ANGER MANAGEMENT The right approach can transform even the scariest surgeons.

How many times have you heard He's a great surgeon, but ? Being technically competent is important, but docs who are a constant challenge to deal with may not be great surgeons. Worse, they might jeopardize patient care and put your facility at risk of legal liability. The best approach to address their troublesome behavior swiftly and effectively is to use a graded and graduated model.

• The first incident. For a single unprofessional incident, share your concerns in an informal way: "Hey, I observed you yelling at that nurse. That's not who I know you to be and I want to make sure you're aware that we're all committed to treating each other with respect." One caveat: Incidents that involve violations of sexual or physical boundaries with patients or staff members demand immediate advancement up the ladder of disciplinary action.
• Apparent pattern. Surgeons who appear to be associated with a pattern of troublesome behavior require an awareness intervention, a peer-to-peer, non-judgmental encounter. You'll get the best response if you send a peer physician armed with data about the offending doc's behavior. The intervening surgeon can say, "We received 3 reports of you having difficult interactions with nurses. This appears to be a pattern. I wanted to bring this to your attention because I know you'll reflect on that. I've got the reports right here and I'm asking you to consider why you appear to be associated with more of these complaints than your colleagues."
• Persistant incidents. Consider a second awareness intervention if the pattern of behavior persists, but this time have someone in a position of authority talk to the offending doc, stating, "You've had a couple conversations about your behavior, yet the pattern continues. Now I'm going to help you come up with a plan of corrective action." The corrective action plan might involve physical and mental health evaluations, or anger management classes.
• Continued incidents. If surgeons receive authority interventions and resources for help, but their behavior continues to escalate, interventions are needed that could involve formal disciplinary actions such as fines, suspensions or loss of credentials to operate. Physicians who fail to respond to awareness and authority interventions may be more likely to have more problems with substance abuse, mental illness or early cognitive impairment than their colleagues, so drilling down to the root cause of unchecked problematic behavior is a real opportunity to help a troubled individual. In general, when bad behavior continues to escalate despite a series of attempts to stop it, there could be an underlying reason for it and the person might need professional help.

What about big-time surgeons?
If you apply graded responses fairly and consistently, most troublesome docs will change their ways (see "A Few Bad Apples Often to Blame"), no matter how many cases they bring in or which fancy robot they work with. And it's never too late to act. Research has shown that interventions can make a difference in misbehaving docs who haven't been confronted in as long as 20 years.

You'll likely get pushback or might hesitate when faced with disciplining a high-volume, revenue-generating surgeon. You might not want to lose his moneymaking cases, but can you afford not to take action? Think of the costs to your facility in terms of malpractice risk, reputation and staff turnover.

You must have a fair disciplinary process that's applied equitably to everyone. Why is that so important? There's a liability to the organization in treating people differently. If you address one person's bad behavior, but dismiss another's just because he generates revenue, you're putting yourself at further legal liability. In addition, business literature shows that when a single person on a team has a behavior that undermines that team's ability to achieve its goals, people lose trust in the organization, they perform poorly at their assigned tasks or they leave.

Now think about the OR: The circulating nurse is getting materials together for a case, the anesthetist is drawing up medications, the patient is in the room and the scrub nurse is getting instruments lined up. When a surgeon brings peace to the room, everyone goes about their business, waits for the case to start and readies for the time out. But a surgeon who screams and threatens keeps the surgical team on edge. They're more worried about getting their heads bitten off than paying attention to the task at hand. Risk for error increases.

Correcting problem behavior helps the offender regain his career and helps the organization as a whole. When you consider the ripple effect on the experience patients have when they're cared for by the surgeon and his team, the widespread benefit of stopping problematic behavior is profound.

Ignorance is not bliss
Never ignore troublesome behaviors, because they usually won't go away on their own. The keys to successfully defusing these behaviors are to identifying problematic patterns early on and to intervene as soon as possible. When you work with a fair system, with fair data collection and a graded response, the earlier you intervene, the less likely the behavior will escalate.