WHAT TO DO ABOUT
THE DISRUPTIVE PHYSICIAN?
Up to a third of complaints received by state medical
societies are for disruptive behavior. Often disruptive behavior is tolerated
until a crisis emerges, which then triggers disciplinary action. How else
might we handle this very delicate situation?
Welcome to the clinicians roundtable. I am Dr. Leslie
Lundt, your host and with me today is William Swiggart. Mr. Swiggart is the
co-director for the Center for Professional Health at Vanderbilt University
Medical Center in Nashville, Tennessee.
Welcome to Reach MD.
Bill, tell us about the Center for Professional Health.
Well, we are a center that actually was established in the
late 90s, and we really began as a continuing medical education center to deal
with physicians who got in trouble for misprescribing scheduled drugs and then
shortly after that, we added a course on sexual boundary violations for physicians
who get in some trouble for a variety of sexual boundary issues, may be as
serious as having an affair with the patient or staff or sexual harassment
charges or just inappropriate behavior joking those kinds of things, so we are
on a pretty large gamut of problems. We have national programs, so we get
referrals really from all over the country to our courses. Our courses are
run on about a 3-day format of pretty intense CME activity, and then most
recently we added a third course on disruptive behavior that we call the
Program for Distressed Physicians.
And how did that program begin?
Well, it began because when we noticed that there was a big
need in the country and both need for physicians to learn alternative behaviors
to deal with their frustrations and issues and for institutions, practices,
hospitals so forth to have a strategy for working with these docs that they
want to keep their valuable members of the medical community, but their
behavior is causing problems that make it hard for them to work with.
So is this a CME course or is this a separate treatment
It is a CME course one term I would like to use as we are a
mid-level response that there are certainly people who can make corrections in
their behavior with less intervention and there are certainly some people that
need may be to leave their practice or may be to get real psychiatric treatment
to deal with their behavior and then there are those in the middle that
hopefully an educational approach can be beneficial and workable.
And I guess I am just not clear why a CME course versus what
we would consider to be a traditional treatment kind of program?
Well, couple of reasons – (1) I think it destigmatizes the
intervention for the physician themselves. (2) I think there are a lot of
issues around or lack of skills, lack of alternative behaviors, and CME course
is a perfect venue for teaching some of those behaviors and skills that
physician may not have learnt any other way.
Now I know at our professional society and psychiatry at the
APA, you also give this course.
Correct, we offered it for the first time last year and we
will be offering it again in San Francisco.
So at least for a psychiatrist that would be a way for
people interested to receive this information?
Are you planning to do that with other specialties?
I have not as of yet. We have done some grand rounds at
some different places and have talked to some medical boards around the
country, but that all we could put on our plate right now.
I would think you are really busy, now where did your referrals
come from, you said nationally, but who typically refers physicians to you?
Normally in our other courses, it is physicians’ health
programs and physician boards and to a small degree lawyers. For this course,
the referrers tend to be large practices or large groups or hospitals, areas
that really this kind of behavior did not come before the board or the physicians'
health program regularly like may be just prescribing _____ or something else.
So there are really these practices that are interested.
And what do the physicians that I referred to you, what do
they do while they are there?
Several things. We spent sometime looking at what I would
call both internal and external factors, so what kind of skills or deficits did
you come to the practice with that we can teach and then some external things,
what are some things you can change, how can you do some things differently so
that you are not the eye of the storm anymore or not attracting wrong kind of attention.
Is there one specialty that might be over represented among
these disruptive physicians?
You know, this is the place where we say surgeons are
terrible, but actually they are not necessarily overly represented. What is represented
highly are interventionalists. So whether they are from internal medicine or
surgery or whatever, it is those interventionalists that seem to be the heavy
hitters. We get about 20% from either specialty or general surgery, about 25%
our medicine specialties, and then OB/GYN, anesthesiology, neurology, other
No, no, do not tell me that.
Well, I guess we are human after all, huh?
