Be curious, not judgmental. –Walt Whitman
I hear and I forget. I see and I remember. I do and I understand. –Chinese proverb
Investigating professional behavior complaints is part of your leadership journey and experience. Creating a standardized process and approach helps you manage the situations and circumstances, which is important for several reasons.
First, your emotional response will decrease over time, and as you get more experience, your comfort with handling difficult situations will increase. More than a decade ago, as a newly minted chair of the department, I looked forward to the projects and progress, but I was wholly unprepared for investigating and navigating the professional conduct complaints. I believe that one of the primary reasons many physicians do not aspire to a leadership role is the undesirable aspects of the leadership responsibility.
Leadership positions transform your relationships with your peers. After I accepted the position as chair, I thought to myself, “How will I fulfill the duties assigned to this role without damaging professional or personal relationships?” It is a legitimate question, and navigating these waters is difficult.
It is easy to feel like Odysseus, in Homer’s Odyssey, crossing the Strait of Messina between Scylla and Charybdis where he faced the decision whether to sail near Scylla, the monster, or Charybdis, the whirlpool. Sailing by Scylla meant the loss of a few lives as men were plucked off the deck. Sailing near the whirlpool meant the loss of the entire crew and ship. Either path led to destruction in some form. You, too, will make unpopular, uncomfortable decisions. The best decisions accomplish the goals with the least amount of professional, personal, and institutional disruption.
When you learn of a professional behavior complaint, your emotional response is likely a combination of anxiety, dread, and frustration. Acknowledge these emotions — they are a normal, natural result of receiving bad news. Then:
Take a deep breath. (This is about their behavior, not yours).
Avoid jumping to conclusions.
Seek the facts.
As a department chair, you have levels of support above you who have more experience and authority, such as a chief or president of the medical staff, vice president of the medical staff or affairs, or a chief medical officer. If these individuals are not available, seek guidance from a senior leader who has experience as a chair and can offer support. It is important to recognize that you are not alone; asking questions is more beneficial than making assumptions and mistakes. Always take the time to do it right.
Be Curious
Behavior is a response to a series of events and circumstances, and we are all complex human beings with needs, motivations, and individual personalities. As much as we may want to know why someone engages in a behavior, the task is to strip away all emotion, all motives, and simply ask who, what, when, where, and how? Being curious means getting the whole story in chronological order, starting with who was involved, what occurred, and if there are witnesses.
Behavior occurrence forms or anonymous reports are only one side of the story; they are not complete. A series of events usually occurs prior to the behavior. (This is not always the case if there is an established pattern of behavior, and the event is one of many in a series of similar events with the same conduct involving the same physician.)
Physicians are accountable for their actions at all times, and past transgressions matter. “Inheriting” a problem physician is not a pleasant experience. When I accepted a new position a few years ago, I was rightfully, and thankfully, alerted to ongoing concerns with a couple of providers. I was given background and context for any new behaviors. Having written reports and outcomes from prior professional behavior interventions is helpful as well.
Importantly, if a physician has an extensive history of professional behavior complaints, the physician does not get a “clean slate” with new leadership.
Physicians are accountable for their actions at all times, and past transgressions matter. If you are in a leadership position and this is the fourth, fifth, or sixth complaint about the same physician, you are obligated to do everything possible to ensure the behavior stops.
In the past, high-earning physicians got a renewable “get out of jail free” card with no more than a slap on the wrist for each incident. Allowing a high-earning physician to continue to practice under a different set of rules is a double standard, and it erodes trust and staff morale.
Once the groundwork for the issue has been established, it is time to talk, preferably directly, with all parties involved.
Talk With Parties Involved and Witnesses
For some passive-aggressive behaviors, there are no witnesses in the traditional sense. Chronic tardiness, incomplete charts, unanswered phone calls, texts, and so on do not require a witness, but they do require documentation or evidence. For most other professional conduct complaints, there are witnesses — always the attributed physician and any other individual or individuals involved in the behavior or incident.
Some institutions have anonymous reporting processes to protect the individual (victim or witness). Other institutions rely on frontline staff to report to managers or directors and provide formal written reports. If possible, speak directly with the parties involved and affirm you will protect their anonymity. Write down objective facts, times, and exactly what was done or said, and by whom. If patient care was compromised as a result of the conduct, document that as well, because it may become a peer review concern.
In the past, I called or met with the attributed physician “over a cup of coffee” to discuss their first offense. It is a personal way to handle some professional behavior complaints, but I no longer engage in the cup-of-coffee conversations, for several reasons.
