The Informal Chat May Not Be Enough
A Chief of Staff is told by a nursing supervisor that one of the senior physicians is making inappropriate comments about the appearance of some of the nurses on his clinical unit. The nurses have expressed their concerns to their supervisor.
Medical leaders in hospitals, whether they are Chiefs of Staff, Department Chiefs or Division Heads, will be responsible for dealing with concerns related to an individual physician’s performance or behaviour. Most of us are not eager to deal with these matters that are often compounded by the existence of long-term friendly or collegial relationships. We all would like to avoid potentially time-consuming tasks, which may be compounded by the lack of clear institutional policies. In some instances, medical leaders may have to deal with a physician who is felt to be “indispensable” to the institution.
After gathering the basic facts of the concern, it may be very tempting to have an informal, “off the record” chat with the individual. The implied hope in this scenario is that one’s past relationship with the individual and making them aware that you, as a leader, are aware of the concern, will be sufficient to deal with the matter. With some individuals that approach may be adequate. However, a completely “off the record” strategy may come back to compromise future actions by the medical leader if the physician’s behaviours persist or recur. Physicians are aware that in their own patient care records, “if it wasn’t documented, it didn’t occur.” Regrettably, the offending physician may claim in the future that their subsequent incident “was the first instance.” In the absence of documentation to contradict that assertion, the medical leader will have little recourse but to start formalization of the process after the second or future incident.
The College of Physicians and Surgeons of Ontario Guidebook for Managing Disruptive Physician Behaviour (2008) addresses this matter in the discussion about Stage one interventions, which are defined as “informal.” The Guidebook suggests that administrative responses must always be commensurate with the seriousness of the concern, but still recommends that a note should be made of the discussion and that the note should be retained in the physician’s file. The Guidebook goes further and recommends a scheduled follow-up meeting three months after the first meeting, to ensure that the concern has not arisen again. This second meeting should also be documented.
Many medical leaders take the opportunity to share the administrative note with the physician at the time of filing. This assists in ensuring accuracy but also signals to the physician that the matter has been taken seriously by the medical leader and by the institution, and that the concern has been documented in the administrative file.
There may be instances where such an approach puts an added strain on the relationship between the medical leader and the physician. In the case of one-time-only concerns, those relationships will likely heal in time as the physician realizes that the medical leader does have responsibilities to the institution and to the profession. In the case of recurring concerns, the medical leader will have the necessary documentation to adequately describe the time-course of the concerns, from its very first reported occurrence.
In summary, although an informal chat may be a beginning, it should be followed with appropriate documentation.
About the Author
Tom Dickson, MD, FRCSC, Partner, The Medfall Group
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