Protocol for Referrals
from Hospitals or Physician Groups to TMF-PHP

“Distressed Physicians”

1. Signed release of information for all parties involved in referral,
including (as appropriate):
Hospital Chief of Staff
Medical Executive Committee
VP of Medical Affairs
Senior or referring partner

2. Referral source encouraged to set a time limit for evaluation to occur (usually 1-2 weeks).

3. Referral source to identify at time of referral:
Specific problem behaviors
What is disciplinary protocol and where is physician in that process, e.g. verbal warning, written warning, etc.
Time frame for corrective action
Consequences of noncompliance with contract, either reoccurrence of behavior or lack of follow-through with treatment recommendations
Expectations at outset (i.e. need for ongoing therapy or monitoring vs. acceptability of assessment only)

4. If further in-depth assessment is done at PHP recommendation: Recommendations communicated to PHP prior to feedback to physician “System dynamics” feedback given ONLY to hospital or referring group, not to physician

5. Signed contract between hospital <-> physician <->PHP
Physician to take contract back to hospital
Copies to all parties
Contract to specify problem behaviors and consequences

Checklist for referral of distressed physician [Attach additional sheet(s) as necessary]

Name:

1. What are specific problem behaviors?



2. What is disciplinary protocol and where is physician in the disciplinary process (e.g. verbal warning, written warning, etc.)



3. Time frame for corrective action (i.e., 6-12 months vs. on the brink of being terminated, etc)



4. Consequences of noncompliance with contract, either reoccurrence of behavior or lack of follow-through with treatment recommendations





5. What are expectations of referral source at outset (i.e. need for ongoing therapy or monitoring vs. acceptability of assessment only)



distressed Behavior

Since the decision of Darling v. Charleston Memorial Hospital; where the court decided that hospitals and their governing bodies were more than realtors in providing space for independent contractors (physicians) to practice their art and were responsible to patients for the competence and continued supervision of physicians granted medical staff privileges (corporate liability), hospitals have effectively devised bylaws, policies and procedures to address physicians impaired by reason of physical or mental illness, including drug and alcohol abuse.

In recent years, however, there has been a marked increased in the rather amorphous category of “distressed” or “behaviorally handicapped” physician. The Alabama Physician Health Program recently reported that the distressed physician has accounted for 12% of recent referrals to the program.

Some possible causes for this increase have been theorized:

The empowerment of groups that previously suffered this behavior in silence certain that any complaint would be ignored or result in retribution. Many companies now at the insistence of their insurance carriers require “sensitivity training” that describes unacceptable behavior and the channels available to voice their grievances.
Physicians who have perceived themselves as independent entrepreneurs now find themselves subject to scrutiny and control by multiple parties. These fearful, frustrated, angry physicians may act out more frequently than previously in the work place.
Current rapid changes in the health care delivery system have stressed many physicians. Many physicians have grown up in an abusive environment at home. In medical school they may have been the object of physical, verbal and mental abuse. This behavior by their teachers and mentors has left an imprint upon them. Not only was this behavior tolerated previously but was seen as a mark of the abuser’s position and genius. Frequently this behavior was emulated by succeeding generations.
Medical training has emphasized intellectual capacity at the expense of fostering and teaching interpersonal skills.

While it is difficult to precisely define “distressed behavior,” it is a chronic pattern of contentious, threatening, intractable, litigious behavior that deviates significantly from the cultural norm of the peer group, crating an atmosphere that interferes with the efficient functioning of the health care staff and the institution. The use of the word ‘chronic’ in this definition implies a habitual pattern of behavior as opposed to the rare or occasional outburst on the part of the acutely fatigued or stressed physician, which is usually recognized even by the offending physician as exaggerated and inappropriate.

