Interview with Dr. Bob Sockochoff – Dealing with Clinicians Displaying Dysfunctional Behavior

This interview is part of a series of posts about  Disruptive Behavior.  Dr. Sockochoff has developed expertise in dealing with this difficult issue through focused training and real life experience. I am delighted he has chosen to share his experiences with us.

Please  introduce yourself.  I’m Bob Sockochoff, I’m currently the Regional Vice President for Ministry Medical Group, Northern Region. I’m a family practice physician who has been in family practice for 27 years and over the last 5 years I’ve taken on a greater administrative role.

Bob, in your role as Administrative Physician you’ve increasingly been dealing with physicians displaying dysfunctional behavior.  Could you tell us a little bit about the journey that you’ve followed and how you learned the skills necessary to deal with these issues?  Dysfunctional behavior amongst physicians is one of those issues that frequently gets ignored,  and in fact, under certain circumstances, has been accepted as “normal” behavior. Dr. Mo Nunez, our previous CEO, developed an initiative to provide us with some more education and tools around this issue.  You could say we had a backlog of dysfunctional physician behavior within our medical group.  He enlisted the help of Dr. Kent Neff, who is an expert in dealing with these issues.  Kent is a Psychiatrist and author with many years of experience in the field.  He provided educational sessions for medical and administrative leadership.  He helped us develop standards and processes to help us address these problems more effectively. We termed the road map the Principles of Partnership.  (I will place the Principles of Partnership into a separate post early next week)

What are the steps you now follow when you become aware of dysfunctional behavior that needs to be addressed?  The first thing we do is try to judge the severity of the behavior and determine from that initial assessment how quickly we need to react. If you are faced with some obviously outrageous behavior then we react immediately to intervene and stop it.  Often though, what we found was that an individual episode wasn’t particularly outrageous but the cumulative over time was toxic.  Often there was a pattern of disrespectful behavior that may have repeated itself over many, many years.  Occasionally the behavior has propagated itself throughout multiple members of a department.  The Neff approach is simple and respectful:  1)Good person 2)Unacceptable Behavior 3)Consequences and Future Expectations. The general approach would be to set up a meeting with the physician that has been exhibiting the behavior.  The meeting generally should be on administrative or neutral turf out of the office space the provider.  We always arrange for two or more people (a mix of medical directors and administrative partners) to meet with the provider.  We arrange a pre-meeting to discuss individual roles in the conversation – sometime even going so far as to role play.  When you first get into the room with the physician,  you ask them to agree to certain ground rules. The way I phrase it would be like this, “Dr. X, Thank-you for coming.  I have some important issues that I would like to discuss with you today. I would ask that you give me time to present all the information that I have and I would ask that you not to interrupt me. After I’m finished presenting my information we’ll have plenty of time to discuss and get your side of the story.  Can we agree to that?”  It is important to get the physician’s agreement before proceeding.  If they do start to interrupt, you can say, “Please Dr. X, you agreed you would let me finish.  Please let me continue and we’ll have plenty of time for your comments after I’m done”.  We would start out the conversation with a statement as to the value of the physician, “Dr. X, you are a good person and an excellent physician.  We appreciate your contributions to your patients and our organization.  But there has been some aspects of your behavior recently that are unacceptable”. The word unacceptable is a word that Dr. Neff suggests using.  We then go on to detail the specific behaviors that are unacceptable.  An example might be, “On May 10th there was an incident while you were talking to your medical assistant. You raised your voice, made threatening gestures, invaded her personal space.  You then slammed your fist on the desk.  Later that afternoon, your MA was seen to be in tears by her coworkers”.  After cataloging the specific behaviors then you move on to options regarding consequences and plans.

As far as the consequences, it depends on the severity, chronicity and repetitive nature of the behavior.  Sometimes, in physicians that have good insight, all it takes is just some consciousness raising and a gentle warning that the behavior should not be repeated.  If the behaviors are more severe an assessment may be necessary.  Assessments can be voluntary or mandatory.  A request for a voluntary assessment takes place in a situation where you have an individual that has a fair amount of self awareness.  This option is framed in a helping, rather than disciplinary, way.  “Dr. X, you’re a good person and a good physician but you really appear to be struggling lately.  Sometimes we all face difficult situations like this. We would like to offer you an opportunity to go for an assessment, so you can figure out how to best address your situation. The organization would be happy to sponsor the assessment.  We can facilitate you getting time off from your practice for the assessment.  We would ensure confidentiality surrounding your decision.”

If the behavior is clearly unacceptable it may be necessary to insist upon a mandatory assessment.  Again, you want to concentrate on the behavior and separate the behavior from the person.  The behavior then becomes a problem that you can work on together, as opposed to some sort of personal failure.  “Dr. X your behavior is so disruptive we feel it’s a threat to you and the organization.  Under these circumstances we must insist that you go for an assessment.”  Such conversations should be accompanied by an official letter that contains the same information as the conversation.  The letter should be presented to the physician after the conversation is completed.  On rare occasions, legal counsel may be involved in the drafting of the letter, especially when disability or ADA issues are involved.

Bob, it sounds like that these can be extraordinarily difficult and emotional situations to deal with. Since you’re often times dealing with clinicians who have exhibited dysfunctional behavior over the course of time many, administrators go into these type of sessions expecting a low success rate.  Do you have a sense of how often your intervention is successful and the dysfunctional behavior is improved? Well, it depends on the physician, the behavior and the nature of the underlying problem. Dr. Neff identified certain types of dysfunctional behavior that had higher degrees of success – a better prognosis.  It turns out that around 20 to 30% of the time physicians with dysfunctional behavior will be have a psychiatric diagnosis.  The most common problem is depression and depression tends to be fairly treatable.  Alcoholism and addictive behavior amongst physicians is double that of the general population and is highly treatable. Dr. Neff commented that he was always happy to see alcoholism at the root of the dysfunction because you had a greater degree of success.  Some other types of psychiatric problems such as bi-polar disorder and personality disorders are more difficult to treat, yet some of those are recoverable as well.  In our own experience, in situations where clinicians have had assessments and received treatment, we’ve been successful around half the time regarding a successful return to work as functional members of their departments.  You might say 50% doesn’t seem all that great, but in the past we really only had two options; one option was to continue to tolerate the behavior and the other option was fire the physician and have them leave the organization.  Our approach has given us a third option with a reasonable degree of success.

There are plenty of good reasons to try, including economic reasons, recruiting reasons, cultural reasons, and the sense that it’s the right thing to do.  Everyone deserves a chance.  If you are successful, you end up with a dedicated and grateful employee that helps with employee commitment and culture.  Physicians generally have a difficult life, they have demanding jobs and it is easy to become frustrated and act in ways that are disrespectful.  If they see one of their partners struggling and see their organization responding it promotes good will and trust within with the organization.

Our policy is to cover the cost of the assessment but make any treatment the responsibility of the physician.  We will work with them in terms of arranging practice coverage, FMLA, sick leave, short term disability etc.  On occasion we’ve made some special arrangements for short term loans to help the physician with their financial needs surrounding treatment.

Bob, thank you very much for your time.  I think many individuals will find this information extremely helpful to them as they begin to develop their own plans as to how to deal with dysfunctional clinicians.

You’re very welcome Pete.

In upcoming posts I will be presenting the contents of a PowerPoint that was presented to a medical staff establishing expectations of respectful behavior and the Principles of Partnership used by Ministry Medical Group.

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Disruptive Behavior

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