When doctors go bad

What do you do when doctors go bad?

Of course it happens. Doctors are human beings, and they have the same faults as other human beings. They can be rude, short-tempered, and hard to work with. They can make enemies in the workplace. They can make mistakes with patient care, and sometimes those mistakes are serious. Some doctors commit sexual harrassment. Some doctors are addicted to alcohol or other drugs. All these things happen. But what can anyone—a clinic, a hospital, or the profession at large—do about it?

Is it a Quality problem?

In a sense this sounds like a Quality problem. Certainly when a doctor goes bad, his patients (and colleagues) aren't "getting what they want." But in the same breath we have to admit that it is a very unusual kind of Quality problem!

• As noted, doctors are human beings; and we don't know nearly as much about human behavior as we do about machines. So while a machine may require no more than simple adjustment to correct its behavior, humans are more complicated.
• In fact, humans have free will, and therefore cannot be simply adjusted the way a machine can. So if a doctor is behaving badly, we have to get his consent before we can expect him to behave any better.
• Why do we need his consent?
• Partly to respect his innate human dignity, that he is free and not a slave.
• And partly because if he does not consent, he or his friends may take steps to frustrate the changes we want him to make.¹ 
• There may also be barriers of an organizational kind.² 
• Complainants might fear legal or organizational retribution.
• The offending doctor might be sufficiently valuable to the organization that management takes his side in a complaint.
• The delay built into processing a complaint might give the offending doctor time to build alliances, and might contribute to a sense in the workplace that the offending behavior is considered "normal."

What has been done so far?

"Disruptive behavior" by doctors is not new. I found one article that surveyed the relevant literature, all the way back to a news item in the New York Times from June 20, 1875.³ But it seems that systemic responses are a comparatively recent development. Back in the late 1970's Dr. Kent Neff, a psychiatrist working in Portland, Oregon, chaired a committee created by the Oregon Medical Association to address concerns about alcoholism among doctors working in hospitals. In 1994, he used the lessons learned from this committee to take charge of the Professional Assessment Program at Abbott Northwestern Hospital in Minneapolis, a program to help hospitals and medical groups with troubled doctors.⁴ Neff has continued to champion this topic in the years since then, as have others of course. In 2012, he prepared a presentation⁵ for The Foundation for Medical Excellence, summarizing the research and practical steps that had been taken at that time. And over the last two decades (at least in the United States), the medical community has been making progress on this front.

Why is it happening only now? I don't know. Studies suggest that disruptive physician behavior (DPB) is not uncommon,⁶ and it is obviously detrimental both to the workplace and to patient outcomes. And yet it seems that even during a century when medicine became ever more professionalized, this topic was overlooked or brushed to the side. According to one study, part of the problem is that there are at least 207 different terms used to describe DPB, so that systematic literature searches are prohibitively difficult. It is possible that this question belongs in a history of medicine, and not in a Quality blog. In any event, the topic of how to respond to DPB is alive today.  

Can we approach this as a Quality problem?

Actually, yes! That's more or less the approach that has been taken. After what I said above about how unusual a Quality problem this is, you might be skeptical. On the other hand, remember that I have characterized the 8D process as "a way to apply the scientific method to solving your organization's problems." And in fact, it turns out to be general enough that we can apply it here too.

So, for any medical organization (hospital, clinic, or other medical provider) to innoculate itself against DPB, the steps look something like this:

Ground rule: Don't blame individuals

• Neff's research is absolutely clear that disruptive physicians are often good doctors (at least potentially) who are caught in a maladaptive system. He insists that the process must be respectful, confidential, and based on objective data. All of these provisions are critical parts of getting the consent of the affected physicians to the new culture that you plan to implement.

D1: Name a team

• Because the solution involves a system-level approach, there will have to be a team to implement it.
• More critically, the team has to include top management, because the work needs their support. They are the only ones who can break down the organizational barriers that might stand in the way. Therefore the administration must clearly understand the cost—in dollars!—that DPB drains from the business every year in operational friction, on top of the risk of huge damages in case of patient harm. And remember—when I reviewed the Quality culture of the Mayo Clinic two years ago, one of my findings was that their "whole Quality initiative had unflinching management support over the long haul."    

D2: State the problem

• Spell out clearly what exactly constitutes unacceptable behavior, and also what constitutes acceptable behavior. It sounds extreme, but there are some physicians who have never had these things articulated for them.
• As Peisah et al. state: "How can those who lack internal loci of control or appropriate social and behavioural skills (for whatever reason), behave appropriately if nobody has articulated what behaviour is expected of them, or the consequences of such behaviour?"

D3: Contain the problem

• Every organization will do what it must to keep the doors open while working this topic.

