In his March 2012 presentation to the American College of Healthcare Executives’ (ACHE) annual congress in Chicago, Dr. Dean White shared horror stories about a few of the disruptive behaviors that had occurred during his tenure as chief of staff at Texas Health Harris Methodist HEB Hospital in Dallas:
- A physician who threatened to use an AK-47
- A sexually harassing doctor who looked at porn on work computers
- A specialist so nasty that nurses drew straws to determine who’d have to interact with her
While these wildly inappropriate behaviors grab headlines, there are less obvious, stealthier forms of passive-aggressive disruption that can be equally if not more threatening to patient safety and staff morale, such as:
- The cardiologist who routinely postpones hospital rounds until visiting hours are over and families have left for the day
- The ER physician who orders each and every patient transported for tests—which keeps ER rooms fully “occupied” but gives the physician free time while waiting for patients to return.
- The pediatrician who won’t respond to pages or return consult calls
- The gastroenterologist who leaves prepped patients lying on tables
- The oncologist who doesn’t complete medical records or withholds information from staff
- The surgeon who disregards safety protocols, and doesn’t wash hands unless reminded
- The attending who’s slow to write discharge orders, condescends to staff and is dismissive of suggestions
While no single incident of any of these behaviors would be cause for alarm or intervention, over time these types of behaviors not only impede effective care and pose a threat to patient safety, they also frustrate patients and their families, lower staff morale, drive up the cost of care delivery and expose healthcare organizations to the risk of malpractice suits.
The Joint Commission’s Sentinel Alert #40 “Behaviors that Undermine a Culture of Safety” issued in 2008, states that healthcare organizations must address disruptive behaviors that threaten the performance of the healthcare team, which specifically include:
“...passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.”
“Overt eye-rolling and sarcastic behavior can be as inhibiting as a temper tantrum,” notes Liz Ferron, senior consultant and manager of clinical services for VITAL WorkLife. “A physician who makes nurses feel idiotic for asking legitimate questions is interfering with the flow of necessary information and ultimately, patient care.”
Passive-aggressive physicians with an “us versus them” attitude toward management, administration, other departments and even patients can be a significant energy drain on other team members as they attempt to share their misery and sense of victimization.
The Scope of the Problem: The ACPE Survey
In the American College of Physician Executive’s (ACPE) 2009 Doctor-Nurse survey, a majority of participants had witnessed personal grudges interfering with patient care. In addition:
- 43% said they’d experienced inappropriate joking
- Refusal to work with each other was cited by 38%
- When asked to rank behavior problems, 72.5% listed “Trying to get someone fired unjustly” as the third most frequent.
“A great many physicians might be unaware of the impact of their behavior, and they operate in an environment where staff and administrators remain largely reluctant to challenge them,” notes Alan Rosenstein, MD, MBA, medical director for VITAL WorkLife.
Understanding Passive-Aggressive Behavior: Getting to the Root Causes
Many physicians lack the communication skills to deal with conflicts or voice their frustrations in a direct, constructive manner. They avoid crucial conversations, so what may be a legitimate concern or question comes out “sideways.”
“Instead of telling an OR manager about frustrations with the way scheduling is managed, a physician may deliberately slow every procedure,” notes Ferron. “He or she not only doesn’t solve the underlying problem, but makes the schedule more punishing for everyone else.”
Passive-aggressive behaviors are often considered safer and less risky by those who engage in them than direct conflict resolution. Physicians are less likely to be called on being sarcastic or talking behind others’ backs. They often have reasonable-sounding excuses for forgetting to call someone back (“It was a busy day”), working too slowly (“I’m just precise”), ignoring others (“I don’t hear well”), avoiding staff meetings (“I’m so busy, and besides nothing important is ever covered”), and failure to comply with policies and procedures (“It’s too hard to try to keep up with all the changes”).
Physicians who feel put upon and are unable to see the options and choices they have for dealing with stress and frustrations may use passive-aggressive behaviors to release anger and frustration and to feel more self-empowered.
Many passive-aggressive physicians are reacting to perceived and sometimes very real disempowerment in their work environment. For example, older physicians, used to far more autonomy and control in their early career, may not yet have fully accepted the “new normal.”
“There’s a natural desire for many administrators to think physicians should have ‘gotten over it’ by now, but healthcare organizations that aren’t providing a forum or outlet for those physicians to work through their disappointment and frustrations with their careers may very well experience a higher level of passive-aggressive behavior,” notes Ferron.
It is not uncommon at all to see passive-aggressive and aggressive behaviors in the same physician. Since passive-aggressive behavior rarely leads to true problem resolution, frustrations build and may lead to occasional explosions.
