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© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 1 of 10
Journal of Business and Human Resource Management
Received: Jul 15, 2016, Accepted: Aug 10, 2016, Published: Aug 14, 2016
J Bus Hum Resour Manag, Volume 2, Issue 2
http://crescopublications.org/pdf/jbhrm/JBHRM-2-012.pdf
Article Number: JBHRM-2-012
Research Article Open Access
“Human Factors Affecting Disruptive Physician Behaviors and its Impact
on the Business of Medicine”
Alan H. Rosenstein MD, MBA*
Practicing Internist in San Francisco, CA and Consultant in Health Care Behavioral Management, USA
*Corresponding Author: Alan H. Rosenstein MD, MBA, Practicing Internist in San Francisco, CA and Consultant in Health
Care Behavioral Management, USA, E-mail: ahrosensteinmd@aol.com
Citation: Alan H. Rosenstein (2016) “Human Factors Affecting Disruptive Physician Behaviors and its Impact on the Business of
Medicine”. J Bus Hum ResourManag 2: 012.
Copyright: © 2016Alan H. Rosenstein. This is an open-access article distributed under the terms of the Creative Commons
Attribution License, which permits unrestricted Access, usage, distribution, and reproduction in any medium, provided the
original author and source are credited.
Abstract
Healthcare is an extremely complex business. While there are many different modalities and entry points for
health care delivery, for more serious illnesses it is the physician who takes primary responsibility for managing and
directing care. In most cases the process works out well for all involved. But in some cases inappropriate disruptive
physician behaviors can lead to significant problems related to the efficiency and quality of care. For many reasons
individuals and organizations have a difficult time in addressing these types of behaviors in an effective manner.
Gaining a better understanding of the human factor forces involved that influence attitudes and behaviors is a crucial
step in developing appropriate strategies to deal with this serious issue.
Introduction
Published studies have reported that 3-5% of
physicians (and nurses) act in a disruptive manner [1].
Disruptive behavior is defined as any inappropriate
behavior, confrontation or conflict ranging from verbal
abuse to physical or sexual harassment that can potentially
negatively impact patient care. The types of offensive
behaviors described in this category include yelling, abusive
language, condescending, berating, undermining,
disrespectful behaviors, or overt bullying, harassment, and
intimidation. Direct physical abuse is reported to occur less
than 5% of the time. Having a clear definition of disruptive
behavior is crucial to developing appropriate policies and
procedures that set the expectations for professional
behaviors and hold non- compliant individuals accountable
for their actions.
Causes
No physician starts out the day planning to be
disruptive. It’s just that things seem to get in the way. There
are multiple different factors influencing the way physicians
think, act, and feel. Table I divides these factors into two
categories: Internal and External Forces. We recognize that
it is impossible to apply a cause and effect relationship to
each individual factor but instead we need to consider the
interplay of each of these factors and their role in
influencing emotions and reactions.
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 2 of 10
Table I: Influencing Factors
Internal Factors: External Factors:
- Age and generation - Training/ hierarchy
- Gender/ sexual orientation - Health Care Reform
- Culture/ethnicity/ spirituality - Stress and burnout
- Geography/ life experiences - Work environment
- Mood/ personality - Adverse events/ Litigation/ Personal issues/ debt
Age and generational issues are based on the values
and perceptions reinforced by the current existing status of
the social, economic, and political environment at the time
in which the individual grew up. Differences in views as to
work ethic, commitment, views of authority, and work life-
balance are different for each of the groups (Millenniums
<1980-1995>, Generation X <1965-1979>, Baby Boomers
<1946-1964>, Veterans/ Traditionalists <pre 1946>) which
under stressful situations may lead to conflict in the
workplace environment. Many organizations have addressed
this issue by offering programs that educate staff about
generational differences and provide strategies to help them
reach compromises during periods of conflict or
disagreement [2].
