The Administrator’s Desk: Dealing with Dr. Difficult

Gail Jones was on the phone with another office manager when one of the doctors in her practice rounded the corner spewing venom - and foul language. Apparently, he was angry with the staff for committing a repeat mistake. “It was a major issue and he was frustrated, but he could have handled it much better,” recalls Jones, who was practice administrator at the time.

The issue escalated into a full-blown incident when the other office manager Jones was talking with overheard and complained to the practice’s head physician, its chief executive officer. At first, recalls Jones, the offending physician denied it, but later acknowledged his lapse in judgment. “He did apologize and he changed his behavior, at least for awhile, but I quit not too long after,” says Jones.

Though the vast majority of physicians maintain a strict code of professional conduct on the job, there are a few who are, well, difficult to love. They alienate patients with their dismissive bedside manner, they reprimand staff for the slightest infractions, and they can’t seem to relinquish control long enough to let everyone else do their jobs. That’s not unique to healthcare, of course, but while most organizations have channels in place to address employee behavior problems (say, a human resources department), that responsibility in a small medical practice is often less clear, putting practice administrators in an awkward position.

Not wishing to bite the hand that feeds them, in fact, many administrators allow behavior problems among their physicians to fester. That, in turn, leads to morale problems and higher turnover - not to mention opens the door to malpractice claims, since patients who perceive their doctor to be insensitive or rude are more likely to sue. “The biggest problem [with dealing with difficult doctors] is that you don’t want to risk your own job,” says Jones, now manager of practice management for the American Academy of Family Physicians. For the good of their practice, however, all administrators should have a plan in place to reign in renegade docs.

Difficult or demanding?

Before approaching any physician, it’s important to distinguish between those who are truly “difficult” and those who simply run a tight ship, says Nick Fabrizio, a consultant for the Medical Group Management Association and former practice administrator. Employers should expect their staff to perform at a certain level. “Because of their training, physicians are exact and precise and they expect excellent performance from their staff,” says Fabrizio. “They may seem demanding, heavy-handed, or abrupt, but when they see employees not working efficiently or being underproductive they get frustrated and I agree with them in some cases. Patient care comes first so if you’re not contributing you’re standing in the way.”

Leave it to the docs

That said, practices that suffer high levels of turnover or receive numerous complaints about an individual physician should still intervene. Depending on the size of your practice, says Fabrizio, you should designate either a medical director or physician shareholder to address such challenges.

As an administrator, “you need to speak with the medical director or owner and let them know that you’ve observed these behaviors and tell them what you think should be done about it,” says Fabrizio. “It’s up to them to take action.” In the most successful practices, he says, the medical director or owner is not only empowered to discipline doctors, but also should be prepared to let repeat offenders go.

“Unfortunately, smaller practices get desperate to keep their physicians because terminating them means higher recruiting costs, more work, and more call for the other physicians, so they start to believe it’s better to have one who is difficult than no one at all,” says Fabrizio.

“But whenever I’m hired to help a practice improve its culture I look first at the staff to see if there’s an outlier. It’s very hypocritical to tell everyone else how to act when one person is guilty of doing it wrong. You lose credibility as an organization.”

It may be professional courtesy to let doctors deal with doctors, notes Fabrizio, but don’t subtract yourself from the equation entirely. “As an administrator, you also have a responsibility to speak with that physician directly,” he says. “Communication is really a requirement of a good administrator. Address the problem in a nonconfrontational way and let that person know you’ve observed a problem.”

Prove it

Be aware, too, that overbearing or rude physicians don’t always realize they’re being difficult, which may make them defensive. So they don’t confuse your criticism with a personal attack, it’s best to back up what you say with comments taken from patient and employee satisfaction surveys. “Surveys help to keep it objective,” says Fabrizio. “That way, it’s not just you or the staff saying these things.”

To nip bad behavior in the bud, in fact, some practices provide survey feedback to physicians on an ongoing basis, along with their monthly financial reports. All the doctors, for example, get a copy of the office performance data (including revenue, profit, and expenses,) while the individual providers (including nurses and physicians assistants) get their own productivity reports, along with any anonymous patient or employee survey comments that pertain to them. The head physician gets a full report on everyone, keeping all the providers accountable. (Note: Some larger medical groups actually base their physician’s salary and bonuses in part on patient satisfaction scores.)

Have a talk

If you haven’t done so already, a simple heart-to-heart with the physician in question can sometimes prove effective - especially if the doctor has been more short-fused than usual. Without prying, try initiating a casual conversation when the time is right with something like: “You haven’t seemed like yourself lately. Is everything OK?”

What you assume to be a personality problem may actually be rooted in work-related stress, challenges at home, or trouble with their finances. “Maybe there’s something you can do to ease their load before filing a complaint, which becomes part of their permanent record,” says Jones, noting doctors are under a lot of pressure. “Sometimes it just takes listening to understand what’s going on with them.” The physician who flew off the handle at her office, adds Jones, had been up all night with a “very sick patient.”

Build an open relationship

You’ll have the most success working with physicians of all temperaments if you establish professional rapport. “Don’t wait for an annual meeting,” says Jones. “Physicians and staff should have weekly sit downs for a few minutes and hash things over. What’s going on? How are you doing?”

Your ultimate goal is 360-degree feedback, she says, where you develop relationships with your physicians that allow you to speak freely about each other’s behavior or performance. “You should be able to talk to them openly and they should be able to say things back to you,” says Jones, adding it never hurts to sandwich constructive criticism in positive comments.

It may be challenging to work with arrogant or impatient physicians, but neither you nor your staff should have to walk around on eggshells. By establishing channels to address bad behavior and maintaining direct communication with your doctors, you can not only help correct the problem, but also restore a more professional office environment for patients and employees alike.

Shelly K. Schwartz, a freelance writer in Maplewood, N.J., has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNN-Money.com, Bankrate.com, and Healthy Family magazine. She can be reached via physicianspractice@cmpmedica.com.

This article originally appeared in the January 2009 issue of Physicians Practice.