Published in the April 2013 issue of Today’s Hospitalist
YOU KNOW THIS HOSPITALIST. He looks good on paper but is a renegade on the job. Maybe he’s rude to nurses, or he goes out of his way to avoid admissions toward the end of his shift. His attitude causes problems among the rest of the group, so morale plummets and the group’s reputation suffers.
Veteran hospitalist Edward Ma, MD, knows the type. He once worked with a program in which some doctors constantly complained about the workload, grew frustrated with even one page from a nurse and really “put on a display of discontent” when the ED called with the first admission of the day.
“That created a negative, pervasive perception of our practice among the specialists, referring primary care doctors, and nurses and ancillary staff,” Dr. Ma says. “The bad behavior of a few made it acceptable for other hospitalists to do likewise.” The more such behavior was tolerated, he adds, the more reasonable physicians grew disillusioned and left.
“The disruptive hospitalists were known to say, ‘What are they going to do, fire me? Where are they going to get another doctor to replace me?’ ” Dr. Ma says.
The reality is that disruptive behavior has been tolerated for that very reason: The demand for hospitalists outweighs supply, creating what Dr. Ma calls “a prima donna attitude.” Add in the lure of a good paycheck, limited hours and the ability to leave work at the door, and the field has attracted some doctors who bristle at the notion of doing or being more.
To be fair, anyone under stress can occasionally get snippy on the job. And it’s easy to label physicians who are resistant to change or respond to criticism defensively as “difficult.” But chronic negative behavior can be toxic, creating a culture of dissatisfaction.
“The ‘bad apple’ is the group’s weakest link, and we’re only as strong as our weakest link,” says Julia Wright, MD, business unit president for the north central region of Cogent HMG, a national hospitalist management group. “It brings morale down and devalues the program.”
And putting up with difficult doctors now has real financial consequences in an era where performance has a growing impact on the bottom line.
“A negative attitude can poison the whole work environment,” says Mary Witt, senior vice president of physician services with The Camden Group, a national health care management and consulting firm. “Think long and hard about whether you can tolerate that kind of behavior.”
What’s the problem?
As tempting as it may be to just cut a difficult person loose or turn a blind eye, experts say such steps can make the disruption worse or cause new problems. Groups need to take a hard look at how their programs are being managed, whether expectations are explicitly spelled out and followed up on, and whether the physicians are a good fit with the program’s culture.
In some cases, problems may stem from simple misunderstandings about the group’s rules of conduct. In a practice in which all doctors do night work, for example, it may be understood (if unwritten) that the day doctor doesn’t leave admissions waiting at the end of his or her shift.
David Grace, MD, senior medical officer of hospital medicine for The Schumacher Group, a physician staffing company based in Lafayette, La., recalls one new doctor who was labeled “difficult” because he called an older specialist by his first name. The difference was quickly ironed out, says Dr. Grace, by letting the new physician know that within the culture of the older doctor, who was not born in the U.S., calling elders by their first name is considered disrespectful.
“How you define ‘difficult’ includes standards of conduct and professionalism and for work expectations and performance,” Dr. Wright says. “The softer side can be difficult to quantify but can be defined as physician behavior contributions, team ethics and ownership.”
New weight on communication
“Difficult” may also describe physicians who just aren’t good at communicating with either patients or other providers ” skills that aren’t taught in training.
Now, however, value-based purchasing (VBP) is putting a new spotlight on doctors’ communication skills. That’s because patients’ satisfaction with physician interactions can directly affect hospital payments.
“There wasn’t quite the same incentive to be nice to patients until VBP,” says Dr. Ma, who’s now medical director of hospitalist services at Brandywine Hospital in Coatesville, Pa. “I didn’t have to build up a ‘clientele’ of patients satisfied with the hospital’s services, but hospitalists now have to.”
As a consultant, Ms. Witt says she usually hears complaints about communication problems from hospital staff or patients’ primary care physicians. When she relays those to the hospitalists themselves, they are often surprised.
“They say, ‘Is it me you’re talking about?’ because they think they’re communicating effectively,” she notes. “They just don’t recognize how their style comes across to others.”
Sharing patient satisfaction scores with those physicians can be helpful, Ms. Witt adds, assuming that the questions ask specifically about doctors’ listening skills and interaction. “Those can get a physician’s attention and facilitate a discussion or willingness to accept training to improve,” she says.
A bad fit
Other physicians can’t or don’t want to juggle responsibilities that emphasize teamwork. Someone “can be a great doctor but a lousy hospitalist” who doesn’t pull his or her own weight or resists change, Dr. Grace says.