Gender differences may also affect the way
individuals react in stressful situations. Males are typically
more assertive, task oriented, domineering, and under
pressure tend to dig in. Women are more socially oriented
and under pressure will look for consensus opinions to
support their points of view. In the past these problems were
exacerbated by the predominantly female nursing workforce
and the predominantly male physician task force. While the
percentages are changing, potential conflicts may still arise.
Many organizations have addressed these issues by
educating staff on sexual orientation including issues related
to traits, equality, sexual orientation, tolerance, and
harassment [3].
The next factor is diversity. With changing world
demographics we are seeing a greater diversity in our patient
and staff populations with a greater influx of foreign born or
foreign trained nursing and medical staff with their own
individual ethnic, cultural, and religious beliefs that affect
values, thoughts, and behaviors as to feelings about religion
and spirituality, hierarchy, authority, and communication
styles. In difficult situations this can lead to
misunderstandings in purpose and intent that may negatively
affect communication efficiency, expectations, and
outcomes. In this regard there is a big push toward training
providers on cultural competency and/ or providing diversity
training to help individuals better understand individual
needs and values, address hidden assumptions or biases, and
provide effective solutions for more effective
communication [4].
All of these internal factors combined with
genetics, socioeconomic factors, geographic influences, and
other individual life experiences help to shape an
individual’s mood and personality. Strategies for
improvement should focus on introducing a variety of
different training programs designed to enhance personality
and relationship management. These programs might
include such topics as sensitivity training, emotional
intelligence, diversity management, cultural competency,
mindfulness, generational gap values, personality traits,
conflict management, stress management, anger
management, sexual harassment training, customer
satisfaction, and improving overall communication and
collaboration skills.
The external factors include current day
circumstances that influence present state perceptions. For
physicians one of the key factors starts with the training
environment. Some equate this training to a fraternity/
sorority hazing type environment where individuals are
harassed to the point of losing self- esteem. In some cases
this can lead to severe cases of stress, burnout, and
depression [5]. In response the trainees try to develop
knowledge and technical competencies through exhaustive
independent study. As a consequence there is no focus on
developing personal skills or team collaboration mechanics
which leads to a lower degree of sensitivity and emotional
intelligence. This presents a definite liability in today’s
complex multi-spectrum health care environment so
dependent on multidisciplinary collaboration. Fortunately,
there are movements in place to try and deal with these
training hazards At the front end Medical Schools are
looking for more “well- rounded” applicants who have
majored in something other than the traditional math and
sciences. At the back end some of the more progressive
Medical Schools are adding programs that focus on
developing personal and team collaboration skills as part of
the freshman year curriculum in an effort to enhance work
relationships. Unfortunately one of the slow to evolve
underlying problems is the traditional hierarchal health care
structure with dedicated roles and responsibilities and set
boundaries between the different health care disciplines.
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 3 of 10
Health Care Reform has added another level of disturbance
to the force. Where physicians used to pride themselves on
their ability to provide best practice care with autonomy and
control, the introduction of new care restrictions, utilization
controls, changing incentives, and performance
accountability metrics based on a series of “questionable”
variables has forced many physicians to reassess their
positions and change models of care. Add to this the
growing complexity of health care management, the
frustrations of dealing with electronic documentation and
other administrative requirements taking physicians away
from face to face direct patient care, school debt, being
involved in an adverse event, concerns about litigation, and
other complicating workplace or personal issues, we can see
how this can have a significant negative impact on physician
attitudes and behaviors. As far as a remedy, it’s unlikely that
we’ll be able to change the system. But what we can do is to
provide more education to help the physician better
understand why this is occurring, the intent, what the
projected service impact will be, and then provide the
necessary support to help physicians adjust and become
more compliant in meeting these new objectives.
