How We Can Help the Disruptive Physician

My physician health colleague Dr. Luis Sanchez has written a superb Viewpoint piece in a recent issue of JAMA on disruptive actions of physicians (1). He updates the reader on this decades-old problem and summarizes the roles that are played not only by the identified physician but also by the institution or so-called medical environment itself. Hospital leaders must be up to speed in knowing how to investigate, how to reach out to the physician, and how to implement the array of options for evaluation and treatment to ensure a culture of safety for all hospital personnel and patients.

My purpose in this short piece is how best to assist a self-referred physician who comes to us should he/she be accused of unacceptable, abusive, oppositional, or bullying behavior in the workplace. Here are some tips:

1. It has been my clinical experience that most physicians who have presented to me with this chief complaint are defensive, angry, humiliated, and often self-righteous. Some already have an attorney. Common defenses are denial, minimization, and rationalization. But, in many cases (but not always) their defenses yield once they get a chance to tell their story in an uninterrupted manner with a dispassionate and empathic listener. They feel they’re in a safe place.
2. Try to obtain a very thorough history of the current event. Is this something de novo or have there been instances in the past (in medical school, residency, early career) that may not have been reported but are concerning (at least to you)?  Remember that you only have your patient’s highly subjective narrative of what happened and the details.
3. It is incumbent that you do a very thorough and comprehensive biopsychosocial assessment, as best you can with only your patient as reporter. Disruptive behavior is a symptom and you really need to rule in or rule out various DSM-5 diagnoses. There are several of these that will guide your line of questioning and listening: bipolar disorder (especially bipolar II type), any of the depressive and anxiety disorders, obsessive-compulsive disorder, acute and posttraumatic stress disorder, various disorders of sleep, substance-related and addictive disorders, and neurocognitive disorders. There may be a personality disorder but we must be careful not to jump to conclusions if there is something above that has been undiagnosed and untreated. Virtually any of the personality disorders can lead to workplace behaviors that are unacceptable and cause grief to co-workers and others. Finally, there is a long list of V codes that capture many of the psychosocial issues that your patient may be dealing with— both the ones that are specific to the work environment as well as ones that are originating within or at home and spilling into the medical setting.
4. Make certain that your patient has a primary care physician and a recent health clearance. Undiagnosed medical conditions in physicians can play havoc at work.
5. Try your best to get your patient’s permission to obtain collateral information. This can aid your diagnostic quest and better inform treatment. Important data may come from the patient’s loved ones or employer, training director, department chair, medical director, and so forth. Contrary to your patient’s belief system, these are often individuals who have the person’s best interests at heart, especially if they have worked with him/her for some time and see a change in behavior and performance. They have been concerned that there is something going on in the person’s life and want him/her to receive help.  
6. Always remember that our treatment is contextual and grounded in a classic doctor-patient relationship. This includes advocacy but it is not without bias. If an independent medical evaluation has not been requested (or required) by the workplace or the state physician health program, you might discuss this with your patient. Those recommendations (many made by Dr. Sanchez in his article)—psychopharmacological consultation, employee assistance programs, physician coaches, wellness committees, physician retreats and more—will round out your treatment and serve your patient well.

Reference

1. Sanchez LT. Disruptive behaviors among physicians. JAMA. 2014; doi: 10.1001/jama.2014.10218