A Systems Approach to Disruptive Behavior in Physicians: a Case Study

نویسندگان

  • Michael V. Williams
  • Mark Speicher
چکیده

Disruptive behavior in a medical setting has been defined as objectionable or offensive interpersonal behavior that leads to disruptions of professional activities in the workplace. The most frequent approaches to disruptive professionals have largely focused exclusively on the identified physician. This focus has been found to be ineffective for a number of reasons, in particular because of the recurrence of the behavior after a period of time. A new conceptualization of disruptive behavior is offered in this paper. The authors argue such behavior is often instrumental — that is to say the behavior is goal oriented and accomplishes a result sought by the disruptive individual. Starting from this conceptualization, a case is reviewed. The case is analyzed, first to demonstrate the effect of the disruption on team functioning. A significant disruption in team communication is demonstrated through an analysis of the clinical team’s social network. Significant role confusion is found among support professionals in the clinical team. The case is then analyzed to determine the instrumentality (usefulness) of the behavior to the disruptive physician. A system-based intervention is developed and the disruptive behavior is reduced. The authors argue disruptive behavior presents a significant risk to patient safety. They also argue regulatory authorities have a duty to reduce this risk and understanding the impact of this behavior on the team, and the delivery of health care services, will allow authorities to effectively intervene and reduce or eliminate the behavior and its safety risk. BACKGROUND: DISRUPTIVE PHYSICIANS It has been estimated about three percent of physicians exhibit disruptive behavior based on interviews with physicians and other health care professionals1 ; however, a state physician health program has reported up to 70 percent of the physicians referred are for problems that could be classified as “disruptive” behavior.2 Disruptive behavior is generally defined as: 1. sexual harassment involving employees or patients 2. racial or ethnic slurs 3. intimidation and abusive language 4. inappropriate criticism, sarcasm or cynicism 5. late or unsuitable replies to calls 6. threats of violence, retribution, or inappropriate use of litigation or threats of litigation3 In the past, hospital administrators, nurses, employees and even patients and their families have often been remarkably tolerant of this aberrant physician behavior. Criticism has frequently been muted through fear of losing “high producers” or through rationalizations that “high strung” behavior merely reflects high stress in an overworked doctor. Indeed, patients can view a physician who reacts with loud anger or heightened criticism toward hospital staff as an advocate. There is increasing awareness of the importance of team communication in the delivery of quality patient care.4 Disruptive behavior reduces communication between members of the health care team and negatively impacts cooperative patient management. There are a number of other costs associated with disruptive physician behavior, including decreased staff morale, decreased job satisfaction, increased staff turnover and increased time spent in investigations and counseling. Pfifferling5 estimates the cost of a disruptive physician to be $150,000. In 2001, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) implemented stanPage 18 Journal of Medical Licensure and Discipline vol 90 Number 4 2004 A SYSTEMS APPROACH TO DISRUPTIVE BEHAVIOR IN PHYSICIANS: A CASE STUDY Michael V. Williams, Ph.D., Principal, Wales Behavioral Assessment Betsy White Williams, Ph.D., M.P.H., Director, Clinical Competence Assessment and Training Program, Rush Behavioral Health, Assistant Professor of Psychology and Psychiatry, Rush University Mark Speicher, M.H.A., President, OptiMed Resources, Inc. dards that direct health care organizations to manage the impact of disruptive physicians through their required physician health program. Traditionally, most hospital well-being committees dealt with substance abuse, but now these programs address and manage a wider range of problems, including disruptive behavior. As a result, hospitals and state physician health programs treat the disruptive behavior in the same manner as other physician health issues, whether that disruptive behavior is primarily due to a psychiatric diagnosis or to other issues. More recently, the use of physician “Codes of Conduct” to allow medical staffs to take a privileging action against physicians who display disruptive behavior has been recommended by hospital counsel. This approach frames the impact of disruptive behavior on a health care team as a patient safety issue. In addition the Federation of State Medical Boards (FSMB) altered its guidelines to: “Accordingly, the Committee proposes amending the Essentials to strengthen Federation policy regarding boards’ ability to discipline physicians whose behavioral interactions with physicians, hospital personnel, patients, family members, or others creates an environment hostile to the delivery of quality health care or otherwise interferes with patient care.”6 Our data supports a view of disruptive behavior in physicians that indicates the behavior has both a mental health component and an “intentional” component, i.e., there are situations in which the disruptive behavior accomplishes certain goals within the system where the physician operates. In terms of the mental health component, Neff7 reports in his sample of physicians initially reported for disruptive behavior that the incidence rate of psychiatric illness is quite high. Neff further reports the physicians met criteria for both Axis I disorders (primarily mood disorder and/or active chemical dependence) as well as Axis II disorders (primarily narcissistic and obsessive/compulsive traits). The determination of the presence/absence and diagnosis of Axis I and Axis II disorders frequently involves a comprehensive assessment involving psychiatric and psychological assessment (including testing) urine toxicology screens, physical examination and record review with collateral information. In order to gain an understanding of the origin and instrumentality of the behavior, additional data must be collected. The use of specific data regarding the observed behaviors, the impact of the behavior on members of the health care team, diagnostic data, and patient management and outcome data are all used to develop a clear picture of the disruptive physician within a clinical microsystem,8 and the parameters of a successful solution. A SYSTEMS VIEW OF DISRUPTIVE BEHAVIOR The authors take a systems view of disruptive behavior in physicians: The behavior is exhibited in a clinical microsystem, and the behavior gains some reward (or at least a response or result that is viewed as a reward by the index physician) for the physician, i.e., these behaviors must be instrumental for the physician or they would ultimately cease.9 The instrumentality might be a surgeon getting the operating room suite he prefers, the hospitalist getting undisturbed rest because nurses avoid him, the intensivist never having to deal with the family of a patient, or even a gain that can only be understood within the setting of the disruptive physician’s own psychiatric disorder. The disruptive behavior, while seen as dysfunctional by hospital administration or others, serves a purpose for the physician, even in cases where there is an underlying psychiatric diagnosis. Taking a systems view of this behavior allows the issues surrounding the physician’s disruptive behavior to be clearly presented, and allows the system to concentrate on changing not only the behavior of the index physician, but the response of the clinical system that enables the disruptive behavior. This helps to ensure that the behavior ceases and does not return. It is vitally important the clinical system change in order to keep the improvements in physician behavior. Consistent monitoring and reinforcement of appropriate behaviors are critical to ensure that change is lasting. A systems approach to disruptive behavior involves gathering and using a great deal of physician data, including background data and 360-degree surveys (see L. Harmon for another example of their application with disruptive cases).10 The main goal of this use of data is to understand the physician’s behavior in terms of preceding events, and consequences for the physician, the hospital, staff and patients. In addition, our criteria for success are a solution that will: i. Reduce level of disruptive behavior ii. Deal with issues related to patient safety iii. Create a good possibility that behavior will not recur THE DISRUPTIVE PHYSICIAN IN PRACTICE:

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تاریخ انتشار 2005