One of the unintended consequences of Health
Care Reform is the growing amount of stress and burnout in
physicians and its impact on their willingness to continue to
practice medicine. Recent studies have shown that more
than 50% of physicians report a significant amount of stress
and burnout which has led to increasing irritability,
cynicism, apathy, fatigue, disillusionment, dissatisfaction,
and in some cases more serious depression, behavioral
disorders, and even suicidal ideation [6]. As a result there is
an increasing amount of physician dissatisfaction, where
many physicians have either changed practice settings,
joined different groups, or moved into salaried positions.
Others have either left the profession entirely or chose early
retirement.
So how do we deal with stress and burnout [7]?
This is obviously a complicated issue. The process starts
with raising physician awareness. Many physicians are
unaware that they are working under stress and the physical
and emotional toll it’s taking on their livelihood. If they do
admit that they are under stress, they accept it as being part
of the job and rationalize that they have been working under
stress all their lives. Even if they think they may need some
outside help they are reluctant to ask in fear of concerns
about their competency, confidentiality, discoverability, or a
blow to their ego. If physicians are reluctant to admit or
accept assistance, we need to look for the organizations that
they are associated with to take a more pro-active stance in
trying to encourage and provide support. These are
significant barriers that need to be addressed before moving
forward.
Solutions actually start at the Medical School level. There is
a growing amount of evidence suggesting that high levels of
stress, burnout, depression, and even suicidal ideation starts
during the first year of medical school. This probably results
from a combination of factors of having individuals driven
by a strong competitive egocentric driven personality being
dropped into an intensely complex bewildering hierarchal
system without direction and a sense of nowhere to go.
These problems are further exacerbated by a sense of
physical and emotional exhaustion, stress, and fatigue,
which can take a toll on physical and mental well- being.
Fortunately many organizations are making a concerted
effort to provide resources to help students adjust to the
pressures in the academic environment [8].
Once a physician gets out into practice there are
other day to day pressures that promote a stressful
environment. As mentioned previously, many physicians are
either unaware or reluctant to admit that they are under
stress, and even if they do recognize it, that won’t take any
action. In this case we need to look for outside assistance
from friends, peers, or the organizations in which the
physician is associated with to help out. The most consistent
approach is to provide pro-active support at the
organizational level. Unfortunately, many physicians feel
that their organizations don’t support them. In a recent study
conducted by Cejka Search and VITAL WorkLife, when
asked if their organization did anything currently to help
physicians deal more effectively with stress and/or burnout,
85% of the respondents said no [9]. So, in an effort to better
address the issue of physician stress and burnout we need to
(1) raise awareness, (2) motivate physician reactiveness, and
(3) have the organizations take a more active role in
providing support services to help physicians better adjust to
the stress and pressures of today’s health care environment.
Support can come from a variety of different
directions. On one level the organization can provide
training on stress management, time management, conflict
management, business management, and other appropriate
programs to teach basic skill sets on stress reduction. On a
deeper level the organization can provide more personalized
support services through Physician Wellness Programs,
Wellness Committees, Physician EAPs (Employee
Assistance Programs), or through individualized coaching or
counseling. Some physicians may require more in-depth
behavioral modification programs. Organizations need to
approach these programs with the idea that they understand
the physician’s world, that they respect and value the
physician’s time and what the physicians do, and that they
are here to help. They need to make an effort to promote
customized individual support and be responsive to
physician resistance, time constraints, and fears of
confidentiality. To motivate physician action the focus needs
to be on the goal of helping the physician do what they want
to do, which is to practice good medical care.
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 4 of 10
Consequences
Despite all the evidence and concern about the
physician behavioral turmoil in many cases it goes
unresolved [10]. Depending on the circumstances, the
combination of internal and external factors can result in
inappropriate actions that lead to disruptive behaviors.
Unfortunately, many disruptive events either go
unrecognized, go unreported, or are ignored for a variety of
different reasons. The problem with this personal and
organizational reluctance is the potential for bad things to
happen to patients, staff, and the organization (Table II).
