Distressed Physician Behavior
Model Policy and Procedures Manual

Medical staff leaders increasingly are calling upon the Tennessee Medical Foundation Physicians Health Program (TMF-PHP) to assist them with colleagues who have behavioral problems. These “distressed physicians” can present quite a challenge to all parties who must interact with them in the workplace.

Therefore, the TMF-PHP has assembled this policy and procedures manual to provide information on how best to identify and deal with physicians who are behaviorally distressed. The TMF designed this policy to be used by hospital chiefs of staff, administrators, and medical staff services coordinators. It also may be adapted for use in a medical group setting as well as for other settings. The TMF will provide this document to interested parties in electronic format.

TMF PHP can recommend resources where these physicians can be evaluated and a corrective plan of action formulated. This evaluation often leads to recommendations for the physician that might help remedy the situation.

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DISTRESSED PHYSICIAN BEHAVIOR

Who or what is a distressed physician?
Sometimes a physician’s conduct is so distressed to the operation of the hospital or the medical staff review process that the value of the physician’s clinical work is outweighed by the negative impact of his or her behavior. Such unacceptable behavior can take many forms including tirades in the operating room, abusive treatment of patients or employees, sexual harassment, or the disruption of meetings. In any case, TMF recommends using the less pejorative and more accurate phrase “distressed behavior” instead of “distressed physician” when medical staffs begin to confront the problem.

Distressed conduct is more than unusual or unorthodox behavior. It typically involves a pattern of behavior characterized by one or more of the following actions.

The physician:
Employs threatening or abusive language directed at nurses, hospital personnel, or other physicians (e.g. belittling, berating, and/or threatening another individual). These attacks usually are personal, irrelevant, and go beyond the bounds of fair professional comment.
Makes degrading or demeaning comments regarding patients, families, nurses, physicians, hospital personnel, or the hospital. The physician’s non-constructive criticism often works to intimidate, undermine confidence, belittle, or imply stupidity or incompetence in his or her victims.
Uses profanity or other grossly offensive language while in a professional setting.
Refuses to accept medical staff assignments or participate in committee or departmental affairs on anything but his or her own terms, or to do so in a distressed manner.
Utilizes threatening or intimidating physical contact.
Makes public derogatory comments about the quality of care being provided by other physicians, nursing personnel, or the hospital.
Writes inappropriate medical records entries concerning the quality of care being provided by the hospital or any other individual. (One may find “cute” illustrations drawn in patient medical records, or other official documents. These communications are designed to impugn the quality of care in the hospital or attack particular physicians, nurses, or hospital policy.)
Imposes idiosyncratic requirements on ancillary staff which have nothing to do with better patient care, but serve only to burden staff with "special" techniques and procedures. Note that we are talking about a pattern of behavior that may or may not overlap a psychiatric diagnosis and/or other impairment such as chemical dependence, major depression or personality disorder. The presence or absence of a diagnosis is important for many reasons, including the ability of the TMF Physicians Health Program, PHP, to help. The presence of a pattern is also very important. PHP usually does not (and generally should not) receive referrals for an isolated incident or very minor instances of distressed behavior.

A hospital is an especially stressful working environment, so outbursts or other misconduct that probably would not be tolerated elsewhere are often excused. If an isolated outburst is followed by an apology, there is most likely not a longer-term problem. There are clearly limits to tolerance, however. When a physician’s conduct disrupts the operation of the hospital, affects the ability of others to get their jobs done, creates a “hostile work environment” for hospital employees or other physicians on the medical staff, or begins to interfere with the physician’s own ability to practice competently, action must be taken.

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When can TMF PHP be of help?

TMF PHP is usually able to help the physician and the referring agency when all of the following are true:

1. A pattern of behavior has been established and documented. The pattern should be clearly documented with examples and consequences to the hospital or clinic. The examples can be used to explore the problem with the physician and look for underlying triggers and issues that can be addressed. Typically, the physician has little or no insight into the effect he or she has on others, or how often the behavior has been a problem. They are focused on clinical and/or systems issues that are often very real and significant, but they are approaching these issues in a destructive and unhealthy way. If PHP has no documentation of specific instances of distressed behavior, it is difficult to help the physician develop any insight into his/her effect on others.

