Paul F. Levy

Leadership Insights

Advocating Through Inquiry

By Paul F. Levy | Oct 31, 2013 | Comments (5)

Here’s a familiar story in America’s hospitals. An “old fashioned” surgeon decides that the protocols and procedures put in place by the medical executive committee or other governing body don’t apply to him. “I’ve done it this way for 30 years, and it works fine. I’m the busiest surgeon here, and no one is going to tell me how to do my job.”

People in the risk management field will advise you that such a person is a high risk. His attitude often carries over to treatment of people in the OR. At best, he is uncompromising and lacking empathy. At worse, he is psychologically or perhaps even physically abusive to lower level staff. He also tends to treat patients with a lack of respect. He has more patient complaints on file compared to his peers. When he finally makes a mistake that causes a patient harm, he is a likely candidate for a large malpractice lawsuit.

And yet, notwithstanding this behavior, the hospital leadership is unlikely to do much to correct the problem. The surgeon has a great reputation in the community and is the source for many referrals. So, at most, when an egregious incident is reported to his chief, the reaction might be, “Yeah, I guess I won’t give him his full bonus this year.”

Clearly, such an approach is inadequate and will not resolve the underlying problems. It fails because the message is not delivered at or near the time of the incident. Also, there is not always a nexus drawn between the financial penalty and the behavioral issue. Finally, financial penalties do not have a lasting impact on behavior, if they work at all.

Institutionally, we are advocates for greater adherence to clinical approaches that are safer and deliver higher quality care. We also seek behavior between doctors and colleagues—and doctors and families—that is mutually respectful and reflects a partnership in delivering care. When a doctor has been habitually misbehaving on any of these fronts, we need a way to persuade him to change his ways.

Authority vs. Awareness Intervention

An alternative and more effective approach is outlined in several articles by Gerald Hickson and others from the Vanderbilt University School of Medicine. One article presents a hypothetical example about an emergency room doctor who has misbehaved:

Dr. Trauma has high productivity. Nonetheless, you cannot offer excuses for his performance. Others in the department conduct themselves professionally. In addition, this is not the first time that Dr. Trauma has behaved this way. During the past two years, other team members submitted event reports that describe similar behaviors. Some of the coworker and patient complaints suggest that Dr. Trauma gets angry in pressured circumstances.

You previously spoke with Dr. Trauma about several complaints from coworkers and patients. You find it concerning that Dr. Trauma failed to self-correct after this feedback. Given the accumulation of patient and staff complaints and the current event analysis, you decide that what is right for Dr. Trauma and the organization is for you, as his chief, to . . . require Dr. Trauma to undergo a comprehensive mental health evaluation and, if indicated, a defined treatment plan. Failure to comply would subject the physician to a loss of privileges.

“When a doctor has been habitually misbehaving on any of these fronts, we need a way to persuade him to change his ways.”

Certainly this kind of “authority intervention” would get someone’s attention, but hospitals are wary of this approach, in that it has the potential of knocking a high performer off the clinical rolls. Also, chiefs often have a personal relationship with the doctor in question, one that makes it difficult to suggest that his colleague is medically impaired.

But Hickson, et al., also point out that a preliminary step can be effective and help avoid the authority intervention. They term this an “awareness intervention” by a peer. Awareness intervention is based on the premise that “each professional has a responsibility that colleagues and systems do no harm” and that “concerted effort to remove systemic or behavioral threats to quality must include willingness to provide feedback to others observed to behave unprofessionally.” It relies on “sharing aggregated data that present the appearance of a pattern that sets the professional apart from his/her peers.”

The key element of awareness intervention is to have a trained peer “messenger” present the data (e.g., the high relative number of patient complaints) and encourage the physician to reflect on what might be behind that pattern, but not to provide directive or corrective advice. The reason? “If a messenger offers a plan that does not ‘work,’ the high-risk doctor can blame the plan and the messenger. We therefore want messengers who promote ‘awareness’ and encourage self regulation.”

The Vanderbilt experience suggests that this form of intervention is often successful. When it is not, the organization moves up the ladder to the type of authority intervention mentioned above.