Table II: Reluctance and Ramifications
Organizational reluctance: Risk of non- action:
- Awareness/ accountability/ tolerance - Staff retention/ recruitment/ patient satisfaction
- Financial - Staff/ patient satisfaction
- Hierarchy/ boundaries/ sacred saints - Quality/ patient safety
- MD autonomy - Medical errors/ care efficiency
- Code of silence/ fear of reporting - Joint Commission accreditation standard
- Conflicts of interest - Liability/ litigation/ fines/ penalties
- Structure?/ skill set?/ solutions? - Reputation/ social media
One of the issues raised earlier was the importance
of defining what disruptive behavior is and holding
individuals accountable for their actions. Many individuals
who act “disruptively” aren’t aware that they are acting in an
inappropriate non-professional manner. This is particularly
true for physicians who are used to taking control, and
“giving orders”. Under times of stress they may yell and
intimidate others and not even realize they are doing it. Even
if they are aware they justify their behaviors as being
necessary to direct patient care. The problem is that they are
oblivious to the downstream negative consequences this
may cause on care relationships, communication efficiency,
task accountability, and patient care.
A second big concern is the issue of organizational
tolerance. Many of the events involve very prominent
physicians who bring a large number of patients and revenue
into the organization. Many organizations are reluctant to
address the issue in fear of antagonizing a physician to the
point where they worry that the physician won’t bring their
patients into the facility. This is particularly true for smaller
organizations where there may be shortage in supply of
certain specialties. There is also the concern about crossing
boundaries. Physicians work autonomously and in many
organizational cultures physicians are viewed as “sacred
saints” impeding the willingness to intervene. There is also a
hidden “code of silence” where health care workers are
reluctant to report disruptive behaviors. This lack of
reporting is accentuated by potential conflicts of interest,
concerns about lack of confidentiality, and/ or fears of
retaliation. Many who do report are frustrated by the lack
administrative support and the fact that despite reporting, the
perception is that nothing ever changes, so why bother.
And lastly is the structure and skill set to deal with
behavioral problems. Organizations have policies and
procedures in place to address clinical competency but may
not be well equipped to deal with behavioral problems. They
need to have the right structure in place supported by
individuals skilled in facilitation and negotiation techniques.
Turning matters over to the Chief or Chairman of the
Department may not lead to an effective resolution.
The Risks of Inaction
The risk of inaction can lead to downstream
consequences that affect moral, culture, workplace
atmosphere, and/ or lead to medical mishaps that have
significant direct or indirect financial penalties [11] (Table
III).
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 5 of 10
Table III: Economic consequences
I- Recruitment and retention- RN: $60,000 – 100,000/ additional opportunity costs
II- Patient satisfaction/ HCAHPS/ Reputation- Market share implications ($?)
III- Adverse events (“No pay” for adverse events initiatives)-
Medication error: $2,000 to $5,800 per case/ > LOS 2.2-4.6 days
Hospital acquired infection: $20,000 to $38,500
Deep Vein Thrombosis: $36,000/ > LOS 4.2 days
Pressure Ulcer: $22,000/ > LOS 4.1 days
Ventilator Associated Pneumonia: 49,000/ > LOS 5.3 days
IV- Joint Commission Standard
V- Compliance issues ($?)-
Impact on documentation and coding
Impact on utilization efficiency (LOS/ resource efficiency/ DC planning)
Impact on quality
Impact on productivity and efficiency (down time/ waste/ delays)
Communication inefficiencies ($4 million 500 bed hospital)
VI- Risk Management/ Malpractice: $521,560/ Lawsuits/ Fines: $25,000 - $100,000
On one level disruptive behaviors have been shown
to have a significant negative impact on nurse satisfaction
and retention [12]. Replacing a nurse can cost the
organization anywhere from $60,000 to $100,000 for
recruitment, training, and secondary opportunity costs.
When it occurs in a public arena disruptive events can also
lead to patient dissatisfaction which can negatively impact
HCAHPS scores and other patient satisfaction pay for
performance initiatives which can have a negative effect on
reimbursement. Then there is the spillover effect on hospital
reputation which may impact market share and contacting.
