Disrupting the Disruptive Physician

Will Latham, MBA
President, Latham Consulting Group, Inc., Chattanooga, TN

One would think (or hope) that by the time anesthesiologists complete their training and begin practicing, they have mastered not only their clinical field, but also the ability to work well with others and behave appropriately. If you’ve spent any time as a member of an anesthesia group, however, you know that it is rare for all of the physicians to “behave” all of the time.

Examples of disruptive behavior are easy to see: physicians putting each other down in front of CRNAs or other staff; inappropriate conversation with hospital administration; damaging comments made to those outside the group; lack of confidentiality regarding group matters; unprofessional behavior in the operating room; and beyond. In more than 25 years of consulting, we’ve either seen or heard it all.

Unfortunately, most anesthesia groups don’t know how to address or resolve such situations. However, while it is impossible to resolve all issues of interpersonal conflict or inappropriate behavior, anesthesia groups can take three important steps to improve their chances of success:

1. Develop a Code of Conduct.
2. Create a system to deal with disruptive physician behavior.
3. Conduct periodic peer evaluations.

Code of Conduct

Developing a Code of Conduct is an important first step in creating a system to deal with disruptive physician behavior. A Code of Conduct is the agreed-upon standards of behavior expected of group members. It sets out, in general terms, the reasonable standards and duties professionals are expected to observe. It is the sort of “rules of the game” that the members of the organization are required to follow.

Anesthesia groups create a Code of Conduct for the following reasons:

• As a vehicle to communicate what the group finds important about physician behavior and conduct
• As a method to improve the chances that the group will continue to have the freedom to govern itself 
• As a method to hold errant physicians in check without making them feel they are under personal attack 
• As a vehicle to remove personalities and private opinions if it becomes necessary to intervene in a situation

What should be considered in a Code of Conduct? Medical groups tend to focus on the following questions:

1. What behaviors do we expect of each other? What is acceptable to us? What is inappropriate?
2. What are some of the “unwritten rules” that guide our behavior that that we should write down so they are universally understood?
3. What are each physician’s rights and responsibilities?

In developing the answers to these questions, it can be useful to break down the answers into various categories, as shown in Exhibit 1. 

Exhibit 1

Categories for a Code of Conduct

• Relations/interactions between the physicians in the group
• Relations/interactions between the physicians and individuals outside of the group. Consider:
  • Patients
  • Surgeons
  • Hospital staff
• Patient care responsibilities 
• Participation in practice management responsibilities
• Confidentiality of practice information
• How the group makes decisions and what decisions mean
• Compliance with applicable fraud, waste and abuse laws/regulations
• Adherence to legal contracts within the group
• Support of group-established plans 
• Goals and policies

Exhibit 2 provides an example of such a document. 

Exhibit 2

Sample Code of Conduct
XYZ Anesthesia Group Code of Conduct

Preamble

Our dealings as a group are guided by our Code of Conduct. We are committed to promoting and encouraging individuality and each member’s strengths, as long as they are consistent with high-quality patient service and the group’s larger goals.

Relationships Among XYZ’s Physicians

• If an XYZ physician has a problem, conflict or issue with another physician in XYZ:
  • The XYZ physician will not complain about the situation with others inside or outside of the group, or make condescending remarks about group members to others inside or outside of the group.
  • The XYZ physician will address the issue with the other physician privately.
  • If the issue is not able to be resolved, the XYZ physician will use the Professional Practice Committee and associated process to work through the issue.
• XYZ physicians will support other physicians in the group and will not “back-stab” each other.

Relationships with Patients 

• XYZ physicians will treat patients with respect at all times. This will include:
  • Involving patients in decision making.
  • Not acting in a condescending or demeaning manner.
  • Treating the patient as a customer.
  • Respecting the patient’s privacy and confidentiality.
• XYZ physicians will present a united front to the patient. XYZ physicians will not put down other XYZ physicians or their plans to patients or others.
• XYZ physicians will support one another to patients. If an XYZ physician disagrees with another physician’s approach, they will take the issue to the physician privately.

