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From the SelectedWorks of William Marty Martin

September 2004

Managing Unmanageable Physicians: Leadership,Stewardship, and Disruptive Behavior

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18 SEPTEMBER•OCTOBER 2004 THE PHYSICIANEXECUTIVE

This approach decreases objectivity and increases therisk of favoring some doctors and not others. In short,physician executives must assert the right to be properlyequipped before being held accountable for any outcomes.

Given the role of physician executives as managersand organizational stewards, they must be prepared tocarry forth the following responsibilities efficiently, effectively and ethically:

• Distribute, communicate and educate every employeein the organization on the appropriate policies andprocedures on disruptive behavior.

• Consult with internal and external experts in law,behavior change and impaired physicians as necessary.

• Monitor all investigations and cases of disruptivebehavior to comply with both the letter and spirit ofthe law.

• Review all allegations and complaints seeking to iden-tify patterns in order to minimize disruptive behavior.

• Update all policies and procedures.

The overwhelming majority of physician executivesare accountable for patient outcomes, patient safety and patient satisfaction at both the individual and theaggregate levels.

To that end, any behavior that detracts from patientoutcomes, patient safety and patient satisfaction must beaddressed. In addition, all managers, including physician

One of the more alarming and stressful challengesphysician executives face is how to deal with disrup-tive behavior. Regardless of the type of organizationor location, physician executives are accountable formanaging disruptive behavior and the associated consequences of this behavior ranging from patientoutcomes to minimizing legal risk exposure.

There is no magic bullet. There is no panacea. Onthe other hand, there are concrete ways to decrease theprevalence of disruptive behavior while at the same timetackling the issue head-on for the benefit of all stake-holders, including the physician who is displaying the disruptive behavior.

Role, rights and responsibilities

Former President Harry Truman is often quoted forsaying, “The buck stops here.” This statement applies toevery physician executive. At the end of the day, thephysician executive is responsible and will be heldaccountable for both the prevention and expeditious resolution of disruptive behavior by physicians.

Physician executives should position themselves totake the lead in dealing with disruptive behavior, especiallyas state medical boards and other non-physician health careexecutives, including CEOs and CNOs, are increasingly taking matters into their own hands.

The ability to minimize and effectively manage disruptive behavior must be built on a foundation of supporting policies, procedures, processes and structures.The absence of this infrastructure places physician execu-tives in the heat of battle without the proper equipmentto carry out their responsibilities.

Moreover, the absence of a supporting infrastructuresubtly signals to the physician demonstrating disruptivebehavior that this will be handled on a case-by-case basisas an individual personnel matter.

Managing Unmanageable PhysiciansLeadership, stewardship and disruptive behaviorBy Timothy Keogh, PhD and William Martin, MPH, PsyD

Physician executives would undoubtedly prefer tospend the bulk of their time inspiring great employeesand building productive teams instead of strugglingwith disruptive physician behavior. Explore ways todiminish the frequency and intensity of disruptivebehavior in your organization and identify your role,rights, responsibilities and accountabilities as a physician leader.

IN THIS ARTICLE…

Dealing with Disruptive Behavior

THE PHYSICIANEXECUTIVE SEPTEMBER•OCTOBER 2004 19

executives, are held accountable for providing a safe working environment, according to theOccupational Safety and Health Act(OSHA) and a “discrimination-freework environment” according toTitle VII of the Civil Rights Act, aswell as other statutes at the federaland state levels. Also, every organi-zation and each profession has itsown set of internal accountabilities.

It is clear that physician leaderswill be held accountable for theirorganization’s vision, mission, values,code of conduct and bylaws, as wellas for the standards of proper con-duct within the profession of medi-cine. In short, accountability is morethan a set of external statutes andrules. Accountability mandates acall to deliberate action on the partof the physician executive.

Taking action

One of the more challengingtasks facing physician leaders is toknow when to intervene and whento sit back and monitor from a distance.

