Fixing the Broken Practice

Physicians begin their careers expecting personal and professional autonomy, collegial encouragement, and thankful patients. In real life, unfortunately, that rarely happens.

The resulting disappointment robs physicians of enthusiasm, humor, and empathy. And because such "psychic numbing" is contagious, it sets entire practices up for dysfunction. A practice may become so "infected" that it is toxic to its physicians, staff, and patients. The results can include incompetent management, lethargic patient care, and even legal risks.

Nonetheless, disengaged physicians are rarely willing or able to get to the heart of the matter, focusing on daily frustrations instead of trying to tackle the bigger emotional issues. It's hard to talk about how the realities of medical practice today create stress and depression.

For example, I worked with one practice in which the senior partner could not admit when he was wrong. He regaled junior partners with stories from his long experience. When they tried to discuss alternative approaches, he gave them the cold shoulder for days -- or longer. This was his way of holding onto whatever power he had left as a physician. He had already lost three other partners because of his autocratic behavior, which endangered both his business success and the continuity of care for his patients.

At another practice, in interviews with all the physician members, each privately described symptoms of burnout and work exhaustion, but none was willing to publicly discuss changing their work schedules. One physician finally forced a change by threatening to quit if the workload didn't improve.

Warning signs

Do any of the following warning signs sound familiar? Yours may be a dysfunctional practice if:

• There are no written policies for a physician grievance process.
• Physicians argue in front of staff.
• Staff or physicians make disparaging remarks to each other and there is a general lack of civility.
• Sarcasm is the usual mode of conversation.
• The practice protects or is unwilling to actively prevent workaholism, sexism, ageism, or avoids confronting someone with alcoholism or a similar problem. 
• A disruptive person undermines practice morale, increases unnecessary turnover, adds to ineffectiveness in teamwork, increases the risk of substandard care, intimidates or threatens harm to others, causes distress to peers and others in the practice, and is allowed to continue without an attempt at solutions.

If you are considering joining a new practice, first ask how they handle transgressions of practice policy or what they do to promote positive morale. If you get a blank stare, reconsider joining such a practice. If you are already working in a dysfunctional practice, consider getting outside help from a consultant to review the quality of physician work life.

Fixing it

Even some of the most frustrating situations can turn around if the physicians in the group can have an honest conversation and address their emotions.

My favorite example involves a physician who was being recruited by several practices. He told his top choice that it was his priority to "know his family, and not just remain an irritated and tired voice."

He asked if the practice would seriously discuss adding a week of vacation for each new partner. The practice eventually voted to add a week of vacation when they added new associates and now have over 10 weeks of vacation a year. They made a commitment to quality of life despite the potential impact on income.

It turned out that, because so much time was available to do personal things, some physicians were able to expand their clinical knowledge and came up with new ways of marketing, expanding, and enhancing clinical services. The practice actually boosted its annual revenue -- an unexpected benefit.

At another practice, physicians felt they had to work even when they were ill, to please their partners and the scheduling office. They discussed the problem and agreed to begin a sick-leave policy. They even asked their physician extenders about pressures on them during difficult personal times or heavy patient care periods, like flu season or the beginning of school. A sick-call schedule was developed and turned out to be a major recruiting tool.

After several physicians in one practice went through litigation experiences, one of them brought up the grueling and violating impact it had. He commented that physicians facing litigation need time for more reading, rest, and affirmations from their partners. It is not atypical for physicians accused of malpractice to feel like their colleagues are abandoning them, or, at the very least, to feel so exhausted by the process that they are less equipped to handle ongoing patient care.

The result was a policy at this particular practice that the group would actively to look at ways to help whenever someone was experiencing any facet of litigation. The office library created a dedicated area that included litigation stress tools, and a plaintiffs'
attorney agreed to visit the group to share insights.

What do these corrective efforts share? A commitment to defining medical practice in realistic ways. At these practices, stress is no longer something shameful, but a given.

Most importantly, peers are available to brainstorm on ways to support each other. Explicit attention is paid not only to the facts of a problem, but to how people feel. The groups have made a commitment to communicating clearly.

Medical partners need to relate in terms of friendship, comfort, understanding, respect, and caring -- not antagonism, stress, competition, and accusation.

Please tell us how your group has made a commitment to the reality of modern medicine and found ways to care for each other. E-mail us at editor@physicianspractice.com.

John-Henry Pfifferling, PhD, is director of the not-for-profit
Center for Professional Well-Being in Durham, N.C. For more information, visit www.cpwb.org. Pfifferling can be reached at cpwb@mindspring.com, (919) 489-9167, or editor@physicianspractice.com.

This article originally appeared in the October 2003 issue of Physicians Practice.