“Hospital medicine now is about transitions of care, documentation, quality billing and risk management issues,” he points out. “That’s different than being a good doctor. It’s being a good citizen of the hospitalist program of the hospital.”
One big clue that the problem might not be a group’s culture is that only one hospitalist is complaining. “It doesn’t mean that person is a bad doctor,” says G. Bruce Waldon, MD, director of the hospitalist division for the Northwest Health System in Bentonville, Ark. “Just a bad fit.”
Or physicians may feel they’re not getting adequately compensated for perceived “extra” work. While pushback may be reasonable when workload demands are too high, it can be a sign of a “mercenary mentality.”
That’s according to Jairy Hunter, MD, MBA, associate executive medical director for case management/care transitions at the Medical University of South Carolina in Charleston, S.C. Dr. Hunter says that some hospitalists think they should receive additional compensation for every function outside of patient care.
In the past, Dr. Hunter says, “doctors used to participate in medical staff proceedings because it was in their patients’ and their own best interests to care about how the hospital operated.” But for some hospitalists now, he adds, nonclinical tasks “even attending group meetings “are viewed instead as an intrusion on their time that should be reimbursed.
“Some are not necessarily married to a practice or even committed long-term to a job.”
A shift mentality
This kind of limited vision is particularly common among new hospitalists, who are focused on the clinical aspect of being a physician and likely have little education in quality improvement or health care finance, says Jeffrey Frank, MD, MBA, medical director of inpatient case management at John Muir Health in Walnut Creek, Calif. “Some hospitalists choose this career because they want shift-based work and they don’t have to be on call,” Dr. Frank notes.
Those expectations, however, may clash with new expectations of efficiency and performance. As hospitals try to implement quality-based programs like value-based purchasing, he adds, only a relatively small number of hospitalists want to do the difficult work of attending meetings and improving systems of care.
“The reality is that lots of doctors are not on board to participate in these projects,” Dr. Frank says. “Most of the work to improve hospitals is done by 10% of hospitalists, and it’s hard to get the other 90% engaged. We’re raising expectations because of programs like value-based purchasing, and more people are becoming involved.”
To encourage that engagement, Dr. Frank thinks at least 15% of a physician’s salary needs to be pegged to performance metrics like patient satisfaction and core measures.
“I believe in doing quality projects to improve patient care while optimizing physician and staff workflow,” he says. “But it is easier to get physicians involved when compensation is tied to these efforts and outcomes.”
RVUs and other incentives
The 20-physician hospitalist group at St. Joseph’s Hospital Health Center in Syracuse, N.Y., recently enhanced its incentive plan to persuade physicians to be better citizens.
James Leyhane, MD, director of the group, says that as of this year, a citizenship metric now makes up a portion of hospitalists’ 20% performance incentive. (The remaining 80% of their compensation comes from flat salary.)
Serving on a committee is rewarded in the new incentive package. “Each physician was able to get his or her first or second choice of a committee to serve on and will be evaluated on a ‘citizenship’ metric requiring 60% attendance or active participation,” Dr. Leyhane explains. Hospitalists can also meet that citizenship requirement through teaching or presenting cases at a variety of teaching rounds.
As for motivating low producers, groups can use incentives to reward physicians who do the heavy lifting. Groups can, for instance, increase their internal RVU weight for admissions or discharges to discourage pushing those off onto the next hospitalist coming on shift.
But RVUs without quality or satisfaction incentives can encourage physicians to hurry through patient interactions, Ms. Witt says. “It leads to shift thinking: It’s 6 p.m. and I get to go home.”
Individual or group incentives, or both?
But just how much can groups use individual incentives to make physicians better citizens? One challenge is finding data to provide individual feedback.
“For certain things that are hard to account for like core measures, it’s hard to drill down to the individual hospitalist,” says Dr. Hunter from the Medical University of South Carolina. “Was it the person who cared for patients for five days or the one who did the discharge on the last day?” Who should be accountable for making sure the standard was met?”
In fact, says Dr. Grace from The Schumacher Group, it helps to use a mix of both individual and group incentives to change the behaviors of individual physicians.
Individual incentives allow physicians to rise above the noise of the difficult or under-performing doctor. But group incentives “which no one earns unless the group as a whole hits certain thresholds “force the entire group to police each other and apply pressure to outliers. With a group pool on the line, team members can help program directors push for better individual performance.