The bad news is that no formu-la or algorithm exists. However,there are relatively clear signpoststhat suggest the need to take action.What are these signposts? A usefulframework is what we refer to asThe Ripple Effect of ExecutiveAction. How does The Ripple Effectof Executive Action work?

1. Identify all individuals, patientsand processes that are impactedby the disruptive behavior. Thegreater the number of individu-als impacted, the greater the callto action.

2. Highlight the probable risks toall individuals impacted. Thegreater the risks, the greater thecall to action.

3. Conduct a cost-benefit analysisof acting versus doing nothing.The greater the benefits of actingversus doing nothing, the greaterthe call to action.

4. Select a way to intervene eitherthrough coaching, mediating,referring or disciplining.

The next step in deciding to takedeliberate action is to face an uglyreality. The ACPE Physician BehaviorSurvey found that 38.9 percent of therespondents agree that “physicians inmy organization who generate highamounts of revenue are treated moreleniently when it comes to behaviorproblems than those who bring inless revenue.”

At a minimum, this finding sug-gests that four out of 10 physicianexecutives acknowledge the disparatetreatment or the inconsistent applica-tion of policies and procedures basedupon financial factors alone.

Physician executives mustdecide to uphold the policies andprocedures regarding disruptivephysician behavior regardless ofrevenue generated and other demo-graphic or financial factors that may result in favoritism.

In deciding when to act andwhen to sit back, physician execu-tives need to think about twoimportant leadership questions:

1. What do I unknowingly commu-nicate to others?

2. How can I make sure that I amunderstood?

Most of us don’t have an accu-rate answer to the first question. Dopeople listen to you because ofyour position and your authority inthe organization, or do they listento you because of the clarity ofyour statements, the incisiveness ofyour thinking and the helpfulness ofyour suggestions?

Most people believe they arelistened to because of the latter rea-sons. But the actual answer may bea combination of the two.

Taking deliberate action beginswith deciding to act based on youranalysis of The Ripple Effect ofExecutive Action, then asking

The physician executive is responsible and will be held accountable for both the prevention and expeditious

resolution of disruptive behavior by physicians.

20 SEPTEMBER•OCTOBER 2004 THE PHYSICIANEXECUTIVE

yourself the above questions tomake sure that any action you takewill not be misinterpreted—and,finally, listening carefully to hear allsides involved.

Four tools to tackle problem behavior

Physician executives mustleverage their best leadership skillsto expeditiously resolve disruptivebehavior:

• Coaching

• Mediating

• Referring

• Disciplining

The common theme among allfour of these skills is to target behav-ior: first to reduce or eliminate unde-sirable behavior, second to increaseor bring forth desirable behavior.

The focus is never directedtoward the person, only toward thebehavior. It is far easier to changebehavior than it is to change personality.

Coaching is one of the fourrecommended executive actionsthat physician leaders ought toundertake. In fact, coaching hasincreasingly been recognized as acore leadership competency in allindustries, including health care.

Recently, the Harvard BusinessReview published a landmark articleentitled “Coaching the Alpha Male,”by Kate Ludeman and EddieErlandson that suggests that leadersmust confront alpha males who dis-play disruptive behavior.

“Organizations become dys-functional,” the authors say, “whenpeople avoid dealing with a difficultalpha and instead work around himor simply pay him lip service.”1

The authors advise using the following techniques to coach alphas:

• Capture their attention

• Demand their commitment tochange

NOW HEAR THISGood listening and communication skills arekey to dealing with behavior problems

Listeners may be influenced just as much by the wayyou say things as by what you say. Your style of communi-cation may be more obvious to others than you may think.

When people listen to you, whether they are yourcolleagues, your staff, your boss or the disruptive physi-cian, they are listening to the words you use, but they arealso reading the nonverbal signals you are sending. Thetone of your voice, the way you set your eyebrows, thedistance of your chin from your chest as you speak andthe decibel level at which you speak are all data pointsyour listeners intuitively use to gather meaning.

