No Assholes Allowed

I recently had the opportunity to listen to a CD, The No Asshole Rule, based on book written by Robert Sutton.

We have all had known one, and we have all been one at times – the asshole.  Even though we have all been assholes from time to time only a few of us would qualify as what Sutton calls a certified asshole: displaying episodes of asshole behavior over time directed towards multiple individuals.

Certified Assholes Are Not Limited to Certain Professions

Certified assholes are in every type of business, Sutton provides numerous examples.  My sixteen year old daughter saw The No Asshole Rule CD cover in my car one day when we were driving to an out of town engagement.  She asked a few questions and quickly identified several teachers who are certified assholes.  She is smarter than most of us, she quickly ejected all the assholes out of her life.  Medicine, I am sorry to say, has a large number of assholes.  We refer to physician assholes using a more tolerable term – physicians displaying disruptive behavior.

I first became aware of clinicians showing what we now call disruptive behavior (they were also being certified assholes) in medical school. The culture in medical school accepted asshole behavior especially among prestigious faculty.  Faculty were assholes to residents, residents were assholes to medical students, and medical students in turn were assholes to nursing students.  I personally do not believe the culture produced any new assholes, but it did allow the latent assholes to fester and develop into full blown certified assholes.

Certified Assholes Clinicians Are Often Involved in Sentinel Events

My first dealings with clinician assholes after finishing my medical training occurred when I became a facilitator of root cause analysis of sentinel events in a hospital setting.  A sentinel event is an unexpected occurrence that places the patient at risk for death or serious physical injury.  During a root cause analysis, we ask a series of questions to get beyond the apparent obvious cause of the event to the root causes.  I was amazed at how often a lack of communication was a contributor to the sentinel event. Clinicians who would qualify as certified assholes were at times involved with the event. 

Sutton makes a good case for a large negative economic impact assholes make on an organization.  Had he concentrated on a medical organization, he would have also detailed a large negative patient safety impact.  We began to appreciate clinicians and staff often hesitated to call a certified asshole for questionable issues or point out little errors or inconsistencies.  This lack of communication at times grew to a sentinel event. In reviewing reports from other organizations, clinicians involved in sentinel events have pointed to the episode as a prime example of staff incompetence rather than recognizing it was a direct consequence of his or her certified asshole behavior.

Clinicians Who Are Certified Assholes Are a Danger to Patients

At about the time the hospital organization was recognizing the impact of clinician behavior on patient safety, I assumed a leadership role in the medical group providing the majority of the hospital’s medical staff.  Our certified assholes tended to be very productive; in fact, management had previously tolerated their behavior partly because of productivity.  As we struggled to effectively alter their behavior, we became aware of a program at Abbot Northwestern Hospital in Minneapolis, started by Dr. Kent Neff for troubled doctors.  Dr Neff found clinicians were not recognized as a danger to patients until they had done considerable damage.  Their behavior had been recurrent, ongoing and had affected multiple individuals. Neff’s description of a troubled (now termed disruptive) clinician is nearly identical to Sutton’s definition of a certified asshole.   Neff authored a book, Managing Physicians with Disruptive Behavior, recommending a series of steps useful for confronting and managing clinicians who exhibit disruptive behavior.  His recommended approach is similar to the approach detailed by Sutton.

Past Behavior is a Predictor of Future Behavior

Unfortunately, the negative patient safety impact disruptive clinicians impart on patient care is wide spread because the medical profession has enabled the behavior.  We can go through the pain of addressing the issue within our organization but we can also take action by not allowing asshole clinicians to join our medical staffs or enter our medical groups.  For too long clinician behavior has not been considered a significant factor of clinician competence, but it is.  Both Sutton and Neff point out certified asshole behavior is recurrent.  We can use past behavior as a predictor of future behavior.  We now use a process called “Selecting Winners” to deliver a behavior based interview process when hiring new clinician and staff employees. If a clinician shows prior or current evidence of disruptive behavior, they are not hired.

The cost of certified asshole clinicians in a medical organization are considerable and on going.  In addition to patient safety issues, they are surrounded by staff positions with a higher than average staff turnover and they consume a disproportionate amount of management time.  Afflicted clinicians will have much thicker quality assurance folders and credential folders than normal clinicians.  A recent medical journal article (Papadakis MA, Teherani A, Banach MA, et al. Disciplinary Action by Medical Boards and Prior Behavior in Medical School. N Engl J Med. 2005;353:2673-2682, e22.) suggests the behavior extends to back to at least medical school.  Dealing with disruptive clinicians can be intimidating and is a skill not common among medical leadership.  Intervention is difficult as many of the involved clinicians tend to be very productive and are other wise very competent.

Sutton’s book has significant impact for medical organizations. It is one more body of work detailing the evils of certified assholes while providing a mechanism for an organization to confront the issue.   The No Asshole Rule: Building a Civilized Workplace and Surviving One That Isn’t can be used by management as a call to change medical group culture and should be required reading for medical professionals.

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Disruptive Behavior

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