Sunday, May 12, 2013

Bullying, disruptive physicians and thoughts on administration

One of my fellow physician administrators forwarded this post from Kevin MD.  I have pasted it at the bottom. 

I was talking with the same physician a few months ago and we were discussing how bullying was going to be next club with which physicians were beaten.  In addition the disruptive physician label has become the latest Scarlett A.  Both are perfectly valid concepts, many physicians were or still are bullies.  It is unfortunately the culture in which we were raised if you want to commit sociology.  Likewise there are many disruptive physicians and many of them have continued to be so in part because the system nurtures them.  It is the extension of the terms to legitimate disagreement or dissent that is the problem.

I have to attend a lot of meetings, which we all know are way to deal with any problem.  These include meetings specifically to deal with problems and regular meetings such as what used to called the OR committee and Medical Advisory Committee among others.

The MAC which is supposed to be a meeting of the department heads with senior management is no longer a forum where policy can be discussed or modified, assuming that was ever the case.  About two days before every meeting, I receive by email a massive document dump which I am supposed to read before the meeting.  There is of course no way I can ever read the whole package let alone figure out what parts of the package I should read.  Assuming I did read the whole package, I would find it full of incomprehensible flow charts and neologisms. This is what is called consultation.

Occasionally you may be asked to give feedback into a particular policy during the planning stage.  The meetings will be scheduled in the middle of the day when you can't get to them because you are working.  If you think it is important enough to take an (unpaid) day off, the meeting will be cancelled at the last minute because one of the "stakeholders" can't make it.  They of course never cancel the meeting because you can't make it.  Or they will invite you by the hospital email address you never use because it is too cumbersome to access.  When the policy comes into force, they will say that they consulted you.

Most policies are then presented to the MAC as a fait accompli.  The medical director, now called the Vice President - Medicine may actually have had some input or not.  It was at meeting about a year ago that I realized that there must be a secret administration running the hospital.  We were presented a policy on standing orders made by our quality department that was completely illogical and was going to hamstring care as we knew it.  Despite the fact that our administrator, both medical directors and all the department heads were present, the policy was presented as something we would have to live with and could not be modified.  Discussion did become a little heated and both sides made some edgy comments.  The policy went ahead however and we are gradually learning to live with it.

My father served in the provincial government for over 30 years rising to fairly high levels and attended multiple meetings.  He told me that every committee should have somebody on it whose job is just to say, "BULLSHIT".  He told me that people get irrationally attached to ideas and need somebody to bring them down.  Keep in mind it now almost 30 years since he (or people who think like him apparently) was involved in decision making.  This is not a new concept.  The Vatican when considering somebody for sainthood actually has an individual known as the Devil's Advocate whose job is to argue why the individual should not be a saint.

Nowadays if anybody is brave enough to object to or suggest modifications to some policy or plan they are told one or all of:
  1. It is an accreditation standard.
  2. It is a Zone/Regional/Provincial/National standard.
  3. Administration is committed to the project.
  4. People have already been hired and it is too late to stop.
  5. You have no right to comment on this issue.
  6. You are an asshole. (While it would be nice if they actually called you an asshole, they never phrase it like that, they just make you look like an asshole).
Pointing out how impractical implementing the policy with the resources that you have or that it won't work in the real world is useless.
In three years I have learned a few things about administrators.  I refer to nursing because I deal with them the most but this applies to most of the heirarchies in the hospital.