“It’s easy for a doctor to tell an administrator, ‘You don’t understand, you’re not a doctor,'” says Dr. Grace. But when a hospitalist argues that he can’t take a 16th patient that day because it’s unsafe, peers can offer an informed response. “They can say, ‘It is safe. It just means you’ll go home 45 minutes later,’ ” he says.
And beginning last month, Northwest Health System in Bentonville, Ark., is “unblinding” patient satisfaction score results for the group. “It will be clear which physician has 90% patient satisfaction and which has 40%,” Dr. Waldon says. The point is to use those comparisons to find out what high performers are doing right.
Not surprisingly, everyone isn’t thrilled with the move. “I got some pushback,” Dr. Waldon says, “but we’re all in this together, and we all can learn from each other.” Having an underperforming physician shadow a high performer is another option the group is considering.
When incentives won’t work
However incentives are structured, experts say that performance must be measured and reviewed in meetings that occur at least once a month.
But while bonuses may change individual performance, Dr. Wright cautions that they may not affect a physician’s character or reasonableness. “I don’t think incentives are the major carrot to get people to behave the way we want them to,” she says. Instead, it’s knowing expectations and fitting well within a group’s culture.
Dr. Waldon likewise thinks it’s best to directly confront difficult physicians instead of trying to manipulate compensation to keep them happy. “It’s a lot less work and better for the health of the group,” he says, “to say, ‘This is what we expect, you’re not performing in that way and your behavior indicates you’re not happy. Do you need to find another job?’ ”
Sometimes, radical housecleaning is your only option. That was Dr. Ma’s approach when he joined Brandywine Hospital eight months ago. He found that more than 40 physicians had churned through the six-hospitalist practice over eight years. “Good docs left and the practice had difficulty attracting new ones,” he says.
To turn the group around, he laid down new ground rules: He was willing to hire only long-term, career hospitalists and would no longer use locums. And hospitalists needed to demonstrate a commitment to the practice and hospital by attending committee meetings, picking up open shifts, and becoming more cooperative with nurses and staff.
It hasn’t been easy, and Dr. Ma says he was “held hostage by difficult doctors because we were so short-staffed.” But recruiting one doctor and three nurse practitioners gave him the breathing room he needed to make changes.
“I didn’t want someone who came in just to get a paycheck,” he says. “I was looking for people committed to building a high-functioning practice and improving the hospital’s quality of care.”
Leading with professionalism
Difficult physicians can cause trouble precisely because they are tolerated. But often, experts say, difficult doctors flourish because hospitalist leaders are short on management training or experience.
“The field has grown so fast that I see lots of programs where the medical director is just two years out of residency,” Dr. Grace says. “If we had had a veteran leader, a ‘difficult’ doctor may not have been so difficult.”
Leaders need to model professionalism, mentor when needed and discipline if called for, says Dr. Hunter. “Discipline might include withholding a bonus, suspension from work or even firing if the behavior doesn’t improve.”
But best efforts can’t salvage every case. In some groups, leaders may have to make tough short-term decisions to position the practice for long-term success.
“Setting clear expectations and holding people accountable are critical,” says Ms. Witt. “And if physicians don’t respond, changes have to occur. Making one or two changes in physicians may be enough to send a message so others will change.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.
Finding the right doctor the first time
According to experts, one of the best ways to avoid dealing with difficult doctors is to not hire them in the first place. Instead, spend time during job interviews communicating your group’s expectations and culture and trying to uncover red flags in potential candidates.
Edward Ma, MD, medical director of hospitalist services at Brandywine Hospital in Coatesville, Pa., for instance, always asks for 15 references from a potential candidate’s previous institutions: five physicians, five nurses and five case managers.
“I’m not so concerned with candidates’ clinical skills as their abilities to work with others,” Dr. Ma says. “I can teach someone how to place a central line or treat nocardiosis, but I can’t teach them to be a good, caring human being.”
In Bentonville, Ark., G. Bruce Waldon, MD, director of the hospital division for the Northwest Health System, asks potential hires to respond to a series of scenarios. What would they do, he asks, if they were walking down the hall and heard someone asking for help or saw a light buzzing?
“Go look for a nurse” is not the response he’s looking for. “The right answer is to go in and ask the patient if you can help,” says Dr. Waldon. Another scenario: What would the hospitalist do if he or she was in the patient’s room with a nurse and the patient needed to be scooted up in bed?
“Unless you have a back problem, there’s no reason to walk out and find someone else to do it,” he notes. “Do it yourself. Help the nurse. I want doctors to treat patients like they would treat family, and I try to create that expectation.”