Those listening to you are probably only vaguelyaware that they are monitoring these non-verbal signals,but the signals convey a cumulative message that adds asmuch as 55 percent to the meaning of your words.

In dealing with a disruptive physician, it is crucial for you to have some insight into your personal commu-nication—both verbal and non-verbal styles. Physicianexecutives are often better at analyzing the behavior ofothers than they are at analyzing their own behavior.

It is particularly important to understand how yourbehavior changes when you are tired, hurried or stressed.These internal conditions become obvious to others fromyour facial expressions, your tone of voice, the volume youuse, the brevity of your comments and a range of attributesthat are readily apparent to others, but may be less apparentto you.

Some common communication blind spots we fre-quently notice in others are:

• Cutting people off before they are finished speaking

• Taking too long of a turn when speaking to someoneand not letting them get a word in

• Multi-tasking when we should be listening to someone

It is critical that physician executives demonstrate andmodel a non-judgmental way of listening and makingsense of what they have heard in order to select the best approach to resolving disruptive physician behavior.

So the answer to question #1, “What do I unknow-ingly communicate to others?” is complex and needssome personal insight.

To answer question #2, “How can I make sure that Iam understood?” One practical way is to make sure thatthe listener is “formatted.”

Formatting the listener is an aspect of being listener-centered. It is a check to make sure that you and your listener are on the same page. Just as you cannot copy a

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THE PHYSICIANEXECUTIVE SEPTEMBER•OCTOBER 2004 21

• Communicate in a way that they understand

• Tell the truth fast and hard

• Ignite their competitive strivings

This does not suggest that allphysicians displaying disruptivebehavior are alpha males or alphafemales. However, when dealingwith an alpha personality, here aresome suggestions:

• Avoid social talk—Skip the pre-liminaries. As a matter of fact,alpha types tend to avoid peopleat work who use a lot of socialpreliminaries. Too much chitchatmakes them crazy. With alphas,a little conversation goes a longway.

• Skip the details—The alpha typeis highlight-oriented rather thandetail-oriented. Too many detailstend to complicate their abilityto use their strength, which isquick decision making.

• Bring something to hand over—Use structure in the form of bul-let points or a chart, a graph ora table. Alpha types want infor-mation they can use right away.They are readily persuaded bydata that are presented visually.

• Include steps—Because takingaction is a strong point for alphatypes, play to their strengths bysuggesting a few steps that canbe taken right away.

Even with these suggestions,results don’t always come rightaway. Ludeman and Erlandson sug-gest that those who use the coach-ing approach should be patient.“Changes in behavior typically beginto show in three to six months asthe client harvests low-hanging fruitfrom our initial coaching effects.Sustained change takes about a year.But the goal of coaching is tochange the entire team dynamic, not

simply to treat the alpha as an indi-vidual problem.”1

If physician executives can findsuccess when coaching alphas, thencoaching other types will be a lotless challenging and distressing.

Mediation is a form of conflictmanagement that is typically used insituations where both parties agreeto seek the counsel of a neutralthird party who will serve as aguide to assist in reaching a mutual-ly satisfying agreement to resolvespecific issues.

Physician executives can playthe role of a mediators in certaincases involving disruptive behavior.However, the following conditionsmust be firmly established prior toassuming this role.

• Both parties must voluntarilyagree to participate.

• Both parties must demonstrateearnest efforts toward achievinga mutually satisfying agreement.

• Both parties must attempt toresolve the clearly defined issuesusing this process alone.

• The physician executive must beable to consistently act as a neu-tral third party and take owner-ship for the process and not forthe outcome of the process,which belongs to the two parties.

Referring is another option.Similar to what happens in the clini-cal practice of medicine, referring isnot a public declaration of incompe-tence or lack of caring, but recogni-tion that the patient requires aresource that cannot be provided bythe practicing clinician.

