me was not identifiable. She was so petrified there would be retaliation and that she was violating the group norm, which was, “Don’t snitch.”

Can you talk a little bit about how referrals to your organization work?
They are primarily referred by the vice president of medical affairs, or the chief medical officer. Secondarily, when it’s not a hospital situation, the referral is made by a managing partner of a group. Rarely, they are referred by a staff person. Even more rarely, although we’ve had one a month for the last few months, a spouse will refer. Because whatever’s going on is coming home and the spouse hears complaint after complaint after complaint. We also get referrals from the Medical Board.

How responsive is the person identified as disruptive when you speak to them for the first time?
They’re often angry. Then they progress from anger to saying, “I’m not the worst. I curse once in a while, but Dr. X or Dr. Y curses all the time.” We call that obsessive blame casting. I try to get through to that person and say, “We’re on your team.” I have to convert them to understanding that we’re going to help them and that they are no longer alone.

The negative impact of disruptive behavior on the workplace is pretty well known. How does it negatively impact the alleged perpetrator? Patients?
Starting with the PA or the physician the impact is that their ability to practice medicine is at risk because they are being labelled, treated, assessed, put into intervention/remediation or whatever else, and that gets around. People call each other, “What’s the story with Dr. Y or Dr. Z?” and no one wants to hire them. They can lose everything. The bottom line is their practice is at risk, and also their self esteem.

The patients lose primarily because more mistakes are apt to be made when the staff around the acting out physician, the disrupting physician, doesn’t feel respected, and so crucial information is not shared. Because those people feel that, whatever they say is never correct or never good enough, so they won’t say anything. And then their eyes and ears and intuition and experience are not available to the PA or the doc in the team. There’s tremendous potential for risk and mistakes because there’s not clear, direct, honest give and take among the members of the team. And patients lose because there are so many things that are not black and white on the labs or whatever.

What are some of the most important predictors of successful rehabilitation?
That the individual takes responsibility and asks for help. The second part is that the inevitable blaming … it’s the system, it’s a colleague, it’s the nurse, it’s the EMR, it’s whatever…At some point they have to transcend that and say, “What can I do?” They’ve got to learn the skills that are going to help them and they’ve got to practice them. What we do, and I think we’re good at it, is saying to the person, “Yes, you’ve been labelled a disruptive physician, but all of it is perceptual. How do we change that perception? What can you do that makes a difference so that you’re not a target anymore?
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What is the Center for Professional Well-Being’s track record at helping people get better?
We’re an interventional organization, not a research organization, so we don’t have data. We think we’re close to 90 percent. But we can’t work with everyone and we sometimes “fire” people. That usually happens when someone refuses to stop the blame casting. It’s always somebody else and they refuse to take responsibility. I can’t afford my time or your practice’s money [practices often pay for all or part of at least the initial session], if they’re not willing to do that.

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Traits of a 'disruptor'

• Consistently curses, without clarifying that the language is not directed at co-workers


• Openly reprimands, demeans, or ignores a coworker in the presence of a patient


• Disparages care rendered by another in the presence of patient, family or colleagues


• Disparages organization to others, (or in notes on chart,) without attempt to ameliorate, correct or investigate the alleged problems


• Imposes requirements on staff that do nothing to improve care and serve only to burden staff with "special" techniques


• Shames others for negative outcomes


• Uses abusive, sarcastic or cynical language; provokes arguments


• Threatens, implying danger, retribution or litigation


• Consistently displays anger or outbursts, even after being warned


• Engages in threatening or intimidating physical contact


• Consistently reacts defensively to suggestions or interruptions


• Routinely blames mistakes on others


• Consistently impedes effective interprofessional care and cooperation


• Appears unable to respond in socially appropriate way, after being confronted with accusations of unprofessional behavior

Source: John-Henry Pfifferling, PhD, Center for Professional Well-Being; NC Physicians Health Program


KNOW SOMEONE WHO NEEDS HELP?
Contact NCPHP, based in Raleigh, at 800-783-6792 or visit their website.

Reach John-Henry Pfifferling at the Center for Professional Well-Being in Durham at 919-489-9167 or visit their website.