Guest post by Dr. Michael Rosenblatt. Dr. Rosenblatt is a retired podiatrist on the west coast.
Those older physicians reading this certainly know the World has changed, perhaps some of it for the better. If you served your residency years ago you will remember “disruptive” attendings. Sometimes our own student egos were publicly trashed with snide, cruel comments. You remember these people angrily react with RN and hospital employee staff. An incorrect instrument pass ended in the instrument flying through the air and smashing against the OR wall.
Times have changed for “disruptive” doctors. They more typically face the brunt of angry and anonymous complaints from nursing and hospital staff. These can lead to peer-review and even board actions against you. I think it’s labeled “toxic work environment.” Professional peer review is an onslaught you must avoid. There are no published rules for professional peer review. There are no safeguards for doctors on the wrong side. The only protections are for those who sit on the board.
There is temptation for some teaching doctors to disparage and criticize students and residents for their poor choices and mistakes. Since it is you who takes ultimate responsibility for those errors, your attitude makes eminent sense. And you still want to try to teach them.
Many physicians come from the right hand of the socio-economic curve. Your own parents directed you to achievement and did not suffer incompetence, especially yours. It is not surprising that you view incompetence as a threat to your patients. And you are right to think that.
But you will not do any good for your patients if you are barred from the hospital, ER and OR and no longer permitted to practice due to your own “lack of empathy” and social skills, which others say damage your ability to take care of patients. Sham peer review can very easily end with that result.
Reading Corporate Culture
Many physicians struggle with reading corporate culture. Every institution has its own and it often requires considerable observational skills to auger into it.
When I was a first year resident, my department head led a Grand Rounds presentation on the General surgical ward. Dr. Crawford, although a DPM, presented each patient in a demonstration of general-surgery competence that was nothing short of breathtaking. The other MD residents also accompanied us.
Not surprisingly, I wanted to follow that lead. When I was asked to conduct rounds, I stayed up all night reading all the charts and preparing myself. I presented the rounds, stepping ahead to “introduce” each patient and taking questions.
Later that day, I was called to a small private meeting room where all of the senior residents were sitting at a table. I thought I was to be “congratulated.” How wrong I was. I was excoriated for stepping ahead of the senior resident to introduce the patients. I had no “right” to do this and it would not be tolerated.
This cost me. I never attended another Grand Rounds out of fear. I apologized and left the room, red faced and angry. This was utterly confusing. If they asked me to conduct Rounds, why would I not be “entitled” to lead them? There was no point in discussing it. At the time, I was the only DPM resident at the VA Hospital. I just shut up. It was the wise thing to do. Later on, in the coolness of passing time I thought it might also have been a “test” to see if I “fit in.” Fortunately, nothing like this happened again.
Criticizing an Employee for Errors
We have a duty to our patients; to keep them safe and do our best to obtain excellent clinical outcomes. Mistakes occasionally happen. Our job is to prevent them. Our job is also to learn from them and not repeat them. Educating employees about their mistakes is both necessary and dangerous. I think one way to handle this is to connect your own consequences with their errors. In my own Medicare Certified Surgical Center I authored operations Manuals composed of check lists. If an employee falsified a check list, that could result in my losing accreditation. Unfortunately, this occasionally occurred. I simply and patiently explained to the employee that if she did this again, I would probably lose my accreditation. She would be out of a job because I could no longer afford to pay her. You too can find a way to explain your own personal exposure to an employee’s error, even if you work at a hospital. Many doctors adopt a zero tolerance approach to such actions. It’s a fine line creating a culture where employees are comfortable disclosing errors so all can learn versus keeping patients out of harm’s way. There is no perfect answer.
Firing an Employee
Once I had to fire an employee for incompetence after just the very first day. I won’t go into detail, but in a diverse workforce, there can be unintended misunderstandings based on race, gender, sexual orientation, religion, etc. . I could very easily see a complaint filed against me. I don’t intend any generalizations. All employers have been confronted by incompetent employees of every background.
During the firing, I explained to her that I was in “financial trouble.” I could no longer afford to keep her, and since she was only recently hired, she lacked sufficient seniority. I explained I too had been fired in the past. This was a “sad and distressing event for me; and I lost sleep over it.” I wished her good luck, but said this would be her last day with us. It’s never easy terminating an employee.
Firing employees requires skill, understanding and empathy. You may or may not enjoy firing someone; but that is no place to be an ogre. It is also important to remember that some of these people may want to use any excuse to retaliate. You cannot always guess the mental status of people whom you work with.
Criticizing a Young Resident
Once during a joint replacement surgery on one of my patients, the senior resident removed considerable excess bone and caused the substrate to be very fragile and possibly unsuited to the implant.
(After the surgery) I privately and politely explained the concerns I had about the bone he excessively ground down. Ultimately the patient was fine and the implant held, but it was an important lesson for the resident, whom I had entrusted with the entire procedure. Fortunately that was his only error.
Even more importantly, I explained the “arching” of the bone at the location he worked on and that he needed to review the anatomy of that joint to “see for himself” how easy it is to remove too much bone.
But when he was assigned to my cases in the future, I no longer let him operate. Once was enough. I didn’t make a point about it. I just did the procedure myself. Message sent. I never saw him again on my schedule.
Avoiding Explosive and “Controversial” Behavior
Nowadays, physicians must be in control of their behavior at all times, even at home. You are being judged constantly. An MD friend of mine was reported to CPS by a neighbor for “spanking” his teen son. He had to appear on a misdemeanor charge before a judge. That could result in a Board appearance at the least, or even worse.