D4: Find the root cause

• A lot of research has already been done on this question, and mostly the root causes aren't different from one organization to the next. Among the common characteristics of doctors who exhibit DPB are:
• High intelligence but poor emotional or social skills.
• A history of suffering emotional neglect or abuse. 
• A maladaptive personality.⁷ (Naturally some of these features interrelate.)
• Genuine psychiatric disorders (e.g., depression).
• "Life in the fast lane."
• Medical illness.
• That having been said, it's still early days. Peisah et al. lament that "much of the abundant literature pertaining to DPB is theoretical, with little empirical investigation."
• This is a long list of causes. There does not appear to be a single root cause that can be proven responsible because turning it on and off turns the effect on and off like a light switch. But Peisah et al. argue, "We make this complicated because it is, and because ironically, the more contributors to the problem, the more there are potential targets for remediation, again justifying our position of hope."

D5: Brainstorm possible corrective actions

• Mostly not needed, because some well-defined corrective actions already exist.

D6: Implement corrective actions

• Staff education and training. Identify champions within the staff for the new culture.
• Write policies and procedures to define a consistent reporting and review process supported by audits of adherence.
• Access to support for physical and mental health, and to interventions when necessary.

D7: Assess risks and learn lessons

• Reflect on how the system attracts and fuels bad behavior.
• Institutionalize the new culture through constant repetition. Again, remember our earlier consideration of the Mayo Clinic. In fact, the literature on DPB highlights the Mayo Clinic in particular as an organization where this kind of cultural change has been successful.⁸  

D8: Close the 8D and thank the team

• It's hard to go wrong with pizza.

Of course there are subtleties that are specific to medical care. And clearly there is a whole literature addressing this topic with no explicit connection to the Quality discipline.

But I find it reassuring that the basic techniques of Quality can be made to fit this kind of problem too, unusual though it be. It's another indication that these tools really are as broadly applicable as we have always said they are. So that's nice to know. 

__________

¹ There is an extensive discussion of this risk in Markian Hawryluk, "Doctors under the influence," The Bend Bulletin, Thursday, December 9, 2010. A successful Oregon program for alcoholic doctors, one which guaranteed their confidentiality and emphasized recovery, was replaced by a program with a more punitive focus. The intent was to prioritize justice for patients who had been harmed. The unintended consequence was that doctors stopped volunteering for the program, and also stopped referring their colleagues to it. 

² Citations to professional medical literature will generally be made with a URL. (And when possible, I will direct the URL to the specific relevant section of the article.) But the first time I reference an article, I will give the formal citation as a footnote. For this point, see specifically: Peisah C, Williams B, Hockey P, Lees P, Wright D, Rosenstein A. Pragmatic Systemic Solutions to the Wicked and Persistent Problem of the Unprofessional Disruptive Physician in the Health System. Healthcare (Basel). 2023 Sep 1;11(17):2455. doi: 10.3390/healthcare11172455. PMID: 37685490; PMCID: PMC10487014. I will refer to the authors of this article in the text as "Peisah et al." As for the article's title, Wikipedia defines a "wicked problem" as "a problem that is difficult or impossible to solve because of incomplete, contradictory, and changing requirements that are often difficult to recognize." 

³ Yes, more than a hundred and fifty years ago. That date is not a misprint. The article surveying the literature is: Petrovic MA, Scholl AT. Why We Need a Single Definition of Disruptive Behavior. Cureus. 2018 Mar 18;10(3):e2339. doi: 10.7759/cureus.2339. PMID: 29796352; PMCID: PMC5959733. 

⁴ Atul Gawande, "When Good Doctors Go Bad," New Yorker, July 31, 2000. (Published in the August 7, 2000, print edition.) 

⁵ Kent Neff, "Understanding & Managing Physicians With Disruptive Behavior," The Foundation for Medical Excellence, Organizational Professionalism, October 19, 2012.

⁶ "The data presented show that disruptive behaviors are frequently observed in the daily life of health professionals, and compromise the quality of care, the safety of the patient, and can lead to adverse effects." See: Moreno-Leal P, Leal-Costa C, Díaz-Agea JL, Jiménez-Ruiz I, Ramos-Morcillo AJ, Ruzafa-Martínez M, De Souza Oliveira AC. Disruptive Behavior at Hospitals and Factors Associated to Safer Care: A Systematic Review. Healthcare (Basel). 2021 Dec 23;10(1):19. doi: 10.3390/healthcare10010019. PMID: 35052183; PMCID: PMC8775368. 

⁷ Compare, for example, this article: Bucknall V, Burwaiss S, MacDonald D, Charles K, Clement R. Mirror mirror on the ward, who's the most narcissistic of them all? Pathologic personality traits in health care. CMAJ. 2015 Dec 8;187(18):1359-1363. doi: 10.1503/cmaj.151135. PMID: 26644545; PMCID: PMC4674404. 

⁸ Mueller PS. Incorporating professionalism into medical education: the Mayo Clinic experience. Keio J Med. 2009 Sep;58(3):133-43. doi: 10.2302/kjm.58.133. PMID: 19826207.