The following article was first published on December 18, 2012.
Dear Ron,
I am currently a medical director of emergency services at a small community hospital, and I have an ongoing problem physician who provides outstanding medical care but can’t keep his mouth shut. He offends nursing staff with his obnoxious, condescending, and judgmental comments, and his patient satisfaction scores are horrific, as you might imagine.
I have talked to him about this issue several times, as has the emergency department director at another hospital. I would rather help him improve than fire him and make him someone else’s problem. How can I confront this problem physician about his rude and disrespectful behavior?
Sympathetic Director
Dear Sympathetic,
I admire your concern for this “problem physician.” Too often we, as leaders, treat individuals as cogs in the machine—interchangeable parts to be hired and used. Sometimes we use them up, discard them, and hire some more. This is the danger of literally believing the label that people are only “human resources.” Your concern for the individual is an important starting point for solving this problem.
Another common mistake leaders make is to put our concern about individuals above all other people in the organization. We often hold on to problematic individuals or underperformers at the expense of fellow teammates. In your organization, these teammates might include the nursing staff, patients, and other doctors.
When we allow someone to stay in their position and it results in others being abused, team values being sacrificed, and work being inefficient, it’s not compassion, it’s negligence. The difficult challenge of leadership requires balancing our concern for all the stakeholders and working through their often conflicting needs.
At a minimum, direct reports deserve their leader’s honest evaluation of their work. They deserve targeted, behaviorally specific feedback, and improvement suggestions. Anything less shortchanges the individual and undercuts team and organizational effectiveness.
As leaders, we should also provide the resources and means to make the needed improvements. Many leaders assume the problem with poor performers is they lack motivation; therefore, the obvious way to fix the problem is to motivate their employees. However, motivation is only one of three possible causes of poor performance. It is also possible that the employee wants to perform but is unable to do so because of a lack of skills, knowledge, or resources. A third possible cause is a combination of motivation and ability—they are unable to do what’s required and don’t want to do it even if they could. To try and skill up the unmotivated is a waste of time and resources. To motivate the unable only creates depression, not progress.
You describe the physician’s behavior as “offensive, obnoxious, condescending, and judgmental.” You mention that you and others have talked to him several times with no discernible improvement. Has he expressed a willingness to change, then failed to improve? It might be an ability problem. Has he shrugged off your feedback and shown no interest in trying to change? If this is the case, he probably lacks motivation.
Going forward, here’s my recommendation. Have a crucial conversation with the physician. Don’t try to solve the most recent occurrence; rather, use it as an example of the pattern of behavior you want changed. Be specific. Be factual. Compare what you expected with what occurred. Note that you and others have had several talks with him about this subject, with no discernible improvement. Explain that it’s time to take action, then give him two choices. If he is willing to make a heartfelt effort to stop his hurtful behaviors, offer to give him your complete support. This assistance could include training, coaching, counseling, pairing him with a partner, frequent accountability, or feedback sessions to gauge progress and provide support.
If he is willing to try, set behaviorally specific objectives such as, “You will not call anyone in the hospital a ‘fat head.'” Identify how you will measure his progress—such as peer interviews, surveys, key observer reports—and set specific dates and deadlines to review progress as well as make modifications and changes. Set a final date by which he must demonstrate specific changes or explain that termination will result. Make sure all expectations are absolutely clear about deadlines, the behavior to be changed, and how it will be measured. You don’t require perfection, but you do require sustained, significant improvement. If he agrees, follow the plan.
If he does not agree to the development plan you propose and cannot propose an acceptable alternative, initiate the removal process. Allow no more delays or chances.
Responsible leaders care about their people—the one and the many. They don’t callously fire individuals, nor do they allow a single employee to disrespect, abuse, or negatively impact others. They don’t demand change without helping people have the means to change and reasonable time to do it. Responsible leaders give actionable feedback and recognize progress. And they follow through.
I wish you all the best in the difficult and worthwhile effort of leading and serving others.
Ron
Yes!
Note that it all starts by labeling the real problem (“abuse”),and then *deciding* that it must change. That’s hard until you see a good path. But when you have a path based on mutual respect, mutual purpose, and correct principles, fear subsides.
I especially love how you address the needs of everyone involved (the offender as well as those offended); you break down the possible causes (ability, motivation, or both); you clearly communicate the issue and options to the party; then you invite them to choose their path with your full support. That’s key, because only they can make the final choice. Will they improve or not? Once they choose, then your path is clear. Simple principles, simply applied.