From a patient care perspective the biggest concern
is the occurrence of preventable medical errors or adverse
events. In addition to waste, duplication, and inefficiencies
in management, lack of communication and collaboration
can lead to task failures that result in medication errors,
infections, delays in treatment, and other serious medical
conditions which can increase lengths of stay and accrue
significant non- reimbursable costs of care.
In response to the concerns about the impact of
disruptive behaviors on patient safety in 2010 the Joint
Commission added a new leadership standard requiring
hospitals to have a disruptive behavior policy in place and to
supply support for its intent as part of the leadership
accreditation standards [13]. In order for hospitals to receive
Medicare reimbursements, they need to pass the
accreditation survey criteria requirements.
From a compliance perspective, non- compliant
behaviors that adversely impact coding and documentation
requirements, non- adherence to utilization protocols, and/
or not following best practice guidelines, policies, and
procedures, can all have a significant negative economic and
quality impact on patient care outcomes. It is estimated that
the average yearly cost for a midsize hospital due to
communication deficiencies is $400,000 [14].
From a risk management perspective more
egregious cases can lead to litigation. Time, preparation, and
malpractice awards can result in significant dollar amounts
with average malpractice settlements averaging above a half
a million dollars. In California there is the additional penalty
of hospital fines (ranging from 25,000 – 100,000) for the
occurrence of significant adverse events.
Addressing Disruptive Behaviors
Recognizing the multidimensional cause, nature,
and extent of disruptive behaviors, it is clear that there is no
one solution to resolve the problem. The ultimate objective
is to prevent disruptive behaviors from occurring. If they do
occur the organization and staff need to take immediate
action to lessen the likelihood of any adverse incident
involving staff or patient care. Depending on the nature and
frequency of events, further interventions may be required to
prevent repeated incidents. Table IV provides a list of
recommended strategies. In addition to reducing the
incidence of disruptive behaviors, this approach can also be
used to improve the overall organizational culture, staff
relationships, team collaboration, communication efficiency,
physician engagement, and physician well-being.
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 6 of 10
Table IV: Recommended Strategies
1. Training re-design:
Applications/ MCAT testing
Revised curriculum
2. Organizational Culture/ Work environment:
Hiring/ On-boarding
Mutual alignment
Leadership commitment/ Structure and process
Encourage motivation/ address barriers/ set priorities
Engage Champions/ Catalysts/ Role models
Recognition and rewards
3. Education:
Awareness/ Responsibility/ Accountability
The business of healthcare
Expectations vs. reality
4. Relationship training:
Address factor influences: Generation/ Gender/ Culture/ Ethnicity
Diversity management/ Cultural competency/ sensitivity training
Personality profiling
Customer satisfaction
Stress/ Conflict/ Anger management
Emotional Intelligence
5. Communication skills/ Team collaboration training
6. Behavioral policies and procedures
Definition/ Accountability/ Incident reporting and review
Risk management
7. Intervention:
Prevention
Tiered approach: Informal/ Formal/Disciplinary
8. Staff support:
Administrative/Clinical/ Behavioral (EAP/ Wellness Committees/ Coaching/ Counseling)
Behavioral modification programs
Career guidance
9. Physician Well- Being:
Awareness/ Reflection/ Self- care/ Relaxation
Stress Reduction
Quadruple Aim
Mindfulness
Resilience
10. Physician engagement:
Input/ empathy/ responsiveness/ alignment
Recognition/respect
As discussed earlier, one of the earliest steps to
take is to improve the process and criteria for medical school
selection and enhance personal skill and team collaboration
skills early on in their training curriculum.
From an organizational perspective, hiring and
retaining the right people is key to success. Many
organizations are recognizing the importance of the right
“cultural fit” and are using more selective interviewing
techniques to assure that new hires will work well with the
mission and operational needs of the work environment.
