Bad behavior by physicians can't be ignored
■ How can you help a disruptive colleague?
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA. Posted May 11, 2009.
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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.
Reply: 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:
- 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 (link). 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
The Ethics Group provides discussions on questions of ethics and professionalism in medical practice. Readers are encouraged to submit questions and comments to [email protected], or to Ethics Group, AMA, 515 N. State St., Chicago, IL 60654. Opinions in Ethics Forum reflect the views of the authors and do not constitute official policy of the AMA.