Some readers might be surprised that awareness intervention would achieve any result. But let’s look at the underlying psychology. First, doctors view themselves as scientists and can be persuaded by data. Second, the troubled physician is treated respectfully. Third, the remediation plan is not prescribed by another and therefore cannot be viewed as externally imposed. It is his own creation based on his understanding of his problems.

If we think about it more generally, though, the Vanderbilt approach is based on an old theory of persuasion, one put forth by St. Francis: “Grant that I may not so much … be understood as to understand.” Or as Steven Covey restated it, “Seek first to understand and then to be understood.”

Hickson and colleagues have designed a program that achieves advocacy through inquiry. We stimulate the troubled doctor to consider the reasons for his behavior and the results that stem from it. We ask him to reveal his understanding of those reasons by designing and acting on a plan to remediate them. We learn things about that doctor that can be very helpful in our dealings with him but may also be useful more broadly in our institution. Ultimately, through this process, he understands, too, where we are coming from and adopts behaviors consistent with the greater good. Our advocacy has succeeded.

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  • Bruce K wrote:

    This is where the general medical community parts ways with INDIVIDUALS who have been wronged by seeing the acts of the doctor as an administrative problem, not an ethical or moral problem. Lawsuits for professional negligence are detested as are the attorneys who bring them, but this is another way in which physician, AND hospital behavior is regulated. The fear of malpractice lawsuits may result in many ‘unnecessary’ tests but the truth is that it also encourages physicians to do things the right thing.

  • Jerry Hickson from VanderbiltUniversityMedicalCenter wrote:

    Paul, very well written. Thank you. Our respectful approach is possible because of real and collective leadership that will not blink when unnecessary variation in professionalism displayed by someone of special value faces escalation to intervention by an authority figure. The success of professionals’ efforts to self and group regulate is supported by an infrastructure founded on understandable policies, reliable data collection systems, and a process for sharing to promote accountability.

    I absolutely agree with the theory of persuasion. It is a professional approach and respectful. The only philosopher you omitted was Teddy Roosevelt who said something about walking softly and…….. When we are organized and committed we often don’t have to fight.

  • Israel Green-Hopkins from BostonChildren'sHospital/HarvardMedicalSchool wrote:

    Outstanding commentary – one of the greatest challenges is how hospitals and providers can be encouraged to adopt “Awareness interventions”. Always well-intentioned, they can be challenging to promote and are invariably associated with the wrong stigma – for all parties. I have seen and participated in countless trainings promoting similar interventions and few seem to rise to an appropriate level of adoption. We are a ways from striking a balance in quality and safety promotion, especially as it relates to individual accountability. Every clinician wonders whether a shift, an interaction or a treatment decision went as perfectly as it could have…but rarely do we have the opportunity to adequately reflect on it and receive appropriate feedback. Opportunities are expansive to improve in this area while not impeding workflow. I wonder if the focus area is a main determinant of the lack of adoption – if hospitals were to focus on system-wide promotion of high quality care (in every aspect – large and small) from and to within, might we see improved engagement on behalf of clinicians and providers towards the promotion of healthy clinician behavior?

  • Paul Levy wrote:

    Thanks to Doctor Hickson, especially for the TR reminder.

    Israel’s final sentence is a gem. Hospital-wide adoption of a quality and safety agenda, accompanied by a high level of transparency and implementation of a just culture, can create a foundation of trust and respect that supports peer-influenced behavioral changes.

    Unfortunately, all of those elements are often more honored in the breach than in the adoption. Some of the leaders of the so-called “best” hospitals in the nation still stubbornly refuse to give these areas proper attention. Their boards likewise abdicate their governance responsibility with regard to creating a safe and high quality clinical and professional environment.

    I would hypothesize that, where such an environment does exist, as Israel suggests, incidents of physician misbehavior are reduced and the need to intervene is likewise reduced.

  • Israel Green-Hopkins from BostonChildren'sHospital/HarvardMedicalSchool wrote:

    You are absolutely right, Paul. If the top-down approach doesn’t work, I wonder when and where a bottom-up surge of clinicians who care about health care quality and safety will ensure the cultural changes necessary.

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