2. There is a treatable condition. PHP is primarily set up to assist with actual or potential impairment. The prognosis is actually best for physicians with a well-defined Axis I diagnosis such as depression, bipolar disorder, or chemical dependence. Axis II personality disorders, such as narcissistic or obsessive-compulsive, often require very long-term treatment, and the prognosis varies greatly. The prognosis for those simply prone to angry outbursts (“impulse-control disorders”) also varies greatly and may depend largely on potential consequences.

3. The physicians are willing to take some responsibility for their behavior and acknowledge that they are at least part of the problem. Rarely will the referred individuals take total responsibility for the whole conflict or problem; in many cases this may not even be appropriate. But if they are willing to look at their own behavior to some degree, PHP can work with them to build on this foundation. If, on the other hand, they are unwilling or unable to look at themselves at all, PHP is not likely to be of much help.

4. The referral is presented and intended as being for help rather than punishment. PHP has no ability or authority to punish "bad behavior”, nor is that PHP’s purpose. Some physicians will view the referral as punitive no matter how it is presented; however, a referral to PHP reflecting a positive, cooperative note will increase the chances of a good outcome. This tone also should be taken in the hospital or clinic’s policy on handling of distressed behavior.

5. The referring agency is willing and able to impose consequences if the behavior does not change. The PHP sometimes gets referrals of physicians who have been given "umpteen chances" to correct a problem. The PHP strives to help such physicians look at the underlying causes of their behavior and ideally they will make changes before consequences occur. But the needs of the referring source and the physicians are best served if there are clear limits and consequences established and enforced.

Summary

-Distressed behavior by a physician may or may not relate to a psychiatric diagnosis.
-The hospital, clinic, or other referring entity should be prepared to impose consequences if the behavior continues unchanged. While it may be appropriate to "cut some slack" if the physician is working on underlying issues, few work settings will tolerate unabated distressed behavior for long.
-The physician with distressed behavior is often unaware of their effect on others. It is common for the physician themselves to be only vaguely aware of "a small problem", while nurses and other physicians around them are busy preparing their resumes.

Other points:

-It's crucial to have appropriate expectations. The causes of distressed behavior do not develop overnight, and it's unrealistic to expect the physician to change his or her behavior overnight with no slip-ups. That's one reason it is important to make the referral to PHP before the environment reaches the point of "zero tolerance" for minor infractions.
-The physician with distressed behavior is often a technically excellent clinician. However, their self-assessment often exceeds reality.

Common causes of distressed behavior:

Chemical dependence: Hidden or occult substance abuse may cause significant distress and dysphoria and present as distressed behavior. If the chemical dependence is treated and the individual is subsequently involved in ongoing therapy their entire personality can improve. However, sometimes substance use or abuse is just a coincident problem and not the cause of the distressed behavior.

Medical problem(s): While medical problems are not usually the cause of distressed behavior, other PHPs around the country have encountered poorly controlled diabetes, Cushings disease, and undiagnosed CNS tumors causing personality and behavior changes. If medical problems are a factor, there will often be an acute change in behavior or personality. Sleep deprivation/fatigue: This is usually due either to the consequences of the behavior (e.g. threatened loss of privileges, etc.), or related to overwork and other self-care issues. In other words, sleep problems are more of a symptom than a cause.

Adjustment disorder: Marital, financial, family, legal and other stresses are often found in conjunction with distressed behavior. Personal stress tends to exaggerate pre-existing personality traits, and it's typically not the healthy traits that blossom! Physicians referred to PHP for distressed behavior often will minimize underlying stress, or say they have "already dealt with it". Unfortunately, life has a way of presenting new and recurrent stresses, and the development of healthy coping skills is necessary.

