Physician Wellness Services targets burned-out, problem docs

MINNEAPOLIS, Minnesota — The doctor is a brilliant diagnostician, but a lousy human being. He’s caustic, moody and condescending. He berates his staff, ignores his superiors and plays fast and loose with patient safety. He pops prescription pain killers like they were Skittles and regularly converses with dead colleagues.

If Dr. Gregory House, played by actor Hugh Laurie in the hit FOX drama “House,” was real, he’d be a prime customer for Physician Wellness Services (PWS). The company, a recently formed division of Workplace Behavioral Solutions Inc., designs counseling and intervention programs for hospital and medical organizations to treat problem doctors struggling with stress, substance abuse and depression. Founded in early 2009, PWS  now boasts 30 customers in 10 cities.

House may be fictitious but disruptive physician behavior is very much a real and serious problem, said Dr. Alan Rosenstein, medical director for PWS. A growing body of scientific literature suggests problem docs not only threaten patient safety but expose hospitals to malpractice lawsuits and staff shortages, especially nurses bullied out of their jobs by intimidating physicians.

According to a 2003 survey of 2,000 nurses, pharmacists and other staff by the Institute for Safe Medication Practices, nearly half of the respondents reported intimidating behavior, mostly from doctors, such as strong verbal abuse and threatening body language. Four percent even reported physical abuse.

While hospitals have traditionally tolerated the problem, such behavior has drawn increasing attention in recent years, Dr. Rosenstein said, thanks to a strong focus on physician accountability by outside groups like insurance companies and government officials who demand lower costs and better medical outcomes.

“Physicians realize that they can’t get away with it anymore,” Dr. Rosenstein said.

In 2008, The Joint Commission, an independent, nonprofit organization that accredits and certifies more than 17,000 health care organizations, established new standards that require hospitals to develop “a code of conduct that defines acceptable and disruptive and inappropriate behaviors” and “create and implement a process for managing” such behaviors.

The problem with problem docs stems from a unique, unforgiving culture, said Dr. Rosenstein, a national expert on disruptive physician behavior who has published several articles on the issue. Medical school graduates starting their careers are first “broken down” and told they know nothing, which produces low self esteem and confidence, he said. Then the docs are thrust into a situation where “they work autonomously and autocratically,” Dr. Rosenstein said.

“That’s the way you are trained in medical school,” he said.

The physicians develop big egos that defy any scrutiny of their performance or competence. Throw in long hours, the emotional toll of treating patients and doctors start to suffer from stress and depression, failed marriages and even alcohol and drug abuse. They start to lash out at nurses and other staff, which jeopardizes patient safety because the two groups either won’t or can’t communicate with each other, Dr. Rosenstein said.

According to the 2003 survey, which included 1,565 nurses, 88 percent of respondents encountered condescending language or voice intonation (21 percent often), 87 percent experienced impatience with questions (19 percent often), and 79 percent encountered a reluctance or refusal to answer questions or phone calls (14 percent often). In fact, some experts blame the acute shortage of nurses on disruptive physicians.

“Intimidation clearly impacts patient safety,” the report concluded, citing the 49 percent of respondents who say their past experiences with intimidation altered the way they handled questions over medication orders.

The Joint Commission’s new standards proved to be a watershed moment in spotlighting disruptive physician behavior because the organization carries real weight with hospitals. Whether or not a hospital receives Medicare payments often depends on receiving accreditation from the body.

“The presence of intimidating and disruptive behaviors in an organization erodes professional behavior and creates an unhealthy or even hostile work environment — one that is readily recognized by patients and their families,” The Joint Commission said. “Health care organizations that ignore these behaviors also expose themselves to litigation from both employees and patients.”

Workplace Behavioral Solutions decided to form a unit specifically focused on physicians because they work in such a unique culture, said Lori Brostrom, PWS director of marketing. PWS offers three services: an employee assistance program that provides voluntary counseling to doctors by specially recruited and trained peer doctors, an intervention program for the most serious cases of physician misbehavior, including substance abuse and severe depression, and training, workshops and consulting services.

Dr. Daniel Whitlock, vice president of medical affairs at St. Cloud Hospital, which employs 412 doctors, said he wants to “turn the organization into a caring organization instead of a disciplinary organization.” He recently renewed the hospital’s contract with PWS, which provides an employee assistance program.

Normally, by the time a disruptive doctor demands his attention, Dr. Whitlock takes punitive action. Instead, he prefers to nip the problem in the bud.

“There’s not a lot of leeway when it gets to my desk,” Dr. Whitlock said. “If the only thing you have is the death sentence, then your hands are tied. We would like to ratchet it down, intervene before it boils over into something serious or harmful. Over the years, we found that [doctors’] private lives affects us greatly in how they perform their professional duties. It really cries for help but doctors are not particularly good at asking for help.”

Dr. Whitlock also sees his doctors as investments that need fine-tuning. Just as the hospital will spend money to purchase and maintain expensive equipment like CT scanners, the hospital needs to devote similar time and resources to maintain the emotional welfare of doctors, he said.

“We’re facing a physician shortage,” Dr. Whitlock said. “We have a real difficult time attracting primary care doctors. When we bring a doctor into our community, we make a big investment in that person.”

PWS hopes to expand into 10 more major cities and eventually medical schools. Such institutions tend to emphasize technical skill over emotional competence, Dr. Rosenstein said. Helping students cope with the rigors of their profession in medical school would help prevent disruptive behavior long after they graduate, he said.

A 2005 study published in the New England Journal of Medicine concluded “disciplinary action among practicing physicians by medical boards was strongly associated with unprofessional behavior in medical school. … Professionalism should have a central role in medical academies and throughout one’s medical career.”

Among the behaviors the study identified in problematic medical students were irresponsibility — poor attendance and follow-up patient care — and diminished capacity for self improvement — failure to accept constructive criticism, argumentativeness and a poor attitude. The study also blamed bad behavior on anxiety, nervousness and insecurity.

“We look at this as fertile ground,” Dr. Rosenstein said.