Thanks!
I really enjoyed reading your suggested approach. I would like to also add, that as a leader, something tangible must be done to also begin to heal the recipients of this individuals incivility thus counteracting the toxicity this person instilled into the ER workplace and ultimately improving quality outcomes. Examples being a new zero-tolerance policy, team building and education days, discussion with leadership and floor staff, applauding active identification of issues influencing team process. The triple prong approach: identify the issue, address the behavior, and clean up the mess caused by incivility.
Thanks for discussing this important topic. The case story on the ED MD is nothing unique. I like your approach and offer some additional suggestions. (1) Approach in a non- confrontational manner (2) listen to their input to gain their perspective (3) Make them aware of potential negative repercussions of their behavior and test their sensitivity to the issue (4) Present appropriate standards of professional care guidelines (5) inquire about any underlying causes of stress, burnout, anger etc. and offer support (6) then set criteria and expectations and hold individual accountable for their actions with one possibility being termination. For more information on this topic see my recent article on disruptive behaviors in the ED setting (Rosenstein, A. Naylor, B. “Incidence and Impact of Physician and Nurse Disruptive Behaviors in the Emergency Department” The Journal of Emergency Medicine Vol. 43 Issue 1 July 2012 p.139-148). Happy to discuss if you like. Alan H. Rosenstein MD. MBA ahrosensteinmd@aol.com or see http://www.physiciandisruptivebehavior.com
Subject: Confronting a rude physician colleague
Thanks for the sage advice offered. One additional possibility for that physician is depression. As a medical director and 25 year veteran in the field, I have seen this far too often. Physicians must report their use of psychoactive drugs to licensing agencies and therefore are loathe to receive treatment, even if it would enhance their productivity. We have at least as much psychopathology as the general population. Requiring evaluation and proof of ongoing intervention by a psychiatrist is literally life saving; I have witnessed a medical staff doing this with the result of a transformation of a physician’s personal & professional life- he had been on the verge of losing it all. In contrast, when depression was undiagnosed in another colleague and he lost his privileges, this 32 year old highly trained physician committed suicide the next day. Please include depression in your differential diagnosis of the desribed behavior. You might save lives in doing so.
I enjoyed reading your suggestions and appreciate how you pointed out the importance of the impact on the rest of the team. I would like to encourage the writer to take your recommendations; from personal experience, it is worth the effort. I had to remove an abusive employee from a team that I inherited. She had worked for the company for 15 years, but previous managers had not documented her behavior. After 2 long years of dealing with the abusive behavior and careful documentation, I was able to remove the problem employee. The rest of the team was amazed, thankful, relieved, and impressed. You will stand out as a leader when you take the necessary action – no matter what course of action the problem employee chooses.
Another option for the “difficult physician” is a true lack of social or people skills. Some people bring great technical skill value to the team, but may not have an intrinsic programming to deal effectively with other team members. I do believe that we have encountered this individual behavior on several occasions within our medical service line; the individual was unwilling and unable to change and was terminated ultimately due to the caustic impact on the team. We lost world-class expertise but recaptured our team. This was a very hard balancing act, not taken lightly (we used coaches, counselors, disciplinary measures, and interventions—–all unsuccessfully) RMC
For meetings, I believe that having a set of guidelines that each person agrees to uphold can lessen the occurrence of behavior that prevents real discussion or is outright abusive.
As a reformed rude and disrespectful co-worker, I’d like to weigh in. You mentioned this ER MD provides outstanding medical care. Therein lies the reason for his rude and obnoxious behavior. As with my bad behavior, when we know we’re good, we are arrogant. It isn’t until we get thrown on our backs by life (for me it was physical illness) that we have the opportunity to learn humility. After humility, comes respect and empathy for others. There’s more to it, but this is it in a nutshell, from my perspective.
While I applaud your focus on the rest of the staff you ignore the administrator’s shortsightedness. He asserts that the MD “provides outstanding medical care” and also says “his patient satisfaction scores are horrific.” You do not point out the contradiction. If the patients are not satisfied the medical care is NOT outstanding. It’s unlikely the administrator will point the doctor in the right direction unless the adminstrator sees the issue as well. Yes treat you co-workers with respect. But do not forget the patient.
One added suggestion: Other employees may carry forward their experiences and expectations. This can sabotage your efforts by forcing her/him back into a defensive position. So other employees have to be convinced to give him/her a second chance.