"House" - the TV series following a brilliant, but curmudgeonly and troubled doctor - is of course a Hollywood production, but this fiction may be based in fact. At least one-third of all physicians will experience a time during which they have a physical, mental or behavioral condition that impairs their ability to practice medicine safely, according to The Annals of Internal Medicine.

Historically, not much was done to handle hothead physicians like House, but in 2009, the Joint Commission issued standards requiring accredited organizations to have codes and processes in place to address disruptive physician issues. Still, many health care organizations are straining to find effective ways to intervene, provide treatment and identify ways to mitigate issues that can cause physician stress.

Physicians are more likely to suffer from depression compared to the general population, and often, the stress of the job manifests itself in other areas of a physician's personal life, such as drug and alcohol addiction (the rate of incidence among this profession is at least equal to that of the general population) and divorce (the rate is estimated to be 10% to 20% higher than the general population.)

Further, a 2011 survey conducted by Physician Wellness Services and Cejka Search found that nearly 87% of U.S. physicians are moderately to severely stressed on an average day. Yet only 15% say their organizations take steps to help them deal more effectively with their stress or burnout.

Doctors are constantly on call, have little face-to-face time with patients yet long stretches of time away from home, placing significant strains on their physical and personal lives. Some physicians, questioning whether the stress is worth it, are retiring early. According to PWS, 14% of respondents said they had left their practice because of high stress levels.


Moving from reactive to proactive

"Physicians are basically regular folks in high-stress jobs and have not been good advocates of self-care. We've found that our program has been a welcome outlet for them to seek support in a confidential way," says Matt Steinkamp, vice president of service delivery at PWS, a national provider of physician behavioral health services.

Not to say helping this group is easy. Quite the opposite, health professionals can be even more resistant to seeking treatment than other employee populations. Physicians may be dismissive, judgmental, bullying, condescending or arrogant. They may become irritated when asked to look at things from another perspective or frustrated when things don't go as they wished.

The cost and disruption of replacing a physician, or the revolving door of staff because of a disruptive physician, is often too much. For example, replacing a physician can be extremely costly with recruiting costs for a typical search estimated at $30,000 to $40,000, according to NAS Recruiting (2008) and a 2003 article in the New England Journal of Medicine.

It's understandable then that traditionally, disruptive physicians were dealt with reactively, if at all. A reprimand, if one occurred, generally was a five-minute conversation that led to improved behavior for a short period. However, the problem usually returned and many organizations have dealt with this issue for 10 or 15 years.

While some health organizations have internal employee assistance programs, they are not heavily utilized and often are alcohol and drug abuse programs, which are not relevant in all cases.

Many argue that, especially since the 2009 Joint Commission decision, a medical provider needs a program based on research. They must assign disruptive physicians to an action plan and have access to an EAP with peer coaching specifically for doctors.

"If we have less disruptive behavior, then the entire team functions [more smoothly]. We can make decisions better and less costly if everyone is working together rather than being concerned about disruptive or passive-aggressive behavior in the provider site," explains David Danielson, senior vice president for clinical risk management at Sanford Health, which works with PWS.

Before Sanford Health turned to outside help, they could only terminate the disruptive physician. They soon realized they were terminating more people than they should.

"We decided that if we could identify disruptive behavior earlier, we would try to deal with it earlier, so we could have a chance of retaining those talented clinical physicians that may have a slightly different way of approaching things," Danielson continues.

Now the medical facility starts with an in-house response by identifying the physician or provider that needs corrective action. Then the physician's work group sits down with him or her to set up an action plan. If the individual is not responding, they seek help from an outside physician wellness center, which may include counseling.

Companies like PWS offer physician EAP programs for the physician and their families, and physician intervention services, as well as training and consulting for the organization as a whole.

By implementing such a program, Danielson believes his organization has seen a cultural change.

"The number one win that comes out of it is a culture change within the business," he says. "People are getting more involved in the front end, which is the best part of the whole [program]. Instead of [constantly] turning over physicians, you have the opportunity to make changes in behavior and create something good out of something bad."

Success runs high; Danielson estimates that the percentage of physicians who enter the action plan or program and return to their jobs with changed behavior is in the high 80s.


Putting HR in the driver's seat

On the clinical side, there are often leaders who are experienced in medicine but not in people management. That's where HR/benefits practitioners should enter the equation, experts say. The HR/benefits department can help with management consultation and training, as well as train leaders in having crucial conversations with disruptive physicians.

In many large organizations, there is no coordination among departments; they use a patchwork quilt solution, which can be exacerbated by lack of policies and processes. If HR/benefits pros get involved with the physician population, new procedures can be monitored and measured.

"I think HR has a vital role in helping to determine all of that so that everyone understands what the expectations are and that they are carried out uniformly," says Liz Ferron, a senior consultant at PWS.

One rural hospital that began to work with PWS admitted that they had tolerated physician behavior problems too long, but they felt that if they were to fire the physician then they wouldn't be able to replace him and if they didn't fire him, the other staff would leave.

After five months in the program, the physician has engaged and continues to be high producer, says Steinkamp. He has changed how he acts with the staff, and has a new awareness through concrete and consistent feedback and coaching from PWS.

The program helps physicians improve communication, shows them stress reduction techniques, and addresses daily living and convenience issues that are getting in the way of their work productivity. It also features a concierge services for physicians.

"We've always accepted in the medical business that we have people with bad personal skills but excellent clinical skills, so we've let them get away with some of those behaviors," Danielson admits. "I think society has decided, along with the medical business itself, that we no longer want to tolerate that type of behavior because of its effect on everyone on the health care team."

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