Physician
Physician behavior education
I am intrigued about starting a new dialogue with physicians concerning changes in behavior and education. As many of you are aware, physicians behavior can sometimes not represent the values of the various organizations. We seem to want physicians to change without giving them the appropriate training and tools to do so. I believe that many residencies and fellowship programs don’t address this issues and others that relate to it. Diversity in training, sexual harassment, and other major topics are not openly discussed with medical staffs in the same manner that organizations do with employees. There is limited training in residency and then subsequently little or no training in the post graduate phase. I believe that this could help change our culture and would be curious to hear of suggestions or strategies.
Physician behavior is a challenge for all of us. We have started a program where the Chief of Staff (no CMO @ my Hospital) and CEO have an informal discussion with the physician after his first occurrence. If behavior issues continue then a letter of correction action is given to the physician and a copy placed in the credential file. If pattern continues the credential committee will use all letters to determine if physician is going to be reappointed to the medical staff.
In my organization we have policies in place , which includes everyone including providers. There is ZERO tolerance to any of the above discussed. The policies are sent out to all of us , which we have to go through and sign off on it that we clearly understand what is expected of us. Any changes or updates with any of the above we are informed right away.If there is any such complaint , it is investigated and the necessary action is taken. We also go through modules every few months with a program called the “ Language of Caring “ ( LOC) . It is very helpful.
We do hold docs accountable in the same exact way we’d hold staff accountable. It’s not always that simple, as we know the challenges an unhappy doc can bring….however, it’s putting them on notice of expectations from the get-go, and making them aware of their stature, and how they are viewed in the hospitals by the staff, and how their behavior dilutes that authority and respect. Mandatory training is a great idea. It should be spun as a way to help them, not punitive.
Sir William Osler, FRS FRCP, one of the four founding professors of Johns Hopkins Hospital said, “The good physician treats the disease; the great physician treats the patient who has the disease.” Being a physician is much more than diagnosing and treating patients, it’s demonstrating compassionate patient care and a commitment to those patients. So beyond the degrees and training, physicians need soft skills – people skills or interpersonal skills. Research shows that soft skills such as communications and positive attitude and empathy are crucial to the success of a health system. Helping physicians sharpen their soft skills can be challenging.
In order to truly teach soft skills, take learning outside of the classroom. A blended approach is best, with peer-to-peer discussions and leader-led scenarios. You can talk about how to empathize with a patient and effectively communicate their treatment options, but until a physician has the interaction with a live person, they will not fully grasp the skill.
When teaching soft skills, it’s almost always better to teach (and practice) one at a time. Role playing can be very effective for this.
When you bring physicians together to talk about effective communications, active listening, building trust and respect, these soft skills become abstract concepts that can cause learners to lose interest.
So, in peer to peer discussions or leader-led scenarios, focus on one topic at a time, and give actionable steps that learners can put to practice immediately. Instead of saying, “you need to listen better,” try “to become a better listener, it’s important to repeat three vital points back to the person you’re speaking with.” Instead of saying, “try to be more mindful,” try “it’s important to be mindful when talking with patients. Really give them your undivided attention. This means looking them in the eye and being fully present in the room with them. Watch for cues on what might really be happening.”
Discussions and clear suggestions for words and actions will help to solidify soft skills and give learners something to grasp.
Very interessting topic and discussion. We can see that the discussion slowly moved to sanction and inappropriate behavior and how to track them. For sure, it is important and challenging. Yet, in the beggining of the case it was mentionned “a new dialogue with physicians concerning changes in behavior and education”. I am particularly concerned about ways institution [hospital, clinic, medical university hospital, etc.] must adapt themselves to establish an appropriate sustainable dialogue with young physicians. The latter have new expectations and desires [work life balance, fun, democraty in decision, transparency, etc] and we depend on their willingness and work in our institutions. In that sense, I wonder whether one aspect of a new dialogue should not be revising our own procedures, not only telling young physicians what is a good physicians and what is not but also being told what is a good management style of good physicians *what about a “Language of Caring Physicians”.
One major initiative that has made a significant positive difference have been establishing and educating about the expectations in the Just Culture approach across our health system. This has been combined with multiple event review teams across the departments that then refer concerning individual physician behavioral events to the peer review committees for each department.
The other approach that has helped is to modify the initial orientation process for all physicians starting in an employed role with the health system. During the orientation, the core values and behaviors of the health system are clearly shared with each physician as expectations, and the Just Culture introducation has also been incorporated into the orientation process as well. One hopeful future addition to this orientation process is a stream-lined re-orientation of all those physicians already on staff at the health system (both employed and private practice physicians).
