Disruptive behavior gets slammed down

November 1, 2008

I would like to end this month's Utilization Review Committee meetingby once again addressing the radiology department's failure to rein in inappropriate studies and reports without proper clinical history.

I would like to end this month's Utilization Review Committee meeting by once again addressing the radiology department's failure to rein in inappropriate studies and reports without proper clinical history. The most recent audit shows that we continue to lose revenue because of denials for these cases. Dr. Lurch, as chair of the radiology department, what do you have to say for yourself? It has been a year, and we've not seen any improvement."

"I told you a year ago this wasn't going to work because radiologists don't order studies. You have to go after the doctors who order them to have any impact. We sent out memos. Nothing changed. We had meetings. Nothing. We had workshops. Nothing. We did training. Nothing."

"Well, you need to try harder."

"We did. We refused to do any study with out proper/correct history. What happened? Something! They threatened to take their patients elsewhere, and you told me to stop. Then we tried doing our own chart reviews on these cases to decide which studies to refuse. What happened? Something. Adios patients. We were told to stop.

The radiology department blacklisted the worst offending doctors. Something, again. Same threat. Same result. The three biggest abusers all serve on this committee and are sitting at this table right now. Why don't you ask them what we should do?"

"Well, as one of the doctors Dr. Lurch is attacking, I feel his behavior is more disruptive than helpful. Radiologists just aren't smart enough to be making decisions about what is best for my surgical patients. I think we should give Dr. Lurch more time to come up with a better solution."

"Dr. Lurch, do you have any other ideas?"

"Yeah! I would suspend any doctor who cannot comply with the goals set by this committee. Then you will see some results. You're the hospital administrator. You can do it and you should. Granted, you may lose some doctors and patients as well as some revenue, but this is the only way you will change behavior."

"Hmmm. Does anyone on the committee want to add anything?"

"I'll choose to ignore his tone. However, I think I can speak for most of my colleagues on the medical staff, those of us who admit the majority of patients here, that we would have to agree that what Dr. Lurch says is absolutely true."

"Okay. Anyone opposed to the proposal for suspension? No? The motion passes unopposed. Dr. Lurch, you are suspended until you can decrease the number of denials."

"WHAT?"

"Meeting adjourned."

I'm struck by how the conflict between Russia and Georgia has created a predicament for the West very similar to the problems created by hospital administrators. Russia invades Georgia. The bad behavior is condemned by Europe, but they really don't want to do anything about it, since that would risk offending one of their largest trading partners and single largest provider of energy. Bit of a quandary. What to do?

Rather than take any action, they start to blame Georgia for inciting the invasion because of its attempt to join NATO, which, of course, only provoked Russia. Bad Georgia!

Rather than hold the ordering doctors accountable and risk a breach which, in turn, could depress quarterly revenues, it is safer to make the radiologists responsible. Problem solved.

Curiously enough, this way of solving problems has direct bearing on both a problem I had with a surgeon recently and an article in the AMA News from Aug. 18, 2008, about how the Joint Commission on Accreditation of Healthcare Organizations would now be adding "disruptive" behavior to the list of sentinel events, with the explicit expectation that hospitals crack down on such behavior.

I initially applauded this move because I am sure we as radiologists have all experienced such treatment in the past. At least, I did until I had my problem with a surgeon one night. When I called him with the results of a CT angiogram with a massive pulmonary embolism, he went postal on me for waking him up and then started personally attacking me. It was really, really unpleasant.

I was so shaken up by it, I spoke to the nursing supervisor and an emergency room physician. They both told me that this doctor was a psycho and that the whole hospital had problems with him. Unfortunately, people who complain only end up getting into trouble because he is also quite powerful and brings in a lot of profitable procedures to the hospital. The ER doctor was aggressively egging me on to write a letter of complaint because he said they all wanted this guy to get his comeuppance. Yeah. Right. Like I want to be the one to do that. I would rather rollerskate blindfolded and naked on a well-oiled balance beam.

In a study published by Dr. Alan H. Rosenstein and Michelle O'Daniel, MHA, MSG, in the April 22, 2008, issue of Neurology, "Managing disruptive physician behavior," the authors found that 74% of disruptive behavior was caused by surgeons. Now, most surgeons are good people, but they have a reputation for such behavior that is well known and, for some, well deserved. Why? Simple-because they get away with it.

We have all seen it. Insult a nurse? Nothing. They want to take over a radiology procedure or a vascular lab for themselves? Throw a tantrum, and the hospital will give it to them rather than risk losing their patients.

So this JCAHO mandate should be a good thing, right? JCAHO's prohibited behaviors include such things as condescending language, voice intonation, and impatience. If you ask me, these are nebulous and hard to define terms that could be easily misinterpreted or unevenly applied.

The rules take affect Jan. 1, 2009, but I know how these things work. In 2010, they will add to the list ironic comments, sardonic observations, satiric phrases, snorts, chortles, nose wrinkling, and exasperated sighs. But what I fear most is eye-rolling, because I just can't control that. If someone says something dumb, I roll my eyes reflexively. By 2011, they could add assaulting body odor, offensive hair-cuts, and inopportune belching.

You may want to stay awake at your next medical staff meeting, since JCAHO will "require hospital admin-istrators to adopt codes defining dis-ruptive behavior and develop procedures to discipline medical staff." This is especially critical, as the number of hospitals accused of using such policies for either economic credentialing or removal of physicians who complain about bad hospital policies or substandard care has been steadily rising.

There are even conferences offering the pros and cons of actually doing economic credentialing. I can easily imagine how the consequences for a powerful and profitable surgeon giving a nurse a concussion with a speculum might be far less than for a radiologist accused of being insubordinate for dictating a case without an adequate clinical history, who just happens to have an imaging center across town.

Since I just turned the big five-oh, people have been telling me that things only get harder the older you get. Unfortunately, some things get easier, uncontrollably easier. I can just see myself getting tossed off the medical staff for a trumped-up disruptive "sentinel" event totally beyond my control: impertinent digestion.