First, there are potential legal ramifications. Second, there are no witnesses to your conversation. Third, if the attributed physician is of the opposite sex and you meet behind a closed door or a café for a discussion, you can be accused of sexual harassment. Fourth, if you do this for one physician, you must do it for all physicians to remain fair and objective. Lastly, which types of behaviors or individuals warrant a cup-of-coffee conversation? If fair, objective treatment can be questioned, it is not good practice. And as much as a casual conversation might seem beneficial, it is too informal and subjective.
I ensure I have a witness for one-on-one meetings with an attributed physician and take notes during the meeting, documenting who is present. This protects me and it protects the attributed physician.
Interviewing witnesses is a much simpler task than it might seem. If there is an opportunity, ask other staff and, if appropriate, patients what they saw or heard. If there is agreement and consistency among witnesses about what was heard or said, it is difficult for the attributed physician to provide a different story. In a professional conduct meeting, if there is agreement, I always state that several witnesses agree with the events as described. Witnesses and those affected by the physician’s behavior must be protected from reciprocity or retaliation.
Some witnesses will not want to participate because “nothing is going to change anyway.” One key to your success as a leader is to acknowledge how people feel. And in some cases, I have even told witnesses I am aware of long-standing concerns with an attributed physician. New leaders have an opportunity to set a new tone, but it takes some courage and grit. And sometimes it involves sticking your neck out and telling the witness that the situation can improve only if they are willing to speak out.
Lastly, it is important to caution the witnesses to not talk about the event with other parties. Their testimony is confidential, and it must remain confidential. This is necessary to maintain the integrity of the process and be respectful of everyone involved.
Gather Evidence
In addition to the initial documented reports and witness testimonials, physical evidence includes e-mails, texts, surveillance footage, badge access to entry/exit points, notes, pictures, social media posts, audio recordings, and video recordings. Evidence provides proof of conduct and is critical if the behavior is egregious and involves criminal charges.
Gather and store these documents in electronic or paper format. Do not personally keep the documents in your car, home, or any other location where they can be seen, lost, or stolen. Treat them as legal documents that must be kept as secure as possible. This not only protects you; it also protects the confidentiality of the process. Evidence supports claims, and should the behavior lead to legal action by either party, it can mean the difference between successfully navigating the process to a positive outcome or the converse.
Discuss and Plan
Once the evidence is gathered, it is time to examine the bylaws and conduct code to plan the meeting with the attributed physician. If there is a professional behavior committee, inform the committee of the necessity of a meeting and schedule a pre-meeting to develop a plan on how to present the case to the attributed physician. The pre-meeting agenda includes asking for committee members’ opinions on the issue and helps prevent you from being blindsided by unknown information or opinions. If there is no time for a formal pre-meeting, then meet 30 minutes before the start of the meeting with the physician to discuss the situation. It is not advisable to go in without prior discussion; making time for it will make the meeting far smoother for everyone.
Formal communication to the attributed physician about the meeting can be by a phone call (preferred method) or email. A phone call is personal and less threatening than other forms of communication. For physicians who have a pattern of repeated behaviors, a certified letter is occasionally warranted. A certified letter communicates the seriousness of the meeting and event, and it symbolically escalates the need for change. In addition, if the process leads to legal action, it provides assurance that the physician received notice.
Schedule the meeting, have a discussion with committee members or the CMO prior to the meeting, and communicate the time and place of the meeting to the attributed physician. The medical staff bylaws at your institution are your best guide, and it is imperative you follow the process outlined.
Conduct a Professional Behavior Meeting
No one ever looks forward to these meetings. Emotions run high; the attributed physician is anxious, angry, or both; and nearly everyone feels awkward discussing potentially embarrassing behaviors, events, or circumstances. Have copies of the signed (by the attributed physician) code of conduct, bylaws, and any reports with redacted names to preserve anonymity. If the physician is known to all parties, there is no need for formal introductions. If not, invite everyone to introduce themselves, then jump right in. It is not appropriate to start the meeting with small talk. Be polite, professional, sincere, and courteous. Remind everyone that the discussion is confidential, and any matters discussed are not to be shared with anyone outside of the committee.
Thank the physician for taking time out of a busy day to attend the meeting. This is especially important for physicians who have never had a professional behavior issue that required a higher-level meeting. Give them a copy of their signed conduct form and state why the meeting is taking place.
At this point, pause and allow the attributed physician to tell their side of the story without interruption. The physician deserves the respect of some open airtime. Actively listen and take notes. Once the physician is finished, you can then ask questions or open the floor for further discussion.
On occasion, physicians will attempt to blame others for their own behavior. In high-stress situations, such as missing critical equipment needed for a difficult case, they may lose their composure, become angry, and engage in physically and verbally abusive behaviors. Let the physician vent but also tactfully remind them the reason for the meeting is their behavior; the missing equipment is a separate, important issue for another discussion.