Relationships with Other Physicians

• XYZ physicians will treat other physicians as customers.
• XYZ physicians will focus on the needs of patients.
• XYZ physicians will be diplomatic when a physician does not understand the XYZ physician’s point of view. 
• XYZ physicians will keep physicians abreast of clinical or medical issues.
• XYZ physicians will support all other XYZ physicians in their relationships with their physician colleagues. If an XYZ physician disagrees with another physician’s approach, they will take the issue to the physician privately.
• XYZ physicians are responsible for the decision making in the rooms they cover. It is up to that XYZ physician to make the final decision regarding the patient. In turn, other XYZ physicians will support the decision.

Relationships with Hospital Administration

• XYZ physicians will support the policies of the hospital or seek to change them as a group.
• Official communication with the hospital will go through XYZ’s president.

Relationships with Hospital Staff

• XYZ physicians will treat hospital staff with respect at all times.
• XYZ physicians will follow the hospital’s chain of command when dealing with issues and problems.
• XYZ physicians will not make condescending remarks about hospital staff in public.

Relationships with CRNAs

• XYZ physicians will treat CRNAs with respect at all times.
• XYZ physicians will provide the CRNAs with a chain of command, and will operate through that chain of command.
• XYZ physicians will medically direct or supervise the CRNAs.
• XYZ physicians will involve CRNAs in the anesthetic management of patients.

Relationships with XYZ Employees

• XYZ physicians will treat XYZ employees with respect at all times.
• XYZ physicians will provide XYZ employees with a chain of command, and will operate through that chain of command.

Relationships with All

• XYZ physicians will not verbally or physically assault anyone. 
• If an XYZ physician is approached by those outside the group with a problem: 
  • They will support the group to the outsider.
  • They will bring the issue back to the group for discussion.

Patient Care

• Once a patient care policy has been adopted by XYZ, all XYZ physicians will implement that policy.

Practice Management

• All XYZ physicians are expected to participate in practice management activities when asked. 
• The group will find a job for everyone.

Work Effort

• When XYZ physicians are in the hospital, they will work hard.
• If an XYZ physician is needed, they will make themselves available to work. 
• If an XYZ physician is in a position of responsibility, they will make themselves easy to be found.
• XYZ physicians will respond to pages in a timely fashion.

Confidentiality

• XYZ’s business is strictly confidential. This means:
  • All information is to be considered confidential unless the group agrees otherwise.
  • Information is not to be discussed with people outside of the group (except for spouses).
  • Information is not to be discussed where people outside the group might overhear it.

Decision making

• XYZ physicians will make practice decisions in accordance with the group’s by-laws.
• Once a decision has been made by the group, all XYZ physicians will implement it, abide by it and support it, even if they disagree with the decision.

Other

• XYZ physicians will adhere to all of the group’s legal contracts.
• XYZ physicians will comply with all applicable fraud, waste and abuse laws and/or regulations.*

While such statements may seem simple and self-evident to some, we have found that many physicians need the expected behaviors set out in black and white before they understand that they have to comply with them. If expectations are left as unwritten rules, many physicians will see them as optional.

Further, this tool gives group leaders something to hang their hat on when they must confront disruptive behavior. The matter is no longer a situation of “your opinion versus my opinion” about appropriate behavior. Instead, the discussion becomes “here is what you are doing compared to what the group has agreed to in the Code of Conduct.”

Developing a Code

What is the best way to develop a Code of Conduct? The most important step is to include all physicians in its development. If they are not involved, they will see the document as something imposed on them and will be less likely to adhere to the agreements. The best time to develop a Code of Conduct is during the group’s annual planning retreat. If physician misbehavior is particularly acute, the group might consider a separate meeting to focus on the Code of Conduct.

Dealing With Disruptive Physician Behavior

The first question often asked after development of a Code of Conduct is “What do we do if someone breaks the rules to which we have all agreed?”

There’s no doubt about it, self governance is tough. It is made even tougher when you consider that most physicians are actually conflict avoiders who take the attitude “I will not judge lest I be judged.”

However, the group must find a way to govern itself, and part of selfgovernance is being equipped to deal with disruptive physicians.

