Group Practice Q&A: Advice for dealing with on-the-job problems

October 25, 1999

A gun threat * Inheriting problem patients * My panel is unusually sick * Work beyond your training? * What about when you get sick? * A killer call schedule * Doctor, I want you to help me scam the insurer

Group Practice Q&A:

Advice for dealing with on-the-job problems

Gun threat / Problem patients / Practice beyond training/ Working while sick / Killer call schedule

By Susan Harrington Preston, Senior Associate Editor

A patient threatens violence

Q:I'm an FP. A patient was furious with me because I wouldn't refer herfor an MRI. The test just wasn't called for, but she kept phoning and pesteringme about it.

Finally, her husband called the clinic administrator and said, "Whatdo we need to do to get something done around here--bring in a gun?"

I was frightened, but the administrator wasn't. She just calmly said,"Hey, it wasn't a specific threat, and he hasn't actually brought agun here, so there's nothing we can do. Just talk to the patient and tellher why you can't get the authorization."

But I'd already done that.

The husband never did come in, and he never made threats again. Evenso, the stress and sense of vulnerability weighed on me for months.

Discussion: "Most of us are willing to work with patientsto explain why some tests are useful and some aren't. But you really can'ttake care of a patient who is threatening you," says Suzanne Spencer,clinic chief at Group Health Cooperative of Puget Sound. "Dismiss thepatient and explain why: You can't be bullied into ordering tests."

In Spencer's view, the administrator's role here is to see that you'refollowing the clinic's guidelines about telling a patient why she is beingdismissed. The decision to terminate is the doctor's call. Other consultants,however, feel that the administrator should assume a larger role in decidingwhat action to take.

"You relied on the administrator's retelling of the phone conversationwith the patient's husband," says James E. Orlikoff, a practice consultantspecializing in leadership and management. "If you trust her judgment,then let the whole thing slide.

"But if you don't, phone the husband directly to assess the riskyourself."

If you sense that you or any of your staff members are in danger, Orlikoