Recently, I was fortunate to be an invited guest at the 1st annual George Washington University Graduate Medical Education retreat. I was especially intrigued by a breakout session on how to deal with the disruptive resident or attending, a topic that was the theme of my own institution’s GME retreat earlier this year. I observed a terrific role play by a psychiatrist Charles Samenow, who played the on-call medicine resident, and gynecologist and Associate Dean for Graduate Medical Education Nancy Gaba, who played the role of a medical student who was asked to call the medical resident. I looked on as the resident mistreated a student was told to page the resident to admit a patient from the ER to the medical floor by cutting her off and berating her for calling him before she had seen the patient. Later, one of the audience members was asked to role play how to handle providing feedback to this resident. She demonstrated the ‘bulldozer’ approach of taking the issue head on while the resident tried every trick in the book to avoid the issue at hand (redirect conversation, blame others, etc.).
While this was all make believe, unfortunately, disruptive behavior in the medical workplace is a real problem. And, the most common offenders are physicians. Behaviors could range from the egregious (harassment, verbal or physical abuse, lying, intimidation) to not complying with hospital standards (failing to do dictations for example). Disruptive behavior, especially intimidation, is also a patient safety issue since no one feels like going up against a bully. As a result, the Joint Commission has stepped in, mandating that hospitals have a process to deal with these disruptive docs and raise awareness about unprofessional behavior in the medical workplace.
Fortunately, a team from Vanderbilt led by Dr. Gerald Hickson, has developed a program to remediate disruptive physicians called Patient Advocacy Reporting System (PARS®). The main premise of the program is to take unsolicited patient complaint and look for outliers – these outliers are the bad eggs that are responsible for more than their share of malpractice lawsuits and cost the hospital money down the road. The first intervention is a ‘cup of coffee’ conversation with a trusted peer. This peer will review a standard report that shows the doc is an outlier. Apparently, the cup of coffee works! Most docs respond to this intervention and don’t show up on the outlier list again. However, a small fraction of docs fail this intervention and need more intense remediation or even are let go due to their pattern of unprofessional behavior. Over 30 hospitals, including our own, have signed on to this program, in large part because they can show that this process reduces malpractice costs. As a result, Dr. Hickson’s team has even shown that some doctors who were let go at one institution ‘reappear’ on the grid at another institution in their data. Scary huh?
So far, the PARS® program only deals with data from patients. This may miss some of the disruptive docs who have a terrific bedside manner, but still berate others in the healthcare workplace, like nurses or medical students. That is why many programs are now looking to augment reporting by these groups. For example, the Liaison Committee on Medical Education, which accredits medical schools, is very concerned with the roughly 15 to 20% of graduating students that report mistreatment in the medical workplace. They now require that medical schools develop policies and procedures for students to promptly report mistreatment without fear of retaliation and also educate faculty about student mistreatment. As a result, our medical school has appointed Ombudsmen who discretely investigate student complaints of mistreatment and serve as student advocates in these instances.
However, asking students whether they were mistreated is sometimes very complicated due to differing perceptions of what is appropriate in the context of patient care. For instance, a physician may shout at a medical student to move out of the way during a cardiac arrest or emergent patient situation to ensure that the patient receives urgent attention. There’s always confusion about whether asking a student to get coffee for the team is mistreatment. As a result, my colleague, Dr. Shalini Reddy and I have developed the following guide to help explain to students what mistreatment is (Student Guide to MISTREATment). For any educators out there, there are also plenty of video examples from our favorite medical TV shows to raise awareness of the issue.
So the next time you are asked to get a cup of coffee by a trusted friend, it’s also a good time to think about your behavior.
Vineet Arora, MD