From the Department of Anesthesiology and Pain Management, Baylor University Medical Center, Dallas, Texas; and the Department of Anesthesiology and Pain Management, The University of Texas Southwestern Medical Center at Dallas.

Corresponding author: Michael A. E. Ramsay, MD, Department of Anesthesiology and Pain Management, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, Texas 75246 (e-mail: docram@baylordallas.edu).

Litigation is now readily available for those who feel that they are working in a hostile work environment. The hostile environment may be the result of abusive behavior by other employees, supervisors, or physicians. The abuse may take the form of a demeaning attitude, ridicule, off-color jokes, sexual harassment, or even physical violence. Societies have significantly decreased their tolerance of disruptive behavior. A group or organization can now hold vicarious liability for condoning a hostile work environment if it fails to act when a complaint is made.

DISRUPTIVE PHYSICIANS

Physicians, both male and female, often have hard-driving, type A personalities and little training in interpersonal skills. They may have high IQs but lack emotional intelligence. In the past, physicians were revered as charismatic people who could do no wrong; now they are seen as one part of the health care team. Temper outbursts--with throwing of instruments and loud profanity directed at any unfortunate person who happens to be near at hand--are no longer tolerated. Nurses and technicians have the right to be treated with respect, and they know it.

The dysfunctional physician presents an insidious cost to any practice or health care organization. He or she increases the stress in the work environment and the accompanying loss of efficiency. In a stressful workplace, such as the operating room with a berating physician, morale and team spirit suffer, which results in an increased turnover of staff and a dysfunctional team. Once this stage is reached, various negative factors begin to interplay. Communication is poor, and staff withhold information because of fear of an outburst. The information withheld may be vital for patient well-being. The physician loses staff support and may become isolated. If the problem is severe, retaliation may occur, and this may take many forms: failure to properly assist, the initiation of lawsuits, the support of the plaintiff in a malpractice suit against the physician, or even malicious sabotage of the practice.

Once this dysfunctional behavior pattern is recognized, an intervention should be made. This action is necessary not only for patient safety but also because lack of action could be interpreted by the courts as negligent or as condoning a hostile work environment. When a confrontation is necessary, a team approach should be used, and if possible, a member of the team should be a close acquaintance of the individual, setting up a “good cop-bad cop” scenario. If only one person is involved, the physician may view the intervention as a personal confrontation instead of a peer-related issue. Specific incidents should be documented, and the focus should be on behavior, not personality. Empathy should be expressed but change must be demanded, with a delineation of the consequences if behavior is not improved. The communication should be direct and clear, with the subject not given an opportunity to respond until the end of the dissertation. In this manner, a potential indignant response is often overwhelmed by the data and the presence of peers, and the physician will respond positively to the guidance given or help offered. The goal is to correct the situation and allow the highly trained physician to perform to an optimal degree. Those participating in the confrontation should look for the good in any situation. In this way, the good can be built on, and a positive outcome becomes more likely.

The competent leader will be able to handle difficult people and tense situations with diplomacy and tact. If possible, a win-win solution should be looked for, where the physician sees the advantage to his practice and patient care if resolution can be obtained. However, individuals who have a destructive effect on the workforce should be asked to leave before they cause harm.

PREVENTION OF CONFLICT

To prevent conflicts, a professional code of conduct should be established, not only in the hospital but also as part of group practice policies and medical staff bylaws. Ground rules make it easier to discipline, as they take personality out of the equation. A disciplinary structure should be developed, so that the mechanisms and the referral pattern to higher authority are well understood. General knowledge of this discipline pathway can often facilitate resolution at a lower level. Everyone needs to understand that there are firm limits on inappropriate behavior.

Understanding how conflicts arise is important in their prevention. From an employee's perspective, triggers include lack of communication, colleagues who don't pull their weight, unfair criticism, silly rules, preferential treatment, sexism or racial inequality, being put down, unreasonable expectations, and verbal abuse. On the management side, problems arise from poor communication, inappropriate responses, poor prioritizing, personal work interfering with professional work, and clock-watching.

Pitfalls that leaders should be careful to avoid include taking people for granted, failing to keep promises, failing to take responsibility for one's own errors, and failing to practice what one preaches. The key to survival as a leader is to develop emotional intelligence and to engender it in the work environment.

EMOTIONAL INTELLIGENCE

Emotional intelligence has been recognized as necessary not only to be a successful leader but also to be successful in life. A high mental intelligence quotient revolves around a narrow band of linguistic and mathematical skills, whereas emotional intelligence involves self-awareness, management of emotions, empathy, “people skills,” and motivation.

The development of interpersonal intelligence allows understanding of other people--what makes them “tick,” what motivates them, and how to work with them. This not only enables leaders to “get inside the other person's head,” it lets them understand and recognize their own emotions, making control of those emotions easier. If emotional control is lost, smart people become stupid.

Anger is the most difficult mood to control; it can be energizing, exhilarating, and even seductive. It fuels itself and eventually becomes rage. Rage is a state beyond reason that revolves around revenge and reprisal, with no concern for the consequences and with minimal cognition. Early intervention provides the best chance of successfully defusing the angry situation. A cooling-off period may actually exacerbate the anger. Leaders should stay cool, avoid direct accusation, be good listeners, and repeat the argument in their own words to demonstrate that they are trying to understand the problem. Asking a meaningful question can be a powerful distraction. However, if all is lost, the leader should leave and return another day. Out-of-control emotions can paralyze cognitive function.

VIOLENCE IN THE WORKPLACE

The workplace is becoming more violent as people are unable to handle the stresses of life. Over 1 million workers are assaulted each year in the US workplace, and the health care industry is no exception to this frightening statistic. Violent incidences have been reported between physicians, as the changing pattern of medical practice creates enormous stress on both work and family. If the warning signs are not heeded, disastrous consequences can occur. Similarly, interactions with families of very sick patients can turn physical as emotions overcome rational thought.

The signs of impending violence include verbal threats, profanity, belligerence, and intimidating statements. Threats should always be taken very seriously. Physical signals of a violent confrontation are the gripping of fists, agitated movement, speaking through clenched teeth, and a paranoid stare. The leader should try to defuse the situation by being nonthreatening and by taking verbal control: using a calm, controlled voice, he or she should be very clear and respectful. The leader should take a nonaggressive posture--by not cornering the individual or getting into his or her “space,” by allowing a buffer zone to exist, and by always staying at least an arm's length plus 1-inch distance! The leader should ensure that no objects that could be used as weapons are readily available. When a threatening situation appears to be developing, the leader should take it very seriously and summon help. Potentially vulnerable work areas should have a security evaluation. Access to certain areas should be controlled, particularly at night, so that the staff can feel safe. A protocol should be set in place that can be readily activated if a potentially violent situation arises. The safety of the staff must be a major concern of all administrative leaders.

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