Personality disorder (or traits): The American Psychiatric Association’s Diagnostic and Statistical Manual – Fourth Edition (DSM-IV) defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" manifested in the person's cognition, emotional response, interpersonal relations and/or impulse control. Personality traits are those noticeable characteristics that do not rise to the level of a personality disorder. Obviously, we all have some pathological personality traits, and the line between "healthy" and "unhealthy" is often fuzzy.

The DSM lists ten distinct personality disorders. The ones most commonly associated with distressed behavior are:

Obsessive-Compulsive
Narcissistic
Borderline
Schizoid
Paranoid
Antisocial

The two most frequently encountered are:
Obsessive-Compulsive (O-C): It can be very difficult to agree on what is acceptable vs. unacceptable behavior. At one end of the spectrum is the individual who is extremely rigid, domineering, stubborn, and so focused on getting the details perfect that they miss the major goal of the activity. The perfectionism interferes with task completion, and the O-C doctor will typically run way behind schedule or be hopelessly behind on documentation. They need to be in control and have trouble delegating tasks.

At the other end of the spectrum is the physician who is appropriately compulsive about patient care. All patients want their surgeon to be detail-oriented in the operating room, or their internist to be compulsive in doing a work-up for disease. Indeed, medicine is increasingly rule-driven, and the consequences of not being appropriately compulsive are steadily rising. The key is in the word "appropriate". The distressed O-C physician typically has trouble accepting input from anyone else as to what is appropriate, and almost always has problems in working out differences of opinion. They tend to avoid their anxious feelings through control and action rather than using introspection or diplomacy. Therefore, development of awareness, tolerance, and alternate coping skills for anxiety is crucial.

Narcissistic:
Many would say that the phrase "narcissistic physician" is redundant. Indeed, physicians are trained and expected to be confident in their abilities, and to forego self-doubt in times of crisis. The trick is to avoid what has been called the "M-Deity syndrome", or pathologic narcissism. DSM-IV criteria for Narcissistic Personality Disorder includes:

Arrogance or “condescending superiority"
Exaggerated sense of achievements and talents
Lack of empathy
Craving for admiration
Strong sense of entitlement

In addition, the pathologically narcissistic physician often is intolerant of imperfection (or perceived imperfection) in others. As with all personality disorders, the narcissist has its origins early in life. Parents may set unrealistically high standards for the child who begins to think of him or herself as "special". The parents typically are unable to emotionally nourish the child, and provide harsh criticism for failure. The child internalizes these attitudes and later is unable to empathize with others, etc. Otto Kernberg characterized the unconscious dynamic as: "I am grandiose because I feel unlovable; I cannot be loved unless I am perfect." While these underpinnings of the disorder do not excuse the problems, insight into the narcissist's deep-seated feelings of inadequacy can help the person begin to change behavior over the long term.

How to document and refer: Proper documentation is crucial in helping PHP reach a successful outcome, as well as for legal reasons. PHP will require the following information from the referral source:

Problem behaviors with as many examples of specific incidents as possible.
An explanation of the referring entity’s disciplinary protocol and where the physician is in that process (e.g. verbal warning, written warning, etc.).
The time frame for corrective action.
A statement noting the consequences for noncompliance with the agency/entity’s own behavior (or employment) contract, what will happen upon a reoccurrence of the behavior(s) or the lack of follow-through with treatment recommendations.
The perceived need for the physician to sign a formal monitoring contract with PHP.

The referral source is also encouraged to do the following:
Require the physician to sign a release of information form to allow the PHP to communicate basic findings and recommendations back to the referral source. (TMF has such forms available.)
Set a time limit for the evaluation to occur.

LEGAL CONSIDERATIONS
At least one court has held that hospitals have a duty to take action in such situations. In Leach v. Jefferson Parish Hospital District, No. 2, 870 F.2d 300 (5th Cir. 1989), the Fifth Circuit Court of Appeals stated, “...(T)he hospital clearly has an interest in providing quality medical care to its patients. If a physician is distressed or has personal problems, the hospital has a duty to intervene.”

