When it’s the doctor who misbehaves

Is the physician untrained? Unable to follow procedure? Or just stubborn? Diagnose, then act.

By Derek Preece, MBA

“Doctor, you can’t talk to patients like that!” The practice administrator’s forceful directive was followed by a clear explanation. Patients in the close-knit community in which the doctor practiced were not going to accept physicians who used salty language in the clinic, especially when directing those curse words at their children, no matter how unruly the kids were. The response from the doctor was immediate and defensive: “Well, if parents would control their kids during the exam, I wouldn’t have to correct them.” There was no recognition from the doctor that he played any role or was responsible for the parents’ anger, neither did he admit that his swearing was worse than the children’s fidgeting. Soon, word spread in the community that he was inappropriate during exams, and that began affecting his practice’s reputation.

Protect the practice

Most shareholder and physician employment agreements address what happens to a doctor who loses his medical license or is convicted of a crime, but how should a practice deal with a problem-physician whose difficulties do not fall under the automatic dismissal heading? As ophthalmology groups get larger through mergers, acquisitions and the addition of young doctors, the frequency of problem doctor events will also increase. Practices, therefore, need to have systems in place to help offending physicians correct aberrant or unhealthy behaviors.

Common problems encountered with doctors include disrespecting staff, coding improperly and documenting issues, and not being punctual or showing up regularly. Each of these problem types requires a diagnosis and prescription if the doctor is to be helped—and the practice is to be protected.

Different diagnoses, different scripts

Usually, when a physician has a recurring problem, it’s due to one of the following three reasons:

1. The doctor is untrained.

2. The doctor is unable.

3. The doctor is unwilling.

Each reason requires a separate prescription for successful treatment.

A number of years ago, I helped several doctors in a practice who were concerned that their partner was not documenting patient care correctly. It appeared that the doctor was coding her exams at a higher level than permissible. They had raised the topic in doctors’ meetings, but the situation did not improve. A relatively brief investigation revealed that she didn’t understand many coding rules and didn’t realize that she was not including sufficient documentation in her charts. In this case, the physician was simply untrained; the prescription was to provide additional and better training for her. A coding consultant was brought in to perform a chart audit—for all the doctors—and she was taught how to correctly record the details of her exams and to match those with the proper CPT codes.

We often think that because someone has been told once how to do something, his training is complete. But, training is much more involved than simply telling or briefly explaining. Most of us need repetition, spaced over a period of time, to retain what we have learned, and to eventually use what we have learned. It is necessary to gain a clear understanding of complex topics so we can change our habits. Therefore, for the first diagnosis, providing the prescription of additional training is often all that is required.

The Nonconformist

Sometimes, though, excellent and consistent training is provided and the doctor still does not conform, despite being aware of the parameters of acceptable behavior. So, the physician is either unable or unwilling to change the offensive conduct.

A classic case of this occurred about a decade ago in a mid-sized practice. The doctor in question had reasonably good relations with his technicians, but frequently was at odds with billing and front desk personnel. His rants at seemingly random employees had become a serious problem, with several experienced and capable staff members resigning from the practice rather than wanting to remain the target of his vitriol. He and the group’s senior physicians had many conversations about his outbursts. The administrator spent significant amounts of time attempting to train the doctor in the principles of appropriate staff relations. When confronted with specific incidents, the doctor usually agreed he was out of line; but, he didn’t seem able to control his outbursts. A few years passed with nothing resolved. It became clear he was unable to refrain from making harsh and damaging comments.

The typical prescription for someone who is unable to perform in the manner expected of him is to move that person into a position in which success is attainable. In this case, it wasn’t possible to move the doctor to another position in the practice, so he was effectively removed from contact with the billing department and the front desk staff. He was not permitted to discuss any issues with those employees; instead, he was directed to raise his concerns only with the administrator, who would investigate and take appropriate action as needed. It took a few weeks for him to adjust to the new communication strictures, but the administrator and managing partner applied firm and steady hands, helping him comply with the new rules.

The intransigent MD

In some cases, a doctor has all the training needed to perform well and is capable of making the needed changes; but, he is simply unwilling to correct his aberrant behavior. This problem was illustrated in a group practice in which one partner routinely asked staff to cancel patient appointments with little or no notice. Often the reason for the cancellation was flimsy—a last-minute decision to play in a golf tournament or to take a quick vacation to a sunny beach. No consideration was given to his lost production that increased the overhead burden for his partners, the hours the staff would have to spend rescheduling patients, or the inconvenience to patients who would have to rearrange their calendars (and to the friends or family members who provided rides to the appointments). Staff members began to resent making the phone calls, especially when patients on the receiving end didn’t mince words about having their appointments canceled, once again.

Frank and sometimes heated exchanges between the doctors failed to correct the problem. So, the partners voted to add a new allocation method: A “citizenship” clause was inserted into each owner’s employment agreement that fined the doctor $500 in pay for canceling a clinic day with less than a 90-day notice. When that failed to curb the physician’s abuses, his partners were faced with a new question: Do we terminate the physician for his bad behavior, or do we just live with the consequences? These included losing staff members and patients who were offended by his irresponsible actions.

A diagnosis of unwilling to change prompts a tough prescription choice: live with the problem, and the fallout, or dismiss the perpetrator. If the doctor is not yet a partner-owner, the decision is usually easier and the actions needed to affect a termination much simpler. To remove a partner, the road is often more difficult and involves purchasing that physician’s ownership interest. This can be a long and expensive process, especially if the practice is not adequately protected in the shareholder agreements. For this reason, it is critical that young doctors on a partnership track be vetted carefully—before they are admitted into ownership status—not only for their clinical and surgical abilities, but also for their character.

Process of elimination

When a serious problem with a doctor exists and the diagnosis is not immediately clear the practice has to go through a process of elimination to determine which of the three categories applies. In the case of the physician-partner whose affinity for cursing offended his patients, his partners first made sure his training in the cultural norms of the area was sufficient. They provided one-on-one meetings with practice managers and the managing partner to discuss the problem. When that didn’t work, they initiated a series of patient surveys so the doctor could see the negative comments about him in the patients’ own words. He improved for a while, showing the training had some effect, but long-term changes proved elusive and the diagnosis finally was clear: He was simply unwilling to change. Because the practice could not put up with the inappropriate behavior, the other partners decided to terminate him.

While termination is almost always an option, diagnosing the problem and then attempting to provide assistance in changing aberrant conduct is a process that can sometimes salvage an otherwise intolerable situation. OM

REFERENCE

About the Author
	Derek Preece is a principal and executive consultant with BSM Consulting, an internationally recognized health care consulting firm headquartered in Incline Village, Nevada and Scottsdale, Arizona. For more information about the author, BSM Consulting, or content/resources discussed in this article, please visit www.BSMconsulting.com.