An attributed physician’s response in meetings can be categorized broadly into patterns of responses:
Acceptance: These physicians recognize the issue, apologize, accept responsibility, and state clearly that it will not happen again.
Hijacker: These physicians attempt to control the direction of the meeting, cast blame on others — even, on occasion, at the individual committee members if known to the attributed physician. Meetings can quickly spiral into a heated exchange with insults, foul language, and threats. In some cases, the behavior during the meeting is egregious enough to recommend termination or loss of privileges.
Quiet Acceptance: These physicians know and accept the behavior but are hesitant to provide the committee insight or promises to correct their behavior.
Wasting My Time: These physicians show up, state the meeting is a waste of time, and accept no responsibility.
Angry: These physicians are agitated and angry during the meeting.
I Am Here Again? Repeat offenders are a problem and can be your greatest challenge.
Physicians who are first offenders and accept responsibility usually are no longer a problem; the meetings are smooth. Unfortunately, this is a rare instance. Most meetings involve a small group of physicians who have a pattern of repeated behaviors. Roughly 5% of the physicians create 95% of the problems or complaints.
Disposition and Action Plan
Immediately after the meeting, ask the attributed physician to leave, and allow at least 15 to 30 minutes for an open discussion with other committee members. An open discussion permits members to confirm and validate the responses of the attributed physician. The goal is to agree on the disposition and an action plan. The document generated from the meeting is a legal document; the contents and accuracy protect the organization. The following are two sample letters sent to physicians after such a meeting.
Sample Letter 1
Dr. J. Smith-Johnson
1234 Main Street USA
February 15, 2021
Dear Dr. Smith-Johnson:
Thank you for taking time out of your busy schedule to meet with the Professional Behavior Committee on Thursday, February 13, 2021. We appreciate the compassionate care you provide for the patients at St. Anywhere, and we value your service and commitment. As discussed in the meeting, not returning pages in a timely fashion while on-call has led to delays in patient care in the ICU. Additionally, numerous nurses have also reported a rude and condescending tone when they ask questions or request clarification.
As you revealed in the meeting, you have had a difficult year in your personal life that has impacted your attitude at work. We appreciate your honesty and respect your privacy, and as stated in the meeting, the discussion is confidential. Several of us recommended counseling or a temporary reduction in your workload to help offset current stressors affecting your work. You have a long-standing history of providing excellent, timely care, and we are here to support you.
The committee requests that you meet with me and the Chief Medical Officer, Dr. Jones, in approximately one month for a follow-up discussion. If you have any questions or concerns or need to meet with Dr. Jones or me prior to the next meeting, please do not hesitate to contact either of us.
Respectfully,
Matthew Mazurek, MD, MHA, CPE, FASA
Chair, Professional Behavior Committee
Sample Letter 2
Dr. Miller-Smith
1234 Main Street USA
August 4, 2021
Dear Dr. Miller-Smith:
Thank you for taking time out of your busy schedule to meet with the Professional Behavior Committee on August 1, 2021. As discussed in the meeting, this is the third time in less than four months staff has witnessed you using inappropriate and foul language angrily directed toward staff in the operating room. The latest incident also included you throwing an instrument across the room. As physicians, we have a responsibility to model professional behavior and treat all colleagues, staff, and patients with respect.
We understand your frustration that instruments you frequently use were not contained in the setup trays, which prompted you to berate the staff. We also agree the lack of preparedness for surgery through missing instruments is a patient safety concern. However, an inappropriate response creates an unsafe working environment. Per our discussion, this Committee is drafting a letter of concern to the OR Director, Pamela Hart, and the Chief Medical Officer, Dr. Fine, regarding the continued problem of missing instruments.
The Committee recommends you attend a formal professional behavior management program. We realize attendance at this program will inconvenience you and interrupt patient care, and we desire to minimize the impact this has on your practice. Failure to complete or participate in the program may lead to termination of privileges.
You have a longstanding reputation of providing excellent care for your patients at St. Anywhere, and your patients clearly seek the care you provide, and your colleagues respect your opinions and care. However, as physicians, we have a responsibility to maintain a respectful, collegial, and safe work environment. If possible, schedule a meeting with me within one week to discuss options for enrolling in a program and altering your schedule.
Respectfully,
Matthew Mazurek, MD, MHA, CPE, FASA
Chief of Staff, St. Anywhere
Excerpted from Physicians and Professional Behavior Management Strategies: A Leadership Roadmap and Guide with Case Studies by Matthew Mazurek, MD, MHA, CPE, FASA