  1. Administrators are usually hamstrung by how much money they have to work with and the political agenda of the people who decide how they spend the money (this includes the secret administration).  This is true by the way in both the public and private sectors (the private sector just has more money but also has to make a profit).
  2. Administrators have the best job they have ever had in their life.  Why would they want to risk it by standing up to the people above them.  This is as opposed to physician administrators who are often doing this out of a sense of duty or because it is their turn and either already have a good job outside of administration or could go back to clinical practice and be a lot happier and quite often better paid. Non-physician administrators know this and resent this.
  3. In the health care sector many administrators actually rose up from the trenches.  In a lot of cases this is on merit.  In quite a few cases it is just a case of having been in the right place at the right time.  There is also nepotism.  In one hospital I worked at, most of the nursing supervisors were relatives of a former administrator (she was fired, they stayed around).  The organizational chart resembled the genealogy of the Habsbergs.  Those who rose up on merit usually rose up by virtue of a non-administrative job for example a nurse may become what we used to call a head nurse by virtue of her good work on the floor or by seniority.  Her skills as a nurse however have very little to do with what is required of her (or him) as an administrator.  Frequently nurses who were quite good (or remember themselves as being quite good) have unrealistic expectations of their now subordinates.  Nurses also frequently become administrators for the "wrong reasons", better hours and more pay and who can blame them.  It is of course reasonable to expect anybody to be good as an administrator based on their skills as a clinician.  How many hockey stars became good coaches.  This was called the Peter Principle where people rise to their level of incompetence.  
  4. Lower levels of management have shifted.  When I was in medical wards were run by head nurses who wore uniforms just like the floor nurses and some of them actually helped out when things were busy.  Over them were nursing supervisors who also wore uniforms and helped out on nights and weekends.  In essence head nurses were, to use a military analogy, sergeants   Head nurses are no more, they are now called supervisors and wear plain clothes.  Supervisors now have a different title and are not seen in the hospital after hours.  Essentially it is like the sergeants have been replaced with second lieutenants and anybody who has been in the army (I haven't) knows what that is like. 
  5. Unlike most industries many of the top administrators and almost all the lower administrators are women.  This of course shows that women can be just a arrogant and out of touch as men can.  They also do stupid things, just like men.  It also creates an interesting dynamic for a male physician who has to deal with a female administrator (not that female physicians have any more luck).    It just seems easier to stand up and get into a battle with another man.  
Anyway here is the post from Kevin MD's blog.  I may just try some of his strategies although I know they won't work.

