Most physician leaders will face a dreaded situation at some point: multiple complaints about a physician in the practice whose behavior is causing problems.
The best response is to deal with the challenge head-on because you may have the opportunity to address co-workers’ concerns, salvage a colleague’s job, and burnish your bona fides as an effective leader.
That’s the advice from Charles Stoner, professor emeritus at Bradley University, where he specialized in leadership, interpersonal dynamics, and organizational change, and Jennifer Robin, a psychologist and expert in great workplaces. Both have helped physician leaders navigate the turbulent waters of remediating physician behavior.
“Once a physician is labeled as distressed or disruptive, it’s really hard to come back from,” Robin says. “Part of what makes it possible to come back is the leader, the environment that the leader creates and the support that the physician gets from their leader.”
Stoner and Robin, authors of Working with Distressed Physicians: A Guide for Physician Leaders, shared their insights with Physician Leadership Journal. Their comments have been edited lightly for clarity.
Q. How does a leader know when a physician’s behavior warrants intervention?
Robin: More often than not, it’s a combination of things. The leader may notice what we call disruptive behavior such as unproductive participation in meetings or difficult team relationships. And the leader is likely hearing from staff members that this physician is a problem.
Stoner: It could be that you are seeing some negative or disruptive patient outcomes or key performance metrics that are being missed. Also, the morale of the team is being affected or the kind of culture that the physician leader wants — a working environment with a lot of support and collegiality — is really being undermined.
Given the stress and pressure that physicians are under, there are going to be times when there may be an emotional response or outburst. But when problem behaviors occur over and over again, it has risen to the point where it requires attention because there’s too much at stake.
Q. In your experience, how do leaders typically respond to complaints about a physician in the practice?
Stoner: The research on leadership — not just physician leadership, but leaders in general — shows that the tendency when dealing with conflict is to just ignore it in hopes that the problem will either go away or get better.
Physician leaders in particular typically see their colleagues as talented and valuable and having a lot of potential, so there’s a tendency to think that their fellow physician obviously knows what he or she is doing; the underlying hope is it will get better.
Robin: Physician leaders may think they do not have the skills necessary to approach the situation constructively. So it is sort of natural to say, “I’m going to avoid that tough conversation because the outcome is not guaranteed to be positive.”
Q. Of course physicians value their autonomy and leaders may worry about making the situation worse by calling attention. Is it OK to just observe from the sidelines for a while?
Robin: Addressing things as early as possible gives the leader time to investigate and to solidify their own relationship with the physician before things get urgent. I have heard “Once is a blip on the radar screen; twice is a coincidence; three times is a pattern.” Much more can be done if you engage early.
Stoner: It’s good to have a meeting early on, even if it’s a very informal meeting. Make a point of pulling the person aside, try to be non-confrontational, and just ask: “Is everything all right? It seems like you’ve been a little less focused lately.” That kind of conversation can be an opening.
And then it is really important to stay close. There’s a tendency to say, “This person can be a problem — let me hold them at arm’s length.” That is the exact wrong approach. What you want to do is stay closer with these people and not farther away.
Q. What are the traits commonly found in physicians who exhibit unacceptable behavior?
Stoner: We know from research that certain characteristics — which are largely positive and contribute to their success — are common among physicians. What sometimes happens is the distressed physician simply takes those characteristics to an extreme.
For example, physicians typically have a high need for achievement. There’s nothing wrong with that; we want that. They tend to have some narcissistic tendencies, and there’s nothing wrong with that — except with the distressed physician, when narcissism can become unhealthy and very self-centered.
Most physicians have high needs for control; again, there is nothing wrong with that — we want our physicians to be in control. But the distressed physician often gains that control in an angry way or a way that is dismissive of others. It’s not the control that is the issue; the problem is how they go about exerting the control.
Distressed physicians tend to have a lower degree of interpersonal trust, lower levels of emotional intelligence, maybe a lower level of empathy. It is really important to point out that distressed physicians often are not aware of how their behavior is affecting other people. They may think “well, that’s no big deal,” but to the people who are chronic recipients of their behavior, it is a big deal and becomes a bigger deal over time.
Q. What should a leader keep in mind when they are preparing for a tough conversation with a colleague when the message is that their behavior must change?
Stoner: It’s important for the physician leader to remember that they are taking action to help salvage that individual’s career, at least at that particular organization, so that’s a pretty noble cause.