Once hired, there should be a comprehensive on-boarding
process to first welcome the physician, and then explain
organizational priorities and incentives working under the
complexities of today’s health care environment and the
support available to help physicians negotiate through the
maze of medical requirements.
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 7 of 10
Recognizing administrative concerns for financial
viability, and clinical staff concerns about quality and safety,
there needs to be a mutually agreed upon rallying point and
alignment around best patient care. Organizational culture
sets the tone. Strong and supportive organizational cultures
have been shown to significantly enhance staff morale,
satisfaction, motivation, and engagement which lead to
behaviors that result in best patient outcomes of care [15].
Having a strong, committed, and respectful leadership, an
effective structure and process in place manned by skilled
individuals, a willingness to address and respond to
individual concerns and barriers that pose a potential
disturbance in the force, establishing priorities, and enlisting
the help of key individuals who act as champions and
catalysts to help promote a positive work environment are
the key ingredients to a successful culture. In today’s
multitasking pressure filled here’s what you need to do
world, always remember to take a step back and take time to
recognize physicians and staff for their efforts and say
thanks for a job well done.
Another crucial step is to make an effort to educate
staff about what’s going on, what we need to do in response,
and how it might impact individual roles and
responsibilities. Proving educational sessions on the
evolving health care environment, value based care, system
redesign, performance based accountabilities, and the
business implications of clinical practice, will help set
realistic expectations by giving physicians a better
understanding of what’s happening and how it might affect
their individual practice.
Providing training to enhance relationship
management is crucial. Under an umbrella of increasing
complexity and accountability, more segmentation between
specialty and discipline specific tasks and responsibilities,
and a greater focus on care responsibilities that extend
across the entire spectrum of care, it is crucial for all
members of the health care team to work well together to
provide best patient outcomes. In order to accomplish this,
we need to gain a better understanding of the factors
affecting individual values, perceptions, and behaviors.
Offering educational and training programs on such topics
as diversity management, cultural competency, sensitivity
training, emotional intelligence, generational values,
personality assessments, and customer satisfaction may
prove extremely valuable. Additional programs on conflict
management, anger management, and stress management
may also be of benefit depending on individual
circumstances.
Beyond addressing disruptive behaviors is the need
to improve overall communication and team collaboration
skills. Physicians are typically not the best communicators.
There are many barriers that get in the way [16]. First, they
look at patient management as a one way dictatorial process.
They’re trained to work autonomously, to take control, and
give orders. Communication gaps are further accentuated by
a bureaucratic health care hierarchy, a teaching focus on
gaining knowledge and technical competency rather than
personal skill development, segmented, siloed, and
discipline specific priorities which focus more on the organ
or disease rather than the patient, and an overriding strong
ego that resists outside advise, interference, or involvement.
In today’s complex health care world improving
communication skill sets should be a number one priority.
There are many different types of communication
skills training programs available. The focus is getting the
physician in synch with effective two way communication.
Crucial points emphasized include a proper introduction and
acknowledgement, making time and patience, exhibiting
positive body language and verbal tone, enabling trust,
avoiding distractions or conflict, reflective listening, being
sensitive to the other’s values, needs, and desires, providing
clarification and understanding, and setting appropriate
expectations. In a demanding hectic environment, taking the
time to listen, understanding, responding, and explaining is
the key to gaining compliance and a successful interaction
and outcome [17].
A further extension of communication is to teach
team collaboration. One of the most effective programs in
health care is the TeamStepps program. The focus of the
training program is to teach team members how to (1)
anticipate and assist, (2) build trust, respect, and
commitment, (3) understand your role and roles of others,
(4) reinforce accountability and task responsibilities, (5)
avoid/ manage conflict or confusion, (6) assertiveness and
need to speak up, (7) follow up discussions, and (8) thanks
for a job well done.