Physician Dysfunction can be either of the following: incompetent (lacks the skills in providing care), impaired because of medical/psychiatric/substance abuse and disruptive (they are competent but with limited operational style. Almost all problematic physicians belong to the last which is termed disruptive physicians. According to the code of ethics of the American medical association, disruptive physician is defined as a personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care including actions that interfere with one’s ability to work with other members of the healthcare team. Sometimes physicians are not aware of their behaviour so proper education regarding this topic may help you educate them and proper policy should be in place on how to assess them, then after assessment, their fitness for duty should be determined on whether disruptive physician is still capable of practicing without jeopardising patient safety. There are some principles that can be implemented to help promote positive Working relationships:
– Treat colleagues and co workers as valued individual who deserve to have their points of view listened and validated.
– Respond promptly to calls from those with whom you work and show up for meetings on time. Both behaviours indicate respect for others.
– Make a point of trying to mentalize a coworker’s perspective on a situation, recognising that it may be different from one’s own but equally legitimate.
– Be aware of competitiveness and try to minimise this disruptive effect on the working relationships.
– Always be aware of the hierarchical nature of the the work setting and the power differential that is present even when you think it is not operating.
– Remember that racial and ethnic issues may be the most difficult one to talk about and maybe undercurrents in working groups that are never discussed but are secretly observed by all.
– Give feedbacks to other in private so that it can be heard without the effects of humiliation.
– Be aware that strong emotional reactions occurring toward others may be influenced by individual patients and groups/institutional dynamics that are largely unconscious.
Source: Disruptive Healthcare Provider Behaviour An Evidenced Bases Guide
Author: Rade B Vukmir
A few years ago we began our “Just Culture” journey with patient centered transparency. As long the behaviors are not “criminal” or related to substance abuse, we implemented a process where every case was reviewed by a senior committee and depending on the frequency, severity of the events, we either requested a letter explaining the events, had a cup of coffee” conversation or brought the individual in front of the committee to explain in person their conduct. When we place the patient first, and remove blame from the process, trying to find the real reason why the outburst, we gain the trust of the physicians and employees.
In our experience, the best way to manage this issue is the role model from the top leaders of the institution. If you do want to be respected, respect everyone, if you want to be listened , you must listen first and so on with the soft competences. Of course in a small hospital and with fewer medical schools it is much easier to get involved in the process of physician – education and be able to share the experiences with real patients, real colleagues and develop sensitiviy for the patient´s needs and expectation besides the technical practices.
A very thorough induction program in which patient focus groups are invited to share experiences and expected behaviors from the health care team are important, not only to physicians but to the entire multidisciplinary team.
One last thing we have learned the hard way. How to manage labor relations with the millenials or young physicians taking into considerations the generational gap present. The resentment to authority, the need for frequent recognition and motivational feedback, the need for inmediate sucess and higher positions within the organization etc. It took us time to understand what motivates groups to education, better performance and positive behaviors.
Medical Education course contents were designed a long time back. True, it has and must evolve with time. But with todays dramatically changing environment, perhaps the change in context is somewhat needing an Edit. It would be prudent to imbibe these values and Code of Ethics along with necessary technical trainings like admissible/non admissible, insurance, regulatory, medico legal aspect et al.
thereby combining Medical Knowledge with practical tools for maximising delivery.
Physician behaviors need to be managed starting in their training programs. In medical school there needs to be a didactic component that instructs around the the ‘managerial” and “teaming” components of medicine. During residency key portions should include the same training and instruction that new managers receive around leading, coaching and accountability. Until that occurs we will continue to have physicians employed and voluntary on our medical staffs. At this point a formalized program to have physician to physician conversations around these issues is necessary. This will allow for the “education” to occur help shift the behaviors. Egregious behavior needs to be dealt with quickly by the medical staff leadership which will start setting the tone and pathway forward. Taking advantage of cultural issues, like the current #metoo movement creates a platform for educating physicians around their law and by extension their own behaviors.
Like others, I think behavior training should begin much earlier. But as we are in the middle of this it does not provide a solution for now. Clearly setting the culture of the organization is a start, however, there must be a system to hold physicians accountable for behavior that by others would be deemed inappropriate. Typically, these physicians know their behavior is not acceptable but there is not a system to make consequences. An idea is to bring physicians together and ask them to develop a code of conduct policy that includes discipline measures as well as team goals for doing well.