When they have that conversation, they should let the target physician know how valuable they are. Any time you tell someone “I need to give you some feedback,” they are going to become defensive. So the leader should focus on that individual’s contributions. Your goal is to help them overcome some things that block them from being as successful as they can be.
Robin: When you are five minutes away from that meeting, don’t allow headspace to be taken up with “I’ve never done this before” or “This person is my colleague.” Remember that you are sitting across from a whole person, not just a person who is engaging in disruptive behavior, and you are saving a career here.
Stoner: When you approach a distressed physician from that perspective, they can recognize and appreciate that you are in it, to a great extent at least, for them.
Q. Should other members of the staff know that a physician is being asked to remediate certain behaviors? Or should this process be strictly confidential?
Robin: Of course in personnel matters there are things we need to keep confidential, but this type of situation may be an opportunity to make sure that the culture of the unit includes a sense of psychological safety. That is the idea that, as a team, we feel we can voice opinions, we can make mistakes, and we can collaborate with others to resolve those mistakes. The throughline there is that it makes vulnerability a little less scary. So creating an environment of learning and development involves the whole team.
Also, physician leaders can role-model certain behaviors. For example, they can talk about the deficiencies that they are working on and the things that they would like to seek grace for in their unit. For instance, they may say something like, “Hey, I’m trying to pull myself away from my desk during my admin days just to make sure that I check in on everybody. That’s something that I want to do more of, so please give me some feedback.” That demonstrates that everyone should be working on interpersonal skills.
Q. Changing problem behaviors takes time. Is it a good idea to hire a coach to help a physician?
Stoner: Passing the situation off to an outside coach is probably not the best way to go. We prefer to have physician leaders deal with these situations on their own, although if outside coaches work in collaboration with the physician leader, they can be another voice helping with the concern.
Robin: We do not recommend that every physician leader goes out and becomes a coach, but some of the coaching tools can be really helpful to leaders. Good coaching skills are good human skills, so it can never hurt to shore up that coaching skillset for situations like this.
One coaching framework that can be useful is the GROW model (popularized by Herminia Ibarra and Anne Scoular in their 2019 Harvard Business Review article), which has four steps. That starts with GOAL, or defining clear objectives, and REALITY, meaning you must assess the current situation. Then there is OPTIONS, which is exploring possible solutions, and WILL, making a commitment to act.
I like this approach because it lets the person across from you decide what it is that they want, compared to where they are now, come up with some things that they can possibly do and then decide what they are willing to do. That is a good template no matter who you are dealing with or in what context to facilitate a person’s thinking about how to move forward.
Q. If the target physician is resistant to the idea that change is necessary, is that a normal response or a red flag that the situation cannot be remediated?
Robin: Resistance is logical in some ways because their pattern of behavior has been working for them up until this point. So one route is to say, “Look, this isn’t going to work for you any longer.” This is one of the reasons to start early when you see a problem emerging because it gives a little bit more runway to start talking about the possibilities of change.
It could be that while this behavior has been working, it is not providing everything that the individual wants. So you might have a conversation: “What would everything you want look like? And how can you achieve that through better team relationships and developing better interpersonal skills that will help you?”
Stoner: If a person does not have a readiness for change — an awareness of the need to change and a desire to do so — it is hard as the devil to improve a situation. Physicians are bright people; they can obfuscate and push you off course quite effectively and probably have done so over the years. So that is a reality that we must face.
It is important to help the individual build a readiness for change, and a lot of that has to do with the consequences. If the physician understands “If I don’t do something and make a change, I don’t like what’s going to happen to my career or to my progress in this organization,” they will be more vested in wanting to have a solution.
For example, we worked with a physician leader who knew the target physician wanted to take on leadership roles in the organization. The physician leader simply said, “One of the consequences is, unless these things are remediated, I won’t be able to recommend you for a leadership role.” That touched a very real need of the target physician, so the individual had greater motivation to care. Sometimes it takes a bit of a search to find what those motivating factors might be, but that can be worthwhile.
Q. How can a physician leader feel confident that the individual will follow through on a commitment to change?
Robin: There needs to be a plan of action that taps into some goal of the target physician whether that is achieving higher patient satisfaction or better work-life balance or an opportunity to move into leadership — whatever it is that will motivate the physician. Then there needs to be a reality check — where we are now and what is needed to close that gap. The action steps can be micro-changes, trying some things to see if it produces the change that is needed, and staying in close contact to discuss what is working and how to make it work even better.