Physician incivility isn’t a new problem. Although numerous studies show the negative impact incivility has on patient outcomes, the problem persists. One of the most common questions we get asked regarding physician behavior is, “How do I address physicians who are great docs but lousy team citizens?” They are so brilliant but act in ways that are uncivil, rude, and disruptive. In this article, I provide strong evidence from research studies including my own on how to erode uncivil behaviors, build new behaviors of professionalism and respect, and sustain everyday civility with physicians.
When disruptive behaviors are ignored, even when the disruptors are physicians, bad things happen to employees and patients.
We can do better by creating physician partner teams of everyday civility. Here are a few tips:
Tip #1. Share hard data regarding the impact of uncivil behaviors.
Because physicians are both scientists and practitioners they want strong evidence how toxic behaviors impact performance. Therefore, share some of the more prominent studies showing the negative impact disruptive behaviors have on patient outcomes:
- Link to medical errors. 71% of survey respondents associated disruptive behaviors with negative patient outcomes (Jt Comm J Qual Patient Saf.).
- Misinterpreted medical orders. The Institute for Safe Medication Practices found that 75% of respondents avoided advice from intimidating physicians and went to another colleague to interpret an order; this is an opportunity for grave medical errors.
- More patient errors. 51% of nurses reported an increase in patient errors as a result of verbal abuse (Orthop Nurs.).
- Less critical thinking. 57.6% of nurses reported a decrease in critical thinking as a result of uncivil physician behaviors (Healthcare Manager).
- More surgical complications. In a 2019 JAMA article surveying 13,653 patients of 202 surgeons, surgeons with more coworker complaints about uncivil behaviors had more complications (JAMA).
- Increased financial cost. 12% of targets of incivility quit. Replacing those who quit are 30%, 150%, and 400% of salaries for: entry-level, mid-level, and high-level professionals, respectively. Those who quit could be some of your best docs and other team members!
Tip #2. Engage physicians in designing a compact of professional behaviors.
Once physician partners understand these hard data, you are better poised to engage others in creating a compact of professional behaviors. At the Healthy Workforce Institute, we have used this strategy in which partners brainstorm behaviors they want to see more of, as well as less of. When we engage professionals early on, there is a significantly higher probability that behaviors will change.
In this process, each partner receives dozens of Post-It notes on which to jot down both positive behaviors they would like to see increased—and those they want to erode. This takes about 10-15 minutes of a professional’s time. They then post this on a giant flipchart.
After all physicians have had an opportunity to share their views, we then drafted a compact of professional behaviors that everyone must agree to.
Tip #3. Design a policy of progressive discipline for partners.
Progressive discipline means that there are expected consequences for disruptive behaviors; each consequence gets selectively more robust. If the consequence fails to change the behavior at one stage, you proceed to the next. One of my clients recently engaged all the partners to create consensus around the progressive discipline process as can be seen below:
Sample progressive discipline process to encourage everyday civility with physicians.
Offense Progression + Consequence Progression:
First offense – Medical leader shares hard data about the impact of uncivil behaviors.
Second offense – Medical leader gives feedback with required actions. Incident is documented and placed in their file.
Third offense – Medical leader and all the medical partners provide feedback with required actions. Incident is documented, placed in their file, and consequences outlined clearly if incident occurs again.
Fourth offense – Medical leader informs the physician that they must take one-week leave, or forego one week of compensation, lose privileges, or may be dismissed according to policy.
Tip #4. Coach the right way: Script it!
Coaching physicians is difficult, especially in how to begin the conversation. At times, leaders provide too much positive feedback, then later barrage the partner with a litany of negative behaviors—often called “the set-up.” At other times, physician leaders hit hard right away and turn off any opportunity for meaningful discussion. Both methods have a high probability of failure.
Scripting is an essential component of the coaching process. First, the “intro” is clear and respectful. Second, the behavior is concrete and specific. Third, the “toss back” provides an opportunity for a discussion. Finally, you identify consequences; these should be both positive and negative.
For example:
Intro:
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- “Help me understand this.”
- “I’m not sure you’re aware of this.”
- “I was offended by a comment of yours.”
Behavior:
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- “I noticed you rolled your eyes several times when I spoke.”
- “I’m not certain why you raised your voice at me.”
- “At our team meeting, you said that I don’t know what I’m talking about.”
The Toss Back:
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- “What do you think?”
- “Can we set up a time to talk further about this?
- “I would appreciate talking about this. Is this a good time?”
Consequences:
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- Positive consequence: “If you pause more, this will give others an opportunity to share their views and build greater team trust.”
- Negative consequence: “If you continue to raise your voice, others will likely tune out your good messages.”
Change Is Less About Bold Strokes and More About a Steady Pace
It’s the little things we do every day that make the biggest difference. Start small. Take any one of these four strategies and talk it over with your colleagues. As you develop everyday civility with physicians, you will be on the road to creating improving personal well-being, team performance, and the patient experience.
This article was written by HWI Consultant Dr. Mitchell Kusy.
