When a Florida obstetrician wouldn't stop swearing around her patients and staff, her partners were stymied.
They tried talking to and counseling her about how vulgar language was inappropriate. Still, the gutter language continued. The group finally sat down, spelled out the problem and said they would fine her if she didn't stop, says Meryl Luallin of Sullivan/Luallin, a San Diego-based healthcare consulting firm.
The partners fined the foul-mouthed physician $6,000.
Luallin declined to name the doctor or the practice. But the need to rein in physicians' behavior and improve their performance has become a pressing issue facing practices.
The number of physicians whose inappropriate behavior disrupts a practice hasn't increased, Luallin says. But the perception of more problems has been created because patients and staff are more sophisticated and unwilling to tolerate what was once considered eccentric behavior, she says. Those same comments and actions are now considered "boorish and damaging," says Luallin, whose firm has worked with groups to improve physician performance since 1983.
While the issue centers around inappropriate behavior by physicians, it's important not to classify physicians as "behavior problems," she says.
"It's easy to doctor-bash. What we have to recognize is that doctors are very, very bright people. . . . No one wants to think they'll be considered a Dr. Dragon," Luallin says, using her moniker for doctors who act inappropriately.
"Doctors are not deliberately antagonistic toward others any more than anyone else is."
Physicians face tighter restrictions and less autonomy than they ever anticipated, Luallin says. Those factors result in "anger that's misdirected," she says.
That misdirected anger often rears its head as a refusal or inability to follow schedules, thereby disrupting the flow of the office, one of the most common forms of inappropriate behavior, Luallin says.
Another, more damaging display is inappropriate behavior toward staff members.
Employees leave or worse, mentally quit their jobs but continue to work, she says. Physician abuse toward staff members is a common misbehavior, but addressing it can be difficult.
One clinic called "code greens" when a physician would start acting inappropriately and excessively berating staff members for incidents such as overbooking a schedule, Luallin said at the Medical Group Management Association convention last fall. As the physician confronted the employee, all the nurses and staff members would silently line up behind the employee. They just looked at the doctor, who suddenly would stop yelling.
Most damaging to finances and image is when staff members file suit over hostile work environments, she says.
There aren't many hard statistics on cases, and only a few lawsuits have been filed against doctors for abusive behavior by staff or patients, says Edward Green, an attorney with the Chicago office of Foley & Lardner, a healthcare law practice. However, the lack of suits doesn't absolve groups' responsibility for employee behavior. Employers can be held liable for employees' behavior while that employee is performing his or her job duties, Green says.
The best approach is to give physicians policies on expectations and outline consequences for missteps, Green says. Those policies should be distributed immediately when the doctor is hired, he says.
The policies must include a due process procedure that outlines what will happen each step of the way, says Triste Lieteau, M.D., an associate with Foley & Lardner.
Addressing problems has to be a physician-led effort, Luallin says. "A clinic manager has no legs. That person is there on a contract basis. A lead physician, a senior partner has a stronger influence and also cannot be easily removed."
But before that confrontation can take place, the physicians must have data to support the claims. Detailed patient satisfaction surveys, employee exit interviews and tracking requests for chart transfers are tools that can provide those numbers, Luallin says.
"If you're going to confront a physician, you must have data, and the data has to be as specific as possible," Luallin says.
When physicians are confronted about their behavior, they need to be given a point-by-point outline about what is not appropriate, what steps must be taken and what outcomes are expected in a specified time frame, Luallin says.
At Holzer Clinic in Gallipolis, Ohio, physicians are evaluated just as other staff members are. The reviews--which are conducted by physician department chairs and department managers--include a survey of the physician's peers, outcomes information and staff surveys.
"All the information is compiled and shared with the physician on an annual basis," says Patrick Connors, chief operating officer at Holzer Clinic, which has tracked physician performance for three years. The multispecialty clinic has 101 physicians. "Our belief is that physicians are very intelligent people. If you give them information, the majority will react to it."
If physicians are told they're not team players, for example, they will be asked what they think that means and what they need to do to improve.
The information isn't gathered to target a specific physician, Connors says. The statistics are compiled for each physician and are used during performance reviews.
While the nonphysician manager plays an important role and the staff surveys are a valuable tool, Connors says it's vital that physicians be involved in creating the evaluations and processes that address physician performance.
After about three years of keeping track of patient data, almost 90 percent of physicians support the program and the idea, he says. The performance reviews and patient satisfaction data are mandatory for each doctor, but some doctors don't like their authority and autonomy challenged and don't think tracking their behavior is a good idea.
But the majority of them do, Connors says. Part of that buy-in begins when the clinic hires a physician. Connors sits down with the physician and conducts a patient-physician relationship educational session. The focus, through books and videos, is on interview skills.
The process by which patients determine satisfaction is foreign to physicians, Connors says. "It's easy for you and I to say we judge someone within the first four minutes. . . . The doctor hasn't even touched us yet, and if we have a negative feeling, the outcome will be negative, even if clinically it's positive."