This same logic applies to man-agerial situations. Do not riskattempting to be the Renaissanceperson as a physician executive.

Depending on the assistancerequired, some potential experts forreferral are human resource profes-sionals, executive coaches both for

document onto a disk or CDunless the disk or CD is first for-matted, you cannot copy orplace your words in the listener’shead unless you provide clearverbal guidelines to focus theconversation.

In other words, don’tassume anything. When it comesto unambiguous communication,the listener needs structure.Before you begin your conversa-tion with the disruptive physi-cian, collect any data that showsthe gap between the expectedperformance of your organiza-tion and the physician’s actualperformance. Base your conversation on that data.

The importance of providinga suitable, conversational formatfor the listener was shown in anexperiment to discover how fre-quently speakers use formatting.

Linguists Charlotte Linde andWilliam Labov conducted anexperiment called the New YorkCity Apartment Experiment.1

They set up an office in NewYork City as if they were censustakers and asked volunteers todescribe the layout of their apart-ments. They found that 97 per-cent of the subjects describedtheir apartments in a room-by-room fashion as if they were taking the listener on a mentalwalking tour through the apart-ment without regard for how the listener was able to visualize thelayout of the rooms.

For the speaker, this mentalwalking tour was an efficientway to visualize and describeall of the apartment’s rooms. For the listener, however, it wasquite difficult to visualize the lay-out. Having never actually seenthe apartment, the listener hadno context and the speaker didnot give any structure to describethe layout of the apartment.

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22 SEPTEMBER•OCTOBER 2004 THE PHYSICIANEXECUTIVE

the disruptive physician and/or thephysician executive, mediators,mental health professionals andattorneys. Regardless of the setting,it is often wise to seek the advice oflegal counsel to mitigate legal risks.

As is true with any consulta-tion, it is important to keep thelines of communication open and tocollaborate in the assessment, inter-vention and evaluation stages ofthis process.

It is particularly important inmanagerial situations that issues relat-ed to confidentiality, conditionalemployment and other legal mattersbe clearly identified prior to establish-ing a relationship with any referralsource. It is also important to clarifywho the client is because the clientmay be different from the individualwho is paying the referral bill.

Disciplining is the consequen-tial process when coaching, mediat-ing and referring fail to yieldexpected results, or for those situa-

tions in which the single behavior isso egregious that discipline is thefirst response.

Disciplining is not to be associ-ated with punishing. They are notthe same. In fact, disciplining is amore tailored coaching process inwhich the physician executive clearly spells out the range of consequences—both positive fordemonstrating the expected behav-ior and negative for continuing thedisruptive behavior.

A key success factor when dis-ciplining is to make certain that thephysician executive has access toconsequences. For example, whencoaching and mediating have failedto work, the physician executivemay find that the physician display-ing disruptive behavior did an endrun to neutralize all consequencesthat the physician executive wasabout to initiate.

To avoid this problem andensure access to consequences, go to

your boss and other key stakeholdersin the power hierarchy prior to disciplining to make sure that youcan impose specific consequences.

In the end, preventing andmanaging disruptive behavior isdirectly proportional to your organi-zation’s underlying performancemanagement system and associatedpolicies and procedures.

Physician executives dealingwith disruptive behavior should beable to clarify their roles and respon-sibilities and act accordingly, beingcareful to act as stewards of organi-zational resources rather than “lonewolves” against other lone wolves.

Managing disruptive behavior is one of the most stressful andchallenging tasks that any physicianexecutive faces, but the rewards ofdirectly addressing this behaviorwhen it first occurs reaps many dividends for patients, for staff andfor fellow physicians.

Timothy Keogh, PhD, isclinical associate profes-sor in the Department of

Health Systems Management, School ofPublic and Tropical Medicine, TulaneUniversity Health Sciences Center, andadjunct professor, A.B. FreemanSchool of Business, Tulane Universityin New Orleans, La. He can bereached at 504-988-3837 ortkeogh@tulane.edu.

