“If they will hand me the instruments when I need them, then they won’t get yelled at. This is my OR and my rules.”
“Well, I’ve always prescribed Cipro for strep throat. In my experience, it always works. No one can tell me how to practice medicine.”
We’ve all heard stuff like that before. Try to offer a correction or suggestion to a colleague and the walls go up immediately. It can be very uncomfortable, especially for non-physician staff, when a physician shuts down a conversation. Physicians often implicitly hold the most power in conversations or interactions that they have with staff and patients. If they refuse to discuss something further, then there is little recourse, but the long-lasting impact on relationships can be irreparable.
So how do we deal with this? As a supervisor, how do I hold staff accountable? As a colleague, how do you approach someone and speak up when you see a problem? It will always be uncomfortable to criticize someone, but if structured correctly, criticism can lead to growth.
If structured incorrectly, then these conversations can lead to worsening distrust within healthcare organizations. If administrators thought their job was hard now, try to lead a cadre of physicians that refuse any attempts you make at change or improvement. It can get ugly fast.
Peer To Peer Conversations
Physicians correct other physicians. That is the practice in my organization, and it is essential. Due to the extensive amount of training that the average physician undergoes, it is very difficult for non-physicians to grasp the knowledge base and unique experience that most physicians have.
This is similar to many other highly specialized fields. I wouldn’t dream of micromanaging the daily tasks of a nuclear physicist. I have no clue what he does on a daily basis. In the same way, physicians are much more apt to listen to a fellow colleague than a non-physician.
My first thought when an MBA tells me I’m not seeing enough patients? Who does this bean-counter think he is (no offense!)?
My first thought when a fellow internist tells me I’m not seeing enough patients? Holy crap, am I not pulling my weight?
Establish the Standards
If you’re going to hold someone accountable, then you need to define what the standards are. Decide the standards up front and include physicians in the decisions regarding this. As I always say, the mission is the answer, and you have to very clearly delineate what you expect your staff to accomplish when they show up at work.
These standards can get as specific or as broad as you like. I personally prefer to keep them broad so we hold each other to the spirit of the law rather than the letter of the law.
I may receive hate mail for this as well, but I think you should define what the standards are not only when it comes to behavior, but also clinical practice. Civility and respect should be a common expectation in all interactions, and most will not have a problem with this. ZdoggMD has an excellent video below demonstrating how to appropriately talk to patients:
OK, maybe not, but I think you get what I’m going for here.
There are numerous benefits to establishing clinical practice standards as well. If all physicians practice in a similar way, then it is much easier for staff to effectively do their jobs. We use published clinical practice guidelines as our starting point and have established methods for deviating from them if there is a compelling clinical reason that the physician staff can agree on.
If a situation is outside of established guidelines, then physicians need a formal venue for peer assistance. This can be through interdisciplinary rounds, tumor boards, etc. The purpose of clinical practice standards is not to cram every patient into the same box. The purpose is to practice in an evidence based manner where evidence is clear, and allow for reasonable judgement when the evidence is not clear.
Public Praise, Private Correction
Do you enjoy being called out in public? Didn’t think so. Then don’t do it to other people! Physicians are no different. Nobody responds well when called out in a meeting of their peers. A justified critique will easily be interpreted as a personal attack because of the venue.
Despite what some may think, adding the extra humiliation of public critique doesn’t “add emphasis” to what you say or “make them remember.” It just builds resentment. The average physician is a driven, hard working individual that will have no trouble remembering any criticism they receive.
In contrast, everyone wants their accolades to be publicly broadcasted. Even folks that shy away from the limelight enjoy being congratulated in front of their peers, whether they admit it or not.
Again, physicians, on average, amplify this even more. Physicians pride themselves on the quality of their work and enjoy seeing that work recognized. Remember you are talking to a group of people that earned a lot of A’s during their school years! Feed the ego a bit and let everyone know when someone performs well.
I hear this phrase thrown around a lot in break rooms. Several physicians have told me before they should be “given the benefit of the doubt” or shown a little “professional courtesy.” Unfortunately, they don’t seem to know what that really means when they say it.
I think our professional athlete colleagues can assist us with an example. Here is Peyton Manning and Jeff Saturday, formerly of the Indianopolis Colts, giving a wonderful example of professional courtesy (note there is some language in the video courtesy of Youtube):
See, professional courtesy means you just sweep problems under the rug, right? Ha! Professional courtesy means I do you the courtesy of coming to you, peer to peer, to ask about what happened rather than simply acting on the information I receive (or calling a press conference in Peyton’s case), under the assumption that we are both on the same page regarding our common mission and goals.
There are many vocations where someone reporting your misdeeds leads directly to termination or other bad consequences. Try working at McDonald’s and have one of your co-workers report that you stole something. Your manager will have a conversation with you, but it will be very brief and will likely end with you handing in your name tag.
Professional courtesy means if someone reports a potential problem to me about a physician, then I do not pass judgement during that initial conversation. I will promise to investigate, but I will not promise to punish or even agree. This can be frustrating for other staff at times, but to me, innocent until proven guilty is an essential part of professional courtesy.
Second, I will review the facts surrounding the case myself and come to you, physician to physician, to discuss the matter (hopefully with fewer bleeps than Peyton). I will not pass judgement before talking to you, and I am open to hearing your reasoning for your actions. This may or may not change my mind, but I will speak directly to you and not to anyone else.
As I said before, professional courtesy never means that I will ignore problems. Our standards are our standards and everyone must be accountable to them. However, I will absolutely promise to come to you, and no one else, to discuss the issue. That is professional courtesy.
Address Problems Now
If there is any final piece of advice I can give, it is to address problems immediately. Don’t ignore them. Don’t say you’ll “address it next time.” Address it now. Show your colleagues that you really think accountability and performance standards matter. Demonstrate urgency with your actions.
The single greatest problem I see amongst physicians and physician supervisors is lack of urgency when it comes to accountability. We get caught in this every man is an island mode of thinking where we simply throw up our hands and say “he’s responsible for his own actions.”
We have to acknowledge that our fates as physicians are tied together and act accordingly. It is always better for physicians to collectively improve. Always. No improvement happens without accountability.
Remember that, at the end of the day, we are going to be accountable to someone. We can either be accountable to ourselves or to someone else. We’ve tried the someone else route in medicine. Time to do something different, wouldn’t you say?
Have you ever tried to correct a colleague or bring up a problem? Did it blow up in your face and turn out well? Tell me about your experience in the comments!