MSQC is assisting department chairs in dealing with a particular behavior or problem. “It is a venue to vet particular problems and solutions,” he says. Ultimately, if there are repeated transgressions and administration is not satisfied that their directives have been followed, the committee can recommend revoking a physician’s medical staff privileges and implementing a remediation plan.
Those robust systems have not differed in medical institutions for the last 50 years. “I think what has changed is people are less willing to tolerate this persistently,” says Dr. Flanders. “People used to put up with the disruptive physician, the badly behaving physician, and if he was bringing in lots of research dollars or if he was a great scientist, [they’d be more likely to] accept bad behavior.”
With the increased risk of litigation and the increasing scrutiny on patient safety, these offenses can no longer be tolerated.8
At a community hospital, the hierarchies and channels of communication for handling behavioral issues are different. Because of the different atmosphere and mood of a hospitalist department, says Dr. Izakovic, who is also adjunct clinical assistant professor, Department of Internal Medicine, University of Iowa–Carver College of Medicine, Iowa City, “plus word of mouth, it is easier to either enforce or, even more, lead by example [such that] certain behaviors are [encouraged] and certain behavior types are suppressed.”
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Michael Zavarin, MD, director of the hospitalist group at Jordan Hospital in Plymouth, Mass., agrees that the environment of a community hospital may be different enough so that handling disruptive behavior also occurs differently than it does in an academic medical center.
Dr. Zavarin’s group is composed of 6.5 full-time day hospitalists and one full-time night hospitalist, as well as two nurse practitioners. Disruptive behavior in his group “really hasn’t been an issue, so I guess it is [dealt with] on an as-needed basis,” he says, and he can only speculate that the proper channel for dealing with situations involving disruptive behavior would be his institution’s medical executive committee.
When Dr. Izakovic faces situations involving disruptive behavior, he says, it is generally an instance in which a hospitalist has “a good intention, but feels pressured by overwork or patient care circumstances, or [has] difficulty communicating or handling the nursing staff … who perceive [the physician’s behavior] as being either threatening or disrespectful or just not called for.”9
He estimates that these instances occur most often when a physician’s expectations are not met regarding duties being performed in a timely manner. Formal complaints are rarely made in his group—maybe two or three times a year. In those cases, he is responsible for formal follow-up, which requires having a one-on-one conversation with the physician and reporting back to the risk management department. But he prefers doing what is necessary to avoid a situation getting to that stage. Informal behavior-related events happen at least monthly, he estimates. “I’d rather hear earlier than later, with no formal complaint, no formal channel,” says Dr. Izakovic.
Blow the Whistle
What are the political ramifications of blowing the whistle on a disruptive colleague? The University of Michigan’s MSQC was created largely to help get at that issue and to create a place where such subjects can be brought up anonymously. [It can be done] if the reporting person wishes. In most situations, there has been a concerted effort against backlash just as there is when incidents and errors are reported to improve or maintain patient safety.
“As the patient safety culture changes, and I think it is changing, it’s going to facilitate culture change on this issue, too,” says Dr. Flanders, “because I think people are beginning to recognize, appropriately so, that some of these behavioral issues are safety issues.”