The distressed physician often lacks the ability of self-observation. They view:
Themselves as clinically superior (and they often are)
Other members of the health care team as less competent or incompetent, weak and vulnerable.
Themselves as champions for their patients (often the patients share this view).
Their distressed behaviors are used either consciously or subconsciously to intimidate, control and blame others (for bad results). They are unable to perceive that the victims feel harassed, manipulated, controlled and abused. And their actions cause:
A decrease in morale.
Increase in the level of workplace stress.
Inordinate time spent by staff appeasing or avoiding them.
Increased risk for errors - communication breakdown that can result in delays and mistakes in making and implementing critical medical decisions. Often these errors then result in another and escalated round of inappropriate behavior.
Increased potential for malpractice litigation.

When confronted with their behavior they frequently feel misunderstood and the object of envy and jealousy by others.

Not all distressed physicians engage in these behaviors. Each behavior may have its own characteristics and require an individualized treatment plan.

***

Following is a list of inappropriate behaviors:

1. Inappropriate anger or resentment
Intimidation
Abusive language
Demeaning other staff
Blaming or shaming others for possible adverse outcomes
Unnecessary sarcasm or cynicism
Threats of violence, retribution or litigation

2. Inappropriate words or actions directed toward another person
Sexual comments, jokes or innuendo
Flirtation, sexual harassment
Seductive, aggressive or assaultive behavior
Racial, ethnic or socioeconomic bias or slurs
Lack of regard for personal comfort and dignity of others

3. Inappropriate responses to patients needs or staff requests
Uncooperative, defiant, rigid, inflexible
Avoidant, unreliable
Late or unsuitable replies to pages and calls or exaggerated response
Unprofessional demeanor or conduct
Arrogant, disrespectful
Inadequate communication in quantity, quality and promptness
Recurrent conflict with others, particularly authority figures—irrational, oppositional

Remediation

If you have never experienced a distressed physician who is either on your staff or applying for staff privileges, you can expect at some point that you will. Many hospitals, even after having experienced the agony of handling one of these problem physicians, will fail to anticipate that it can and probably will happen again. They find themselves inventing rules, policies and procedures as they proceed.

Successful management includes:

• Have a bylaw or policy in place. Case law has been accumulating in recent years asserting a hospital’s right (and even duty) to deny, suspend or revoke staff privileges on the basis of an “inability to work harmoniously with others”: Nana vats v. Burdette Tomlin Memorial Hospital (526 A. 2 d. N.J. 1987) eventually reached the New Jersey Supreme Court. The charges were:
Unfair criticism of nursing staff causing a breakdown in morale and discipline.
— Questioning patients as to why they had chosen another physician.
— Pre-emption of hospital beds contrary to hospital policy.

The court stated “in evaluating a physician for staff membership, a hospital may consider not only technical skills, but also his or her ability to work with others. Consequently, a hospital may adopt a bylaw providing that the inability of a doctor to work with others will be considered grounds for denying or terminating staff privileges. For disharmony to constitute a good cause for dismissal from a hospital staff, however, it is unnecessary that it cause actual harm to patients.” In Robbin v. Ong, 452 F Supp 116 (SD. GA 1978) and in other cases the court has made two basic points:
• Hospital staff appointment is a privilege and not a right.
• A direct relationship to patient care need not be demonstrated for action against a physician because Of his behavior to proceed.

In Miller v. Eisenhauer Medical Center, the California court stated “ability to work with others is not sufficient grounds for action against a distressed physician” but there must be “a real or substantial danger that patient care would be impaired.” Fortunately, this option is in the minority.

Bylaws

An example of a bylaw covering the distressed physician is available. The recommendation is that each medical staff and hospital craft its own bylaw in consultation with an attorney.

Bylaws must emphasize the hospital’s right to impose sanctions up to and including dismissal.

The second preparatory measure is the development of a clear corporate policy defining the corporate culture and behaviors which are unacceptable. These policies, rules and regulations should be presented to all hospital employees and medical staff both in written form and in an ongoing series of educational seminars.