William Martin, MPH,PsyD, associate professor,Department of

Management, College of Commerce,DePaul University in Chicago. He canbe reached at 847-574-4765 or martym@depaul.edu.

Reference

1. Ludeman K and Erlandson E. “Coachingthe alpha male.” Harvard BusinessReview, May, 2004.

What did the other three percent of the subjects in this experimentdo? These three percent began their descriptions by stating some simple,organizing pattern—a format—around which the listener could mentallyview the rooms.

For example, the speaker would say something like, “Well, my apart-ment is in the shape of a rectangle with the living quarters on the left andthe sleeping quarters on the right.” Then the speaker would proceed on to amore detailed description of the layout of the rooms.

By using a geometrical shape to provide formatting, it was easy forthe listener to visualize and mentally organize the rooms. There was struc-ture to the conversation. Three percent of the subjects in this experiment didwhat good communicators do and what physician executives must remem-ber—ground your listener by using a structured conversation that is non-judgmental, mutually understandable and listener-centered.

It is interesting to speculate why only 3 percent of the subjects in thisexperiment provided formatting when they described their apartments. Itmay be that for most of us it is difficult to be listener-centered; that is, it isdifficult to stop and think about the listener’s need for structure.

By Timothy Keogh, PhD and William Martin, MPH, PsyD

Reference:

1. Linde C and Lebov W. “Spatial networks as a site for the study of language andthought.” Language, Issue 51, 1975.

THE PHYSICIANEXECUTIVE SEPTEMBER•OCTOBER 2004 23

R-E-S-P-E-C-TAretha Franklin captured theattention of audiences worldwidewith her smash hit R-E-S-P-E-C-T.Embedded in the lyrics of thissong is a leadership maxim: Findout what it means to me.

The Queen of Soul is telling lis-teners, including physician leaders,that respect is individually defined.The challenge for physician execu-tives is to find out how each oftheir direct reports, colleagues andpatients defines respect. Then, theymust act accordingly.

Consider this case

A physician assistant who reportsto one of your physicians at a clinicapproaches you for the third time ina month with a complaint. “I knowthat you must be tired of me comingto you about Doctor X but I am sickand tired of Doctor X not respectingme. Doctor X has no respect for meor anybody else in this clinic.”

In this case, Aretha Franklin’slyrics should be the prompt for yourresponse. “In order for me to addressthis very important issue, it is criticalfor me to understand what you meanwhen you say Doctor X does notrespect you. Can you give me someexamples of when people at workrespect you and when they don’trespect you so that I can fully under-stand this from your perspective?”

At this point, most people willshare stories with you or list a number of characteristics thatdemonstrate respect or the lack ofit. Based on that information, youhave the behavioral expressions ofrespect for this individual.

Now you are more fully pre-pared to approach Doctor X withsome tailored behaviors that willsignal a greater show of respect.

Another way that physicianexecutives approach the challengeof respect is to shape the organiza-tional culture to show that respect isa cornerstone of that culture. LynnSharp Paine, author of Value Shift,shares the following perspective ofculture shaping:

“Managers talk about values asessential for encouraging coopera-tion, inspiring commitment, nurtur-ing creativity and innovation, andenergizing the organization’s mem-bers about a positive self image.

They seek ideals like respect, honesty, and fair dealing as thebuilding blocks of a high-perform-ance culture . . . [Employees] wantto be respected, treated fairly, andrecognized for their contributions.They prefer colleagues who are trust-worthy and who can be counted onto keep their promises.”1

Moreover, the benefits of takingaction will accrue to the group andto the organization and shape theculture for the benefit of the patient.

Reference:

1. Paine LS. Value Shift. New York:McGraw Hill, 2003.

Bedrock of satisfaction and effectiveness for organizations and individualsBy Timothy Keogh, PhD and William Martin, MPH, PsyD