More than 4 years ago, Raymond M. Pomm, M.D., started to see a pattern of disruptive behavior occurring in physicians across Florida, where he is the medical director for the state's Impaired Professionals Program.
Hospitals were reporting a range of inappropriate and disruptive behaviors, from yelling to berating nurses in front of other staffers to physical violence. But the behavior didn't fit any patterns typically associated with psychiatric disorders such as bipolar disorder or substance abuse, he said, so he searched the country for a person or program that could help to change the behavior.
“It became a real dilemma,” Dr. Pomm said.
Then in 2002, Eva Ritvo, M.D., a psychiatrist, and Larry Harmon, Ph.D., a psychologist, stepped forward with a unique approach.
They started the Physicians Development Program, which provides a complete psychiatric, psychological, and workplace evaluation of potentially disruptive physicians, offers referrals to local treatment, and monitors behavior to chart improvement.
“We really try to tailor the program to the individual doctor,” said Dr. Ritvo of the department of psychiatry and behavioral sciences at the University of Miami and chair of the department of psychiatry at Mount Sinai Medical Center in Miami Beach.
They also use the Physicians' Universal Leadership Skills Survey Enhancement (PULSE) tool to evaluate and monitor physician behavior. The survey was developed by asking a variety of health care professionals what their colleagues do at work that motivates them to perform at their best, and what disrupts or discourages them.
When a physician agrees to go through the program, Dr. Harmon sends the survey to nurses, physician colleagues, and hospital leadership to find out how the individual physician behaves.
This feedback gives the physician some insight into how he or she is viewed by colleagues. This is a “magic moment” in the program, said Dr. Harmon, who is chair of the ethics advisory board of the Florida Psychological Association.
The physicians, along with hospital administrators, choose the people who will complete the survey. “This is not mental health treatment, this is physician development,” Dr. Harmon said.
Seeing this report usually turns around the behavior, Dr. Harmon said. Once the behavior is pointed out in a structured, objective way by a neutral third party, the findings are seen as credible and have an impact on the doctor.
The feedback report allows Dr. Harmon to constructively confront the doctor's lack of insight, he said. Physicians do not notice their disruptive impact on others until they see the collective voice of their team members reflected in the report. It's also the best way to find out if a physician isn't being disruptive, but may be a political target at the hospital.
After the survey is shown to the physician, Dr. Harmon conducts a follow-up survey to chart the physician's progress.
So far, all of the physicians who have been through the program have improved their behavior, he said.
About 42 physicians have completed the program since its inception in 2002. They come from around the country and from various specialties, Dr. Ritvo said.
“Typically, our physicians are not what you'd expect,” she said.
These physicians usually don't see their behavior as inappropriate and will say that they are just trying to get the best care for their patients. And they are usually excellent doctors but they are operating under a lot of stress and generally have some type of personality disorder involving obsessive behavior and control issues. “We see a lot of perfectionism,” Dr. Ritvo said.
In the future, Dr. Ritvo said she hopes to focus more on prevention and to be able to offer physicians a chance to assess their behavior before they are reported for inappropriate behavior.
The Physicians Development Program isn't just for disruptive physicians, Dr. Harmon said. It can also be used by groups of physicians who want to provide confidential feedback about how they are impacting their staff and colleagues. “It gives physicians a chance to see themselves as others see them, and maybe for the first time.”
Prevention is key, Dr. Pomm said. Hospitals should conduct ongoing assessments of personnel and work environments and offer help to employees, he said.
State medical boards are also in a position to help physicians get help before a disciplinary action is necessary, said James N. Thompson, M.D., president and CEO of the Federation of State Medical Boards.
Developing a nonpunitive way to identify physicians who are heading toward trouble would serve the public, reduce disciplinary actions, and keep physicians in practice longer, Dr. Thompson said.