Do nurses feel comfortable reporting such instances? “I think it depends on the personality,” says Dr. Izakovic. “Some do, and some feel less comfortable; there are nurses who never complain and nurses who always complain, like doctors and everybody else. But I think that the climate is changing [so] that raising your voice and pointing toward deficiency and/or imperfection is becoming, if not [socially] acceptable, then [at least] a standard of behavior.”
Behavior, Safety, and Quality
“Communication is the key to success in today’s medicine,” says Dr. Izakovic. “Specifically among hospitalists: You communicate with the family physician, the patient, the referring specialist, or specialist that you called, the family, nurses, and patients all around the hospital.” And although communication is the most important part of the hospitalist’s practice, he says, “it sometimes leads to tension, and it’s not as much the message that you want to convey as the form [you use] and how it is transferred.”
Nurses are key stakeholders in reporting these behaviors, just as they are encouraged to report errors as an expression of their professionalism. Certainly, Dr. Flanders says, reporting a behavioral incident is “a lot more personal and less tangible than reporting a wrong dose on a medication.”
He has noticed a dramatic increase in the number of messages he receives about inappropriate or dangerous behavior among physicians. Everyone has a bad day from time to time, he says, but at the end of the year, “if I have one physician who has been mentioned 15 times, that helps me assess that person overall as a professional and be able to say, ‘Listen, there may be some red flags here’ and [then we can] begin to intervene and try to change that behavior.”
Effective systems employed to adequately address performance problems should be fair, objective, and responsive, writes Dr. Leape.2,6 Strategies available to handle incidents of disruptive behavior include adopting performance standards for behavior as well as competence. All physicians should be required to acknowledge in writing that they have read and understood these standards and that persistent failure to uphold them will result in loss of clinical privileges. Adherence to standards should be monitored annually and provided confidentially to each individual. Finally, assessment and treatment programs must be available to manage all the underlying causes of sub-par performance. The long-term objective is to enable physicians to continue to practice, as opposed to attempting to “weed them out.”
Prevention
According to Balazs Zsenits, MD, director, Division of Hospital Medicine at Rochester General Hospital, Rochester, N.Y., two mechanisms should be applied when discussing the prevention of disruptive behavior.
“First, physician selection should be conducted by a thorough interview process,” he says, “including at least a full-day face-to-face interview, discussion with previous employers, assessment of team-participation experience, and communication skills.”
Also, you need to clarify your expectations by means of “written policies, leading by example, promoting this culture in meetings, etc., and proactively monitoring performance,” says Dr. Zsenits. That means talking with doctors, nurses, and families and actively looking for feedback. “This process is time-intensive and may be under-recognized during resource allocation, but I believe it is a tool that may prevent this and many other common problems from growing out of control.”
A director of a hospital medicine group may have to deal with the perception of an escalating number of complaints about physician behaviors. “The growth of a hospitalist program that goes from seeing a small fraction of patients within a hospital to seeing the majority of medical admissions creates challenges beyond just simply managing the increased number of doctors and complaints,” says Dr. Zsenits. “Our co-workers and stakeholders might develop an impression that ‘most doctor problems’ in the hospital are related to the hospitalists. Even if this is [because] the hospitalists actually take care of most patients in house, and each hospitalist takes care of many more patients than private attendings used to, avoiding the perception that this single group is associated with most complaints is a difficult task.”