Education & Training: Shedding Light on Grey Areas
Organizations should not only make it clear in their policies around disruptive behavior that NO behavior will be tolerated that undermines patient safety and negatively impacts quality of care, directly or indirectly, they should also provide staff training about what constitutes respectful communication.
- Physicians should know who they should contact if they have concerns about a nurse or technician’s performance—and make it clear they have options other than public reprimands.
- Nurses and medical staff should be encouraged to politely ask physicians to refrain from engaging in behavior they find insulting or sarcastic—and talk to a supervisor if the behavior continues.
The ACPE study showed that both doctors and nurses feel more empowered to point out unsafe or unacceptable behaviors at organizations that provide support, training and encouragement for bringing those behaviors forward.
VITAL WorkLife provides training to organizations and work groups on improving and encouraging positive communication skills, dealing effectively with workplace conflict, civility training and other topics surrounding behaviors which can impact patient safety and care.
“It’s much easier to begin conversations around unacceptable behavior when the organization has clearly stated its expectations about everything from respectful communication and attendance or participation in staff meetings, to prompt attention to pages and consult calls,” notes Ferron.
Documenting Unacceptable Behaviors: Keeping Track of Problems
Organizations should put into place mechanisms for tracking and reporting all types of disruptive behavior, in order to:
- Highlight the importance of maintaining standards on all types of behavior that can impact patient safety and quality of care
- Provide safe, confidential methods for staff to report questionable behavior without fear of retribution
- Frame every discussion about unacceptable behavior with objective data and behavioral observations
“Prior to sitting down with the physician, the administrator needs to have objective data on hand to demonstrate that the physician’s behavior is out of bounds—either in terms of stated organizational policy or in terms of performance as compared with other physicians in the organization,” notes Rosenstein.
Addressing Passive-Aggressive Behaviors: Start with a Conversation
While recognizing the different types of passive-aggressive behavior is important, it’s rarely helpful to label the behaviors as such. Rather, the administrator or manager should initiate a conversation that focuses on changing the behavior.
Here’s how one such conversation might play out:
- Name the behavior. “You’ve been consistently running late for monthly staff meetings.”
- Describe impact of the behavior on others, the environment, safety and/or workflow. “When you arrive late to staff meetings, it:
• Interrupts the flow of the meeting
• Takes added time to bring you up to speed
• Sends the message that you don’t see the meeting (or other people’s time) as valuable
What seems to be getting in your way of arriving on time?” - Listen to the physician’s response. At this point, the physician may begin to make excuses—but will be far less defensive than if you’d raised the issue of being passive-aggressive or challenged his or her motivations for being late.
- Address issues as needed. Depending on the issues raised, you may be able to resolve the concerns on the spot.
- Be clear about expectations moving forward. “In the future, I would like you to arrive to meetings on time.”
“Many physicians will commit to modifying their behavior or attitudes after being made aware of the impact it’s having on others,” says Rosenstein. “Improvement can’t be voluntary. They have to know that the behavior has been observed, documented and will be monitored.”
Helping Physicians Resolve Their Issues: The Physician Well Being Resources
In cases where physicians have issues that aren’t resolvable in a simple conversation, administrators have of the option of “reminding” physicians that the Physician Well Being Resources offers free, confidential counseling and physician peer coaching—or making a more definite suggestion.
Whether they come of their own volition or under a certain amount of guidance, The Physician Wellness Resources helps physicians to:
- Identify the underlying causes of their passive-aggressive behavior issues
- See the impact their behaviors and performance has on others
- Understand the needs that are being met by their passive-aggressive behaviors—and the price they’re paying for them.
- Learn alternate (and more effective) methods for getting their needs met
When Passive Behaviors Persist: Escalating Intervention
When physicians are non-compliant in changing or addressing their behaviors, VITAL WorkLife offers a comprehensive intervention solution designed to:
- Coach administrators on how to have effective conversations with physicians, or when and how to make the referral for more in-depth help
- Assess the physician and arrive at a plan to address behaviors
- Provide mentoring or coaching to individual physicians on changing and managing their behaviors and improving their communication skills
Watch the video below to learn more about our Physician Intervention solution and how it can help:
Chronic abusers or recalcitrant individuals may require formal interventions, very specific performance improvement plans and intense counseling over a lengthy period of time. In rare cases, termination may be the final course of action.
“A great many organizations prefer to outsource the intervention, counseling and performance improvement monitoring,” notes Rosenstein. “It’s often easier for physicians to continue or resume their responsibilities when they’ve been referred to an outside entity without the collegial relationships.”
We Can Help
Contact us online to learn how our Physician Well Being Resources can support the well being of your physicians and providers. Click here to learn about our Physician Intervention solution.