One effective method is to establish a Professional Practice Committee. This Committee exists to consider physician conflict, physician performance and quality assurance concerns for the practice. The Committee will either work to resolve issues on its own or bring matters to the attention of the Board for resolution. In most situations, this Committee does not have the power to censure or take action against a physician. Instead, it serves as an intermediary step or process to try to resolve issues before significant steps are taken.

A policy for such a Committee may be found in Exhibit 3.

Exhibit 3

Sample Policy on Professional Practice Committee

MEMBERSHIP

Three physicians elected annually by the Board in July.

QUORUM AND ACTION

Quorum is two of the three physicians.

Action on a matter may be taken on a simple majority.

In the event that a member of this Committee instigates or is subject to action by this Committee, the other two Committee members should appoint a member of the Board to serve as interim Committee member for that issue only.

MEETINGS

This Committee meets monthly to consider issues brought to its attention.

RESPONSIBILITIES

This Committee exists to consider physician conflict, physician performance and quality assurance concerns for the practice. The Committee will either work to resolve issues on its own or bring matters to the attention of the Board for resolution.

PROCESS

1. If a concerned physician has a grievance with another physician (the “physician in question”), or is concerned about quality issues related to another physician, their first step is to discuss their concerns directly with the other physician.
2. If the matter is not satisfactorily resolved in step 1, the concerned physician should handwrite their concerns and present this information to a member of the Committee.
3. At the next scheduled meeting, the Committee should discuss the issue and take one or more of the following actions:
   • Decide if the issue has merit for further action, and if not, communicate this information to the concerned physician.
   • Establish any necessary data-gathering to determine if the concern has merit and what, if any, further action should be taken.
   • Meet with the concerned physician and physician in question, together or separately, to gather information or counsel the physician.
4. If the matter is not satisfactorily resolved in step 3, the Committee should develop a recommendation to the Board for further action to resolve the issue. Such a recommendation could include discipline up to and including expulsion from the group.
   • The Board will consider such issues at its next regularly scheduled meeting.

Peer Evaluation

The third leg of the stool is for the group to conduct periodic peer evaluations.

We believe that when physicians are in a group practice, they are (or should be) accountable to each other. Many top-performing groups set up a formal peer evaluation process for all the physicians in the group, including shareholders.

A peer evaluation process can take many forms and address many issues (clinical as well as behavioral). Here are a few suggestions about how to get started:

1. If you are new to peer evaluation, or if the members of the group are hesitant, set up the first evaluation so that each physician is the only one who sees their feedback.
2. If you use a form to collect information, be sure to allow room for written comments as well as checklists.
3. Set up the system so that it is conducted annually and becomes one of the group’s standard operating practices.
4. Use an external third party to compile the responses. Consider using your accounting firm to do this as they are used to working with confidential information.
5. Check with your attorney to ensure that the information collected is not discoverable in any type of legal process.
6. Make sure that the process includes both shareholders and non-shareholders.

The Time to Act Is Now

In today’s competitive anesthesia market, groups cannot allow an individual physician’s disruptive behavior to jeopardize exclusive contracts, stipends and other arrangements. If you don’t already have them in place, now is the time to develop a Code of Conduct, a system to handle outliers, and a peer evaluation system to prevent and resolve disruptive physician situations.

* The Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) have extensive physician compliance resources available on their respective websites. It is recommended for any provider group to use these regulatory resources to round out this section on compliance with more detail demonstrating alignment with both CMS and the OIG for physician practice management compliance.

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Will Latham, MBA, is President of Latham Consulting Group, Inc., which helps medical group physicians make decisions, resolve conflict and move forward. For more than 25 years Mr. Latham has assisted medical groups in the areas of strategy and planning, governance and organizational effectiveness, and mergers, alliances and networks. During this time he has facilitated over 900 meetings or retreats for medical groups; helped hundreds of medical groups develop strategic plans to guide their growth and development; helped over 130 medical groups improve their governance systems and change their compensation plans; and advised and facilitated the mergers of over 120 medical practices representing over 1,200 physicians. Mr. Latham has an MBA from the University of North Carolina in Charlotte. He is a frequent speaker at local, state, national and specialty-specific healthcare conferences. Mr. Latham can be reached at (704) 365-8889 or wlatham@lathamconsulting.com.