MedicalConspiracies- Bad behavior by physicians can't be ignored

Bad behavior by physicians can't be ignored
Ethics Forum. Posted May 11, 2009.

How can you help a disruptive colleague?
"The Sick Physician,"
http://www.ama-assn.org/amednews/2009/05/11/prca0511.htm

Scenario: How can you help a disruptive colleague?

One of your colleagues is a competent clinician, but patients and
staff have come to you complaining that the person has been rude and
inappropriate at times. The offending clinician uses abusive language
and blames others when something goes wrong. Some staff members have
been so upset that they want to leave the group or the practice.

http://www.ama-assn.org/amednews/2009/05/11/prca0511.htm

Certainly, we can't control others, and we don't want to get into
arguments with our colleagues and practice partners. Yet our ethical
obligations are clear. Our training, education and experiences have
confirmed that this behavior can affect patient care through its
influence on the medical team's effectiveness. Physicians accept the
responsibility to do no harm to their community and their fellow
clinicians as well as to their patients.

It is very difficult to take on the responsibility for correcting or
censuring others, but over time our profession has made statements and
findings that support the ethic of helping our fellow physicians. In
1973, "The Sick Physician," a committee report of the American Medical
Association, was published as the result of activities of the AMA
Council on Mental Health. The report, based on a literature review,
revealed that physicians have a substantial incidence of alcoholism
and drug abuse or dependence, along with other psychiatric illnesses
and suicide, and it concluded that we do have a responsibility to:

■See related content
■Help our fellow physicians who are ill.
■Help refer physicians for treatment and protect patients.
■Educate medical students, residents and colleagues about the
illnesses for prevention.
■Foster model legislation to set up diversion programs.
These four responsibilities have been satisfied in many ways by
physician health programs, which exist in almost every state. These
programs need our continuing support and can, in turn, assist us in
taking actions when a colleague is exhibiting the kind of behavior
described at the beginning of this article.

Another aspect of our responsibility is defined through the mechanism
of civil lawsuits. Several partners in practice groups have been sued
because they were associated with a physician who practiced while ill
from a substance-use disorder or other psychiatric illness. The
liability of partners has been lucrative for patients who are suing a
physician who is no longer working or has lost most of his or her
ability to pay, because the defendant's partners or colleagues, in
contrast, are likely to be working and covered by liability insurance.
Thus, we ignore an impaired colleague at our peril.

Given our ethical -- and legal -- responsibilities for behavior of a
fellow physician that affects patient care directly or through a team,
what do we do? We can handle the situation by ourselves, meet with the
concerned parties if they are willing, obtain consultation from an
outside source or call on the relevant state physician health program.
Most actions are better taken with consultation, often initiated after
contacting the physician health program in your state.

Meeting with the physician alone rarely suffices. If the behavioral
problems are mild and generally out of character for the person,
however, a brief talk over coffee or lunch may be effective,
especially if the practice or group has a code of behavior. This code
should be familiar to all and formally accepted in writing by
physicians and staff. It may even be more powerful if the code was
developed by the entire staff, along with an expert consultant. It is
more difficult to deal with behavior that is not clearly defined as
unacceptable.

If the "coffee meeting" doesn't work, one can call a meeting of the
staff and the physicians to discuss concerns about the offending
physician. A meeting such as this should be conducted with
considerable caution, however. The person who has acted in a manner
unacceptable to one staff member may retaliate against that person.
Retaliation that is overt or a direct expression of anger can be
easily recognized and dealt with.

Much more difficult to manage is retaliation expressed passively.
Passive manifestation of anger may take the form of demands for
unnecessary information or patient care from the partner who initiated
the complaint or disregarding his or her suggestions, all of which
increase the frustration of the person who is the object of the anger.
A staff member who is the object of retaliation and who had been a
valuable contributor to the clinical team may become increasingly
upset and may even consider leaving the practice.

Another danger of handling the situation within the office is the
division of the staff into two camps, one group supporting the
offending physician and the other group supporting the accuser. If
this disagreement is covert and not actively discussed among the
staff, the behavior of the disruptive physician often worsens, and the
office becomes an unpleasant place to work. In this situation, the
practice may need to hire a consultant to meet with the staff and
attempt to resolve the differences by open discussion. This
intervention may be effective even if the differences are not
eliminated but are discussed openly.

Almost every state has a physician health program that will provide
direct consultation or arrange for consultation by qualified
professionals. Contact information can be found on the Federation of
State Physician Health Programs Web site (www.fsphp.org). The state
physician health programs often are aware of consultants who can
manage office personnel. Alternatively, the program may recommend a
consultant who can evaluate the offending physician in hopes of
helping him or her cope better with the practice environment.

Helping the physician requires an initial examination into the causes
of the offending behavior. If this pattern of behavior is a long-
standing one, it is most likely due to a personality disorder. Since
this clinical term has profound implications, I like to use the term
coping style instead when talking with other physicians. Coping styles
are hard to change and take time to change, even under therapy. The
best type of intervention links therapy with feedback from the work
site, allowing the physician to improve behavior that he or she did
not initially recognize as offensive to staff.

If the misbehavior is a recent change, it may be related to the
development of psychiatric or other illnesses. The most common illness
is a substance-use disorder (alcohol or drug abuse/dependence).
Alcoholism develops over time. The average age of physicians with
alcoholism in most treatment programs is the mid-40s, although some
reach their 60s before their illness affects their clinical work. One
needs to look for changes in behavior -- more slowly with alcohol and
more rapidly with drugs such as cocaine and opiates. Manifestations of
illnesses subsumed under the rubric of substance-use disorders often
include irritability, social isolation, blaming, financial problems,
family problems and divorce. These indications of illness occur before
such obvious signs as alcohol on the breath, intoxication at work or
arrest for driving under the influence.

Other psychiatric illnesses such as major depression or bipolar
illness may lead to irritability and disruptive behavior. Again, these
can be identified by evaluations arranged by a state physician health
program. Physical illnesses also may affect behavior. Additionally,
other causes of the behavior may be related to family problems such as
teenagers with difficult behavior, illness in a spouse or unresolved
grief of a family member.

The causes of this type of behavior are not simple, but if the
behavior is new and uncharacteristic, a talk over coffee or lunch may
be effective. If the behavior is a long-standing problem or does not
respond to the "coffee talk," then obtaining a consult may be
valuable.

Like practice guidelines, ethics show us a path to follow. No one
follows the path perfectly, and the path is often changed to
accommodate the environment in which one acts. Facing the troublesome
behavior in your colleague or partner, while helping your fellow
physician to address his or her coping style, illness or environmental
stressor, may provide you with a considerable sense of satisfaction in
doing the right thing and helping your fellow physicians.

--Peter Mansky, MD, executive medical director, Nevada Health
Professionals Assistance Foundation, Las Vegas
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