|
|
|
|
Deal with Difficult Physicians
with Associate Dean for Clinical Affairs and Director of the Center for Patient and Professional Advocacy, Gerald B. Hickson, MD, Vanderbilt Medical Center, Nashville TN |
|
 |
Presenter at Studer Group's What's Right in Health Care Conference |
|
|
| “W |
e've found that the top ten percent of physicians who generate patient
complaints actually account for about half of all physician complaints,” |
explains Dr. Gerald Hickson, associate dean for clinical affairs at Vanderbilt Medical Center in Nashville, TN. “These ten percent also account for more than 40% of risk management file openings and half of dollars paid out in costs, settlements, and rewards.” |
|
| Vanderbilt, which has fine-tuned and hardwired a comprehensive approach to identifying, measuring, and addressing unprofessional physician behaviors over the last 11 years, is currently ranked 19th out of 5,462 hospitals by US News and World Report with five specialties ranking in the top 5% of hospitals. Its School of Medicine is now ranked tenth among U.S. medical schools for NIH funding. Vanderbilt’s average mortality index has also improved 4.19%. In fact it’s been quite a journey since the days when the word on the street was, “Only go there if you’re about to die.” Vanderbilt is also a 2006 Studer Group Fire Starter award winner. |
|
| So how did the transformation occur? Leaders credit the gains at least in part to Vanderbilt’s culture of non-tolerance for physicians with unprofessional behaviors. The approach is comprehensive. First, the medical center uses a video for new patients—as well other surveillance opportunities—to actively solicit concerns about physicians from patients for quick service recovery. All complaints are then coded and tracked by Vanderbilt’s Patient Advocates Reporting and Tracking Systems (PARS©). In addition to facilitating individual responses to patients, the data is also aggregated so it can be sliced and diced to show variance from the norms during physician interventions. And finally, an in-depth training program ensures that “peer messengers” are trained for effective interventions. (Medical students, residents, and other physicians also receive a steady diet of training on communication skills and how to acknowledge and address unprofessional physician incidents.) |
|
The Case for Intervention
Unprofessional physician conduct impairs communication, which leads to adverse clinical events, as is widely documented in the medical literature. It also leads to high employee turnover and higher malpractice claims as noted above. And yet, how do colleagues typically handle physicians who are unprofessional to patients or co-workers? Most ignore it because they lack the skills to confidently address it or perceive lack of support from senior leaders. |
|
 |
Disruptive Behaviour Pyramid |
|
The disruptive behavior pyramid for identifying, assessing, and dealing with unprofessional behavior.
Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007
|
|
Taking Action
At Vanderbilt, physicians are identified and placed into three categories: no complaints, rare complaints, and high complaints. The good news: two-thirds of physicians never or rarely generate patient complaints. The 20 to 25% who do behave in ways that dissatisfy their patients are unlikely to do so repeatedly and are responsive to changing behaviors when made aware. Just two to three percent of physicians show a persistent pattern of disruptive behavior. |
|
| Those with isolated incidents receive an informal intervention, such as a “cup of coffee conversation” from a trained peer mentor in their specialty. Since those who demonstrate a persistent pattern represent a threat to quality and safety, they receive awareness and authority interventions based on what is driving the pattern (e.g. substance abuse, poorly controlled anger, narcissism). Physicians are also presented with data that compares their “complaint index” with that of their colleagues and identifies the type (e.g. communication, accessibility) and number of complaints. |
|
Results
To date, the team at Vanderbilt’s Center for Patient and Professional Advocacy (CPPA) have facilitated over 1000 initial and follow-up physician interventions since 1997 at Vanderbilt and 29 of CPPA’s client sites at various institutions across the country. In follow-up, 59% of these physicians are now good or better, with less than 2% recidivism. Twenty percent of high-complaint physicians have retired or relocated, while an additional 20% require more help to improve. |
|
 |
Gerald B. Hickson, M.D., is associate dean for clinical affairs, director of the center for Patient and Professional Advocacy and director of risk and loss prevention at Vanderbilt University Medical Center. His research has focused on understanding the etiology of adverse events, why families choose to file suit, why certain physicians attract a disproportionate share of malpractice claims, and how to reliably identify and intervene with high malpractice claims physicians to reduce risk. Nationally, he currently serves on the National Patient Safety Foundation Board of Governors. |
|
|
|
|
|
|