In order to hold individuals accountable for their
behaviors the organization needs to have a code of conduct
policy in place that outlines non-professional behaviors and
the ramifications of non-compliance. The policy must be
backed by an effective incident reporting system where each
complaint is evaluated on its own individual merits with
recommendations given for appropriate follow up action. In
order for the program are effective individuals needed to be
willing to report. Barriers to reporting include fear of
whistleblower retaliation, a double standard of reluctance to
apply consistent reprimands when it involves physicians,
and the sense that they report and report and nothing ever
changes. On the incident evaluation side, determinations
need to be made by trained individuals functioning without
personal bias or conflicts of interest with recommendations
passed on to an individual or committee who has the
appropriate facilitation skills to foster accountability and
resolution. When patient quality or safety is of concern
many of these issues fall under a risk management protocol.
When it comes to intervention the first intervention
is prevention. As discussed previously, taking a pro-active
approach in trying to get a better understanding of
behavioral characteristics, and teaching basic principles
about behavioral management can certainly reduce the
predilection for behavioral problems. For recurring issues
early intervention has a much greater potential for success
than waiting until a bad incident occurs where the
interaction take on more of a remedial tone [18].
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 8 of 10
Interventions can occur at several different levels. In all
cases it’s crucial to intervene at the appropriate time and
place with the intervention conducted by someone skilled in
the arts of facilitation and conflict management.
The first intervention is real time. If somebody is
acting inappropriately the recipient needs to be assertive in
addressing their concerns in a respectful professional
manner. The next series of interventions are post-event
interactions. Hickson and his group at Vanderbilt University
have come up with a four phase process for intervention that
includes informal, awareness, authority, and disciplinary
actions [19]. The informal interaction is often described as
the “cup of coffee” approach where you take the physician
aside, describe the series of events, and ask for their
opinion.A good facilitator will listen to what the physician
has to say, ask if they thought that their action was
appropriate, address their concerns and rationalizations,
reframe the issue to bring behaviors into context, ask them
to think about the impact it had on the other person(s)
involved, and what they could have done differently to ease
the angst of the situation. When the situation is addressed
under the guise of raised awareness, most physicians will
self- correct.
For repeat offenders or when the incident is of a
serious nature there needs to be a more formal intervention.
The physician needs to recognize the ramifications of non-
compliance with the code of behavioral standards and the
organization needs to reinforce the importance of a zero
tolerance policy with the potential of disciplinary action. In
some cases the recommendations may be made for anger
management, conflict management, or diversity training,
and in more serious cases the need for individualized
counseling. Always keep in mind the underlying possibility
of drug or alcohol abuse. Depending on the nature of the
problem, some physicians may be required to attend an
outside behavioral modification program.
In the more extreme cases where physicians are
resistant to follow recommended actions the only recourse
may be sanctions or termination of privileges. Having
served as an expert witness on both sides of the picture
(representing hospitals, representing individual
physicians)health care organizations need to have a clear
line of documentation as to the issues, follow due process,
adhere to the bylaws and HCQIA requirements, be
consistent with similar types of cases, document follow up
discussions, comply with the rights of the physician to be
heard, provide specific recommendations designed to
resolve problems, and state the capability to reapply once
the issues are addressed and resolved [20].
When possible the focus of any intervention should
be on trying to help the physician better adjust to the
situation by offering assistance and career guidance rather
than punishment. The primary focus should be on positive
physician support.
