Ten best practices to manage behavioral and impairment issues on the medical staff
Most practitioners who suffer from ongoing behavioral issues or impairments aren’t very interested in being managed, and most medical staff leaders dislike the idea of “rattling the cage” of a valued referral source and peer. Thus, disruptive behavior and impairment tend to be buried or ignored rather than addressed.
I have picked up the following pearls over the last decade helping organizations manage these problems I hope they will be of benefit to you.
1. Behavioral issues: Pay now or pay later. The problem with ignoring behavioral issues is that they grow, or worse, become chronic risks to the organization, patients, staff, and colleagues. According to The Joint Commission’s 2009 Sentinel Event Alert #40, behavioral issues may cause medical errors, death, injury, and turnover. Behavioral issues may also undermine other physicians’ and nurses’ ability to care for patients by breaking down communication and team work. Addressing the issue seems arduous and frustrating, but not facing it may lead to potential harm to patients and mar a physician’s professional reputation and all those who associate with him or her.
2. Potential impairment: Pay now or pay later. The sooner medical staffs identify potential impairment, the longer a physician will be able to successfully practice. Conversely, the longer a medical staff ignores potential impairments, the more likely a physician is to inadvertently cause harm to a patient and to him- or herself, unnecessarily shortening his or her career.
3. Create a behavioral evaluation and referral committee (BERC). A BERC can help medical staffs manage behavioral issues. By and large, medical staff leaders are neither trained in nor inclined to manage problems that are frustrating, chronic, and seemingly endless. Creating a group of professionals who are skilled in and actually get a sense of fulfillment from managing these challenging issues can take a load off everyone’s mind and free leaders up to do other things. Who would be an asset on such a committee? Typically a psychiatrist, psychologist, neurologist, primary care specialist with a flair for managing behavioral issues, a psychiatric social worker, and the VPMA/CMO. Often, these individuals don’t have admitting privileges to the hospital, but they may have a busy behavioral practice in the community and would consider it a community service to provide evaluation and support to their colleagues. Such a committee would report findings and recommend action to the credentials committee or medical executive committee (MEC).
4. Consider a practitioner health committee (PHC) to manage potential impairments. Like its cousin committee in the previous tip, the PHC is made up of professionals (e.g., an internist, family physician, neurologist, psychiatrist, physiatrist, etc.) who are skilled in and interested in managing potential impairments. Like the BERC, it is a sub-committee of the credentials committee or MEC and provides assessment, referral for a fitness-for-work evaluation (see below), and recommendations for ways to help impaired physicians optimize their clinical performance through assistance and rehabilitation.
5. Look for the overlap. According to the American College of Physician Executives (ACPE), approximately one-third of physicians who manifest behavioral issues have a potential and often undiagnosed impairment that may be treatable or even reversible. For example, a physician who experiences outbursts of anger may be suffering from depression, bi-polar disorder, alcohol or drug dependency and withdrawal, obsessive compulsive disorder, anxiety, or metabolic disorders. Ignoring potentially treatable issues is not collegial or supportive and may deny a good physician an opportunity to have a satisfying and successful career.
6. Don’t try to manage behavioral and impairment issues simultaneously. A trap I fell into when I started doing this work was attempting to manage a behavioral issue while diagnosing and treating a potential impairment. Spence Meaghan, MD, the late long-term faculty member of the ACPE, once said, “Managing impairment is a labor of love. Managing disruption is a labor of law.” Managing impairment is about assistance, rehabilitation, and optimizing clinical performance, whereas managing behavioral issues is about restricting dysfunctional behaviors that may cause harm to patients and shorten a physician’s career. It is best if different leaders manage these issues separately so that the approach and recommendations are not confused.
7. Consider a fitness-for-work evaluation for potential impairments. A fitness-for-work evaluation is not a physical or a regular health screening exam. It is a specialized evaluation of an individual’s ability to exercise clinical privileges by a vocational specialist with the express purpose of answering the question, “Does this practitioner have any physical, psychological, or cognitive issues that may undermine his or her ability to safely exercise the requested clinical privileges.” A good source for these referrals is your state medical board. Most boards have a network of individual practitioners that they contract with to provide this service.
8. Frame this work as supportive and collegial and not punitive. Turning our backs on a colleague suffering from a treatable condition is not a good way to support one another or to promote positive performance. I like to reframe working with practitioners as an act of advocacy to support their professional and personal lives. I still receive letters from physicians thanking me for support when their colleagues turned their backs under the assumption that it would be an act of betrayal to confront the issue.
9. Don’t let physicians suffer alone. Not dealing with disruptive behavior and impairment harms patients and ruins professional and personal lives. The problem with burying these issues is that physicians are allowed to suffer alone and patients are inadvertently harmed. The traditional cottage industry culture inhibited us from addressing these issues for fear of betraying our colleagues; a more contemporary approach reminds us that there is a better way.
10. Think from a risk management perspective. Not dealing with these issues harms the reputation of the hospital, the medical staff, and ourselves. It takes years to establish a reputation of quality and trust, which is the greatest driver of superior financial performance for both hospitals and physicians. It can take one tragic outcome to undo decades of effort. Satisfied patients will refer dozens of friends and family to a physician; unsatisfied patients will litigate and drive dozens of friends and family away.
I hope that these points help support your efforts to address the behavioral and potential impairment of good physicians and practitioners who have dedicated their lives to the pursuit of caring and healing and who are often left to suffer alone. This is an opportunity for the medical staff and hospital to support a positive relationship with those whose efforts and dedication drive quality, revenue, and the reputation that takes so long to earn.
Wishing you continued success,
Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, is a senior consultant with The Greeley Company, a division of HCPro, Inc. in Danvers, MA.