Become a disruptive physician: How to do it right

“Disruptive physician” is one of the most misused terms in healthcare these days. In many organizations, those two words have become the c-suite’s trump card to quash any physician resistance to new administrative programs. These programs are often have purely financial motives or are a brazen attempt to dump additional tasks on the physicians with no regard for their workload or stress levels.
The doctor’s legitimate concerns about quality of care don’t matter. They are lost in the politics of the silos of the administrative and clinical sides of the organization. They are quickly seen as not being a team player. The disruptive physician label comes flying out and the doctor is deftly tossed under the bus so the meeting can move on to the next topic.
Often, this is bullying, plain and simple. It can create permanent consequences for the physician, including diversion into any number of treatment programs and not uncommonly losing their job.
However, sometimes the disruptive name calling is just a consequence of a fundamental clash of communication styles between physicians and administrators. In this situation, the skills inside the disruptive physician’s toolkit will allow you to do the following:
  • Air your legitimate concern
  • Be heard by the administration
  • Avoid being labeled disruptive in the process
Physician vs administrator communication clash
Physicians are highly trained experts at finding a unifying diagnosis, the crux of the problem, the thing that is likely to go wrong. We see clinical issues administrators are completely unaware of.  We do all of this at lightening speed, because in our diagnoses often must be made quickly.
When we see a problem, we point it out without hesitation and we are not used to having to explain ourselves. And we shoot from the hip, without regard to the social setting or the politically correct thing to say in the given situation. One word for this is “blurting.”
This is not how you make your point in the midst of a meeting to a group of administrators. They do not think or communicate in this fashion. It is not what you say, but how you are saying it. Disruptive physician labeling can be the result of this clash of communication styles.
The disruptive physician’s toolkit
If you have a concern, talk to as many people as possible before the meeting where this program will be discussed
To raise a concern for the first time in the midst of a meeting is the definition of rude to an administrator. Discovery and building of consensus is best done before the meeting occurs – much like the work in politics is done in conversations before they vote on the bill on the floor. You want your concern to be discussed, shared, understood and at least a partial consensus on what to do about it. All done before any committee meeting.
Always ask questions, rather than making statements
Ask questions of everyone involved in the proposal and everyone who will be part of the decision on whether or not it goes forward.  Always start your questions with the word “what” or “how.“ This guarantees an open ended question that will draw the maximum of information from the person to whom you are speaking.
Here are some very simple and powerful examples:
  • “What are your thoughts on program “X”?”
  • “How do you see program “X” affecting the quality of care?”
  • “I have some concerns about “X”. How do you see we might be able to address them?”
Channel Columbo
Do your best to imitate the character of “Columbo” in the old TV series. Hand to the forehead, self deprecating, “Maybe this is a silly question, but I was wondrin’ … ”
Columbo’s style goes against our doctor programming to be “seldom wrong and never in doubt” and I encourage you to let that go. Columbo was never called disruptive and was always very effective.
  • Try asking questions instead of telling people what to do (giving orders)
  • Try channeling Columbo when you speak
  • You have no idea how massively effective this is with administrators (and everywhere else in your life)
Find solutions and build consensus
In your pre-meeting discussions, if you find your concern is shared by your colleagues, build consensus (before the meeting) on several solutions or ideas to address your concerns. You will have consensus on the concern and the possible solutions in your back pocket before the meeting begins.
Appeal to the highest value possible at all times
Always keep the team focused on the highest possible corporate value – one that everyone can agree to. Usually this will be quality of care or patient satisfaction. This is your trump card. When you are bringing up any clinical concern about an administration proposal, relate it to one of these  higher values whenever you can. It can sound like this.
“I know we all agree that none of us wants the quality of care to suffer as a result of this initiative.”
This phrase used early and often keeps everyone focused on the big picture, and not your objection. It states something no one can disagree with and keeps them from immediately disagreeing with you.
What not to do
  • Don’t communicate like a doctor
  • Do not raise your concern the way you would normally do on automatic pilot, as a declarative statement of fact. Example: “I think this is a bad idea and here’s why.
  • Always ask a question. Remember to channel Columbo. Be either curious or confused.
    • “I am confused here.” (Columbo)
    • This patient flow initiative is supposed to make it easier to see 35 patients a day, but a number of us here are concerned it will only increase the EMR documentation backlog and that will affect the quality of care. I am curious what your thoughts are about our concerns here Mr. CEO?” (open ended question)
  • Do not show any emotion that could be perceived as negative
  • Do not:
    • Stand up
    • Raise your voice
    • Furrow your brow
    • Slam your fist on the table, point fingers, slam doors, swear, throw things
    • Or send any body language signals of anger, frustration or hostility.
  • Focus on your breathing and ask question
  • If you do feel any of these emotions, name them out loud
  • Let people know what you are feeling with a civil tongue. Just make sure you have done the work before the meeting so that everyone is aware of your concerns and feelings.
    • “I must admit when I hear your answer, what comes up for me is frustration.  I am curious (Columbo) what we can come up with for a proposal here that could address both of our concerns. “ (open ended question)
  • Do not leave a paper trail or voice mail trail
    • It is completely appropriate to be seriously paranoid about documentation of any of your concerns in a format that could be shared. Do not send emails, text messages, messages through your EMR or leave voice mails especially if you are upset and venting to someone you feel is a trusted colleague. If you must vent in an email, write it and then delete it. Do not create a paper or voice mail trail.
    • If you do leave recorded or written evidence of your concerns, you are running an almost 100% risk of those documents or voice mails falling into the hands of someone who will label you as the next disruptive physician on staff. Here’s why.
    • It is impossible for them NOT to take your concerns and tone out of context.
    • Make sure you raise your concerns only in conversations, where the other person can understand your energy, tone, body language and caring for everyone involved – especially the patients. There is no way any of that can be understood through a text, email or voice message, especially by an administrator who does not agree with or understand your position.
Ultimately, if you work in an organization with a pattern of hostility towards the physicians and clinical staff and a habit of bullying with the disruptive label, you will decide whether that is something you will tolerate  or not. You always have the option to vote with your feet.
If you do decide to leave, it is my intention that this disruptive physician toolkit ensures the following:
  • Your concerns have been heard
  • You gave it your best shot at ensuring the program made clinical sense
  • You don’t have the disruptive physician label hanging round your neck to get in the way of you finding a better position
Have you ever been labeled as disruptive?
If you are in a leadership position, what communication tools do you use to avoid the disruptive physician label?
If you have tried channeling Columbo, how did that go for you?
Dike Drummond is a family physician and provides burnout prevention and treatment services for healthcare professionals at his site, The Happy MD.

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