If the physician is overwhelmed by administrative
requirements and time constraints, the organization needs to
recognize this issue and provide appropriate support. From
an administrative and logistical perspective reducing on- call
scheduling or productivity requirements, and/ or reducing
committee responsibilities will help reduce some of the
administrative load. Offering administrative assistance by
providing help with documentation and compliance with
electronic medical records through additional training, staff
support, or using “scribes” will help ease physician
frustrations in this area. From a clinical perspective using
Physician Assistants, Nurse Practitioners, or Case
Coordinators to help cover some basic medical necessities
will free the physician up to concentrate on more complex
patient management issues. From a behavioral perspective,
providing services to help the physician better adjust to the
pressures of medical practice, organizations can offer
services through Wellness Committees, Employee
Assistance Programs, individualized coaching and
counseling sessions, or other services offered though Human
Resources, Medical Staff Services, or outside referral
services. As mentioned previously stress and burnout are a
major problem affecting physician satisfaction and overall
well- being. Motivation for physician well- being needs to
be linked with the physician’s primary goal and aspirations
to provide best practice care. They need to recognize,
understand, and accept the fact that emotional and physical
well- being affects their levels of energy, purpose, and the
joy of being a physician[21]. This all starts by getting the
physician to understand the importance of good health and
the negative consequences of ill- health on performance that
impacts family, friends, colleagues, staff, and ultimately
patients. They need to understand the importance of
relaxation and recreation, adequate sleep, regular exercise,
and good nutrition. They need to try and avoid stressful
situations, be able to set limits, and be comfortable in saying
no. They also need to be willing to accept outside advice.
One of the most important components is to teach them
techniques to support self- reflection, self- preservation, and
the importance of time off and relaxation to achieve inner
peace. Many organizations are introducing the concepts of
mindfulness and mediation training programs for physicians
as a way to promote self-refection, purpose, and fulfillment,
and enhance physician resilience [22, 23]. For most
physicians the recognition is there but it becomes a
secondary priority to the daily grind. We need to
aggressively promote and support the importance of
physician well- being and get then to commit to make it
happen. The final phase is to enhance physician
engagement [24].Engaged physicians are more satisfied,
energetic, and less likely to behave in an unprofessional
manner.Part of their frustration is the lack of physician
input. With growing frustrations from outside intrusions and
having someone else telling them what they need to do,
physicians react negatively when they don’t have a voice.
© 2016Alan H. Rosenstein. Volume 2 Issue 2 JBHRM-2-012 Page 9 of 10
Input can be gathered from several different sources. These
include surveys, discussions at Town Hall or Department
meetings, specialized task forces, or better yet, one on one
conversation with administrative and clinical leaders.
Allowing input diffuses some of the frustrations particularly
if there are expressions of empathy and understanding of the
physician world. Input must be followed by responsiveness.
It’s not that you’ll be able to solve every problem, but at
least you can provide an explanation and coordinate next
steps on achieving mutually aligned objectives. There is a
strong correlation between physician engagement, physician
alignment, physician well-being, physician satisfaction,
physician motivation, improved relationships, and improved
outcomes of care. And always remember to visibly show
respect and thank physicians for what they do.
Conclusion
Physician disruptive behaviors can have a
significant impact on staff relationships, care efficiency, and
clinical outcomes of patient care. There are multiple
influencing deep seated internal and real time external forces
at play which influence moods, perceptions, biases, values,
priorities, and attitudes that impact behavioral output. For a
number of different reasons, physicians have a unique set of
circumstances that affect their persona and by nature of the
business are under increasing levels of stress that may
perpetuate burnout and depression that further aggravate the
potential for disruptive actions. Most physicians are usually
unaware of the consequences of their actions. Rather than
taking a remedial approach to behavioral management we
need to look at physicians as being precious resource and
proactively provide the appropriate administrative, clinical,
and behavioral support in an effort to help them better adjust
to the pressures of today’s health care environment. Early
intervention is the key. A combination of cultural
understanding and support, education, relationship training,
and communication skillsdevelopment will help improve
work dynamics. Some physicians will require additional
personalized coaching or counseling and in rare instances
require more intense behavioral modification interventions.
Efforts need to be made to support and enhance physician
well- being. Lastly, we need to make a conscious effort to
provide opportunities for physician input and discussion in
an effort to improve physician energies, engagement,
satisfaction, and compliance with best practice care
initiatives. We can’t leave it up to the physician to take
action. We need to get out there and try to help them be the
physician they really want to be.
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