If you are just joining us, you are listening to the
clinicians’ roundtable on ReachMD XM157, the channel for medical
professionals. I am Dr. Leslie Lundt, your host and with me today is William
Swiggart. We are discussing what to do about the disruptive physician.
Bill, what interventions typically occur before the
physicians come to your CME course?
Well, a variety of things. Sometimes there is a
confrontation by the practice manager or the group or may be one physician is
practice got together and tell him who has taken a month off and that he had a
month to figure out what to do about his behavior. He found us that way, but
others have been assessed, sometimes a group or hospital or entity will mandate
or suggest a full psychiatric assessment. Occasionally there is a form of
disciplinary action by credentialing board or medical board of some sort, but
that is actually fairly rare at least without referrals that being disruptive
in a hospital generally does not violate board action. So generally the
practices and now a fear from lawyers, physicians felt threatened and hardly
could counsel and sometimes they suggested that as part of their working and
their situation and this course might be a good alternative.
Hmm, and what have the results been for the physicians who
have completed your program?
Well, I think actually pretty good. We have a paper that
came out and a physician executive, which has kinds of results of our initial
study and it was interesting that physicians often overestimate how well they
are liked and appreciated on the initial kind of pre-course study. Their
colleagues and other staff tend to rate their improvement though higher than they
do , that is interesting they either they are overestimating themselves or
underestimated how much they changed, so it indicates to me that often these
physicians have not a great idea about how they come across, how people are
perceiving them, which I think can be part of the issue that if they are not
kind of able to read social cues from those around them, then it is awfully
hard to know how they are coming across.
But of course what seems to have made the most important
measure of change is what their coworkers and colleagues think for them?
Absolutely because their coworkers and colleagues are what
is driving their attendance, so absolutely.
Ya, now thinking about our listeners and perhaps there are
somebody out there that does work in a group practice setting or in a hospital,
and there is a fellow physician that perhaps meets some of the criteria as
being a disruptive physician, you know I would think certainly, but me and I am,
assuming not alone here, that the tendency for us, not to act on it, to hope
that it is going to go away or that the person is going to go away and that we
do not have to voice our concerns in a public sort of way. What are the consequences
of disruptive physician behavior if we do not address it earlier?
Well, lots of different consequences. Some are staff
turnover, heard a nurse talk the other day that said that they drew straws to
see who worked with Doctor so and so in the emergency room because he was so
disruptive, so staff turnover, staff morale, obviously one of the sticking
points if a physician is verbally disruptive and angry and demeaning, a nurse
or colleague may be less apt to report a problem or make a phone call, so
sometimes they do not get information that they need because of their
attitude. I think the patient can suffer sometimes for some of the same
reasons, but a lot of the problems tend to be around staff.
That actually is for me to know. A question, do patients
see this behavior in their physicians who are disruptive or are people able to
compartmentalize and only act like this among their colleagues and keep it from
Well, sometimes it is not the patient who gets the burn of
it; for instance, if your surgeon, you come to him and you want to sign off for
surgery and he is a bully and he gets the first operating room in the morning,
gets you the best time, and gets your operation a week before somebody else might
have, then you are going to think he is a pretty great guy. A lot of the
physicians that we get are going to be ones that have problem with staff as
opposed to, though there are some that might have a high complaint ratio from
patients and they will come to the administrator or the practice leaders’
attention in that way.
How can our listeners find out more information about the
Center for Professional Health?
Well, we have a website and on that website, we have all the
papers that we have written their links to them, we have written papers on each
course, and couple of other things; so that is certainly available.
And what is the website address?
The website is www.mc.vanderbilt.edu/cph.
CPH for Center for Professional Health.
The easiest way to probably do this to google Center for
Professional Health and we usually come up first or second on that.
Great. Well, thank you so much for being on our show today.
Well, thank you.
I would like to thank our guest today, William Swiggart who
is the co-director for the Center for Professional Health at Vanderbilt
University Medical Center in Nashville. I am Dr. Leslie Lundt. We have been
discussing what to do about the disruptive physician.
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