For this reason, you might consider dedicating yourself to “mandated unobtrusive and legal behavior.” Outlets allowed for others are just not allowed for physicians. There are enormous political/cultural differences between the different geographic regions of the US. If you have a “personal life” that might lead to criticism, even if legal, you might consider efforts to keep them private. If you decide you want to be one of the first professionals to ”test the waters”, you may also be the first to pay the price for your “advancing” it. If this doesn’t work for you, consider moving. Lots of people do. Life is difficult enough without struggling with social agendas.
I have mentioned it before, but now is a good time to review the Karpman Drama Triangle on the Internet to do some soul searching and learn behavioral skills. Best of all, you can study this in private without disclosure to anyone else, and learn a great deal. (http://en.wikipedia.org/wiki/Karpman_drama_triangle)
The world is now very different. If you engage in “disruptive” behavior and end up facing a board for peer review it could mean the end of your professional career. Often the genesis of such a review can seem exceedingly unimportant or even a forgotten “error” on your part in reading the culture you are a part of.
Finally, even a powerful CEO and well placed senior hospital physician may find him/herself at the wrong end of sham peer review. Being a member of senior staff does not shield you from complaints of lower paid, anonymous employees passed in the hallways. Asserting your superiority may have a future, painful cost. “Thanks and I appreciate you” goes a long way toward keeping you where you are, with your hospital badge firmly attached to your lab coat. You may consider this obsequious and unnecessary. Our culture does not.
As an accomplished, highly educated adult you undoubtedly shouldered many painful and personally difficult experiences. It is not my intention to lecture on personal behavior, comportment or criticize. I am likely older than most here and also a member of a minority medical profession (podiatry) whom some may not even think of as a physician. This has granted me a widened perspective. I have also served as a defense consultant for physicians who have faced sham peer review. That is a road you do not want to take.
Good luck. It’s tough out there.
Michael M. Rosenblatt, DPM
(Dr. Rosenblatt is not a lawyer or a behavioral specialist. This article is presented for your education and personal interest. If you have any questions regarding legal or behavioral issues, contact licensed professionals in your own area.)
Medical Justice Notes: [The days of throwing instruments around and getting away with it are over. That said, the practice of medicine is stressful. Everyone blows off steam sooner or later. A well timed apology for a demeaning remark can head off badness down the road. Your team is your team. If everyone understands you are trying to take care of the patient, making up when the dust has settled should not be taken personally. Do not let grudges fester. Finally, it’s important to have a team approach to patient safety. Not all mistakes are due to individual errors. Some mistakes are due to system errors. Those working with you should feel comfortable speaking up when they perceive danger is around the corner. That voice may save your patient. That voice may save you.]
Thanks for your thoughts on this important topic. I have been around a few years myself and find these observations very helpful and spot on!
Experienced, working physicians in hospitals, especially employed doctors or hospitalists (employed or on contract), must read your wise words of wisdom, Dr Rosenblatt, again and again. Tyranny from the hospital C-Suite, hospital managers and black suit docs, is increasing as part of the War on Doctors. Independent, experienced physicians speaking up in behalf of their patients are at greater risk now than ever for being framed on false charges and fired summarily for no professional reasons. Medicine and surgery is now owned by regulators, including testing industries, administrators (some with limited medical knowledge), and insurers, not physicians or university leaders. Medical leadership no longer follows the best scholars anymore! Some hospital executives with legal protection under the 1986 “Patient Safety” Act may be ingenious and even creative in avoiding responsibility when events go south or problems occur due to institutional problems. Hosp execs have become expert at shifting administrative problems onto physicians through curious peer reviews and nonsense charges these days. I suspect such executive tyranny will force some physicians to unionize. I suspect hospitalists who bear the brunt of EHR regulations and hospital regulatory curios while trying to provide excellent patient care willl unionize first. If doctors unionize for fair practices, in order to have a voice at the bargaining table, they should have at least TWO unions representing them. Like the teachers unions, a monopoly on one bargaining group is an invitation to more tyranny. Thank you, Dr Rosenblatt, for an excellent article. Medical students need a few courses near graduation from their local business schools on adjusting to corporate culture in order to survive in US hospitals.
Having had 25 years experience with “doctors with problems” ( mostly SUD related ) at the hospital board level, the county medical society level, the state medical society level, and on a state physician health program board. I applaud Dr. Rosenblatt’s thoughtful, insightful, and non-judgmental approach to discussing this increasingly important topic.
Tolerating or looking the other way at physician behavioral issues in the work place is not going to occur in today’s world. We, as a profession, must re-educate and re-train ourselves to meet this new level of accountability. Such behaviors are almost never really helpful, and as Dr. R gives examples, there are alternative ways to address those situations which in the past resulted in outbursts of abusive language/behavior. And as he notes, the behavior on our part is perhaps not always intended as harsh, or abusive, but it can be so perceived.
Kudos for a very timely essay.
Mistakes in Medicine but particularly in surgery, can be painful and devastating not only to the patient but also to the conscious physician who is trying to do the best he can for the patient. Traditionally, physicians and surgeons have been made to believe that we are the “captain of the ship”. Yet, truly, is just a myth. We are captains of nothing but our skills and free will. It is a well known fact that most errors are system errors over which we lack control. They arise from lack of cooperation between people taking care of people. They compound because of mandates issued by policy makers far removed from the bedside. Some of these policy makers lacking both knowledge and empathy have the power to conduct sham peer reviews to silence those physicians that dare to speak up.
We, physicians are held accountable only when there is money to be made in the process. We are held accountable either through meritless malpractice lawsuits or through crafty schemes to make us subservient to interests that have little to do with good patient care. It is not surprising then that the spirit of the peer review process has been subverted and used against those whose motivation is to do what is right for a given patient. Other times independent practices have been financially destroyed when they choose not to be assimilated by hospitals and health care systems. As a society, we will ultimately pay a dear price if we fail to address the repeated violation of ethical principles.