Documentation

There should also be training in documentation of the unacceptable behaviors. This should include:

Time and place of the occurrence.
Detailed factual description of the behavior.
Circumstances that precipitated the behavior.
List of others who observed the incident.
Consequences this behavior had on patient care and hospital operations.

This documentation is vital. Unlike medical mishaps that are usually well documented, these incidents may be poorly recorded and it is often the collection of multiple reports from many observers that eventually become grounds for remedial action.

Reporting incidents is most difficult because:

It may have a marked impact on the physician’s career.
It needs to be understood that reporters will be protected.
The hospital itself may be reticent to interfere because of a desire to avoid unpleasant, possible litigious, confrontation. Some hospitals find themselves in an economic bind where the distressed physician is a high volume admitter or the only practitioner of his/her specialty.

Intervention

After the event has occurred, there should be an established progressive series of interventions. Depending on the seriousness of the occurrence, the initial intervention should be performed by two or more senior members of the staff and administration in order to establish:

The seriousness of the situation.
That this represents a unified group decision.

Before the intervention occurs, a clear set of goals should be agreed upon. The intervention should allow for the following:
Occur in a private, quiet, neutral setting - so both parties can leave when the intervention is finished.
Sufficient time should be allotted.
The physician should be assured of privacy and confidentiality.
The information should be presented in a clear non-judgmental, empathetic manner. It should consist of specific, factual data. This information should be related to how it interfered with patient care and hospital function.
Help should be offered.
It should be carefully and clearly stated that the physician will be closely monitored to ensure that the behavior or similar behavior does not recur.
The consequences of failure to change behavior should be explained.

The proceedings of the meeting should be fully documented. A copy of the minutes should be part of the physician’s personnel file.

Referral to the TMF Physician Health Program

The TMF PHP may be in a position to work with the hospital to encourage the distressed physician to seek a formal neutral assessment. Such assessments are done at centers that specialize in distressed physician issues.

Usually, the assessment consists of multidisciplinary team and is designed to determine if any psychiatric disorders are at the base of this behavior, in particular chemical dependency and Axis II Cluster B personality disorders. A personality disorder is described as an enduring pattern of behavior that deviates markedly from the expectations of the individual’s culture. The characteristics are:
• Pervasive
• Onset in childhood or early adulthood
• Stable over time
• Inflexible
• Lead to distress or impairment

The Cluster B personality disorders particularly involved are:
• Narcissistic
•Borderline
• Histrionic
• Paranoid

Other psychiatric problems include:
• Bipolar - cyclothymic
• Major depression
• Dementia
• Schizoid personality - schizophrenia

If there is no change or recurrence of the unacceptable behavior, the next step is to go to a formal hearing held in careful adherence to the hospital and medical staff bylaws. Close consultation with the hospital and staff’s attorneys is vital at this stage as the most frequent cause for overturning a decision is failure to follow procedures as outlined in the bylaws. Care must be taken to adhere to the 14th amendment “due process” requirements.

Recommendations for Action

Following are some action recommendations that hospital medical staffs may use to deal with the distressed physician:

1. Focused education dealing with the following areas:
Anger management
Conflict resolution
Sensitivity training skills
Communication
Behavioral modification: positive and negative incentives
Impulse control training

2. Peer monitoring
3. Leave of absence
4. Partial loss of privileges
5. Temporary suspension of privileges with a clear plan and requirements for re-entry
6. Suspension of privileges
7. Revocation of privileges
8. Denial of appointment or reappointment

No matter what action is taken, medical staffs should work with their legal counsel to address any required follow-up reporting to state and federal agencies. Please note that:

Any change in privileges may be reportable to the state licensing board (for MD physicians, the Board of Medical Examiners (BME); for DO osteopathic physicians, the Board of Osteopathic Examination).

Sanctions or other changes to a physician’s privileges that last for longer than 29 days are reportable to the National Practitioners Data Bank. [See 42 USC §11133.]

Frequently these measures will result in the desired changes.