Many other courts have reinforced the concept that conduct and behavior are appropriate bases for action. An example is Gordon v. Lewistown Hospital, (Pennsylvania Commonwealth Court, July 24, 1998), where the hospital obtained a on the basis of the Health Care Quality Improvement Act of 1986. Dr. Gordon challenged his 28-day suspension after he was told that one more incident of distressed behavior would result in a suspension. The suspension was imposed after he had a verbal altercation with an emergency room nurse in which he told her to “get off her ass.”

The court said:
Because distressed behavior by a physician at work relates to his or her professional conduct, we reject any notion that the Board did not take its professional review action in the reasonable belief that it was furthering quality health care merely because Dr. Gordon ‘S suspension was not based on incompetence.

The first step in dealing with professional conduct is to implement a policy that makes the hospital’s position clear.

****** TIPS FOR HANDLING DISTRESSED PHYSICIANS
Whatever hope a hospital medical staff may have for moderating a distressed physician’s behavior will be best realized by addressing it the problem immediately, before the attitudes of either party have hardened and while it is still possible that the matter is capable of collegial resolution. Certainly, this is so for the physician, but it is also true for the hospital and medical staff leaders. If the physician knows that his or her conduct is unacceptable and that the hospital and medical staff leaders are prepared to act, future incidents may be prevented.

However, just as surely as it is wise to address behavior problems as soon as they occur, it is also wise to do so with caution. Confronting the physician in a heavy-handed, accusatory manner is likely to invite resentment and possible retaliation. The initial approach should be undertaken as a helpful gesture. At the same time, it must be made clear that it is more than a difference of opinion; that is, if the behavior continues, more formal action will be taken to stop it.

If the Chief of Staff is reluctant to meet with the physician or if, for any other reason, the Chief of Staff or the Chief Executive Officer determines it to be appropriate, the Board Chairperson or another Board member could meet with the physician.

Having a Board member meet with the physician has several advantages. It relieves the Chief of Staff of a responsibility for which he or she may have neither the taste nor the experience. And, when a physician understands that he or she is accountable directly to the Board for his or her conduct, it may be easier to correct the situation in an informal manner; rather, if the physician perceives that he or she would be bending to the wishes of other physicians in matters that the physician considers none of their business, it may be more difficult to do so.

The fact that distressed conduct was addressed immediately also will strengthen the hospital’s position if the physician subsequently challenges the disciplinary action in court. A hospital will want to limit the number of participants in any meeting with the physician, not only to minimize the doctor’s feeling that he or she has been the object of widespread discussion, but also to limit the targets of any attempts at retaliation.

The record should not be a catalog of ineffective oral warnings, however. A hospital medical staff will protect itself by following up the warning(s) with written letters to the physician. These writings help to create a record showing that the medical staff made reasonable attempts to deal with the problem, short of terminating the physician’s medical staff appointment and clinical privileges. This written record also prevents a physician’s later claims that no one had ever discussed with him or her the distressed behavior in question.

It does not require medical expertise to determine whether as a qualification for appointment a physician possesses the ability to “work harmoniously with others….” A recommendation from the Medical Executive Committee (or any other medical staff committee) is not necessary in these situations and should not be required.

The TMF drafted this policy with an eye towards ensuring necessary flexibility for dealing with these situations without immobilizing the medical staff or hospital administrative staff. The policy allows the Medical Executive Committee to refer these matters to the Board without recommendations. However, the Medical Executive Committee may handle the matter.

If the hospital follows the procedure either through the Medical Executive Committee or the Board and it is inherently fair and compliant with the staff bylaws, there is a well-documented record of the physician’s conduct and the hospital’s attempts to deal with it, then in all likelihood the hospital’s action will be upheld should the matter proceed to litigation. There are many court decisions upholding hospitals’ disciplinary actions when confronted with a physician’s distressed conduct. The courts have made it abundantly clear that the provision of patient care in an atmosphere of calm, order and respect for the dignity of all need not be sacrificed to the distressed proclivities of any appointee to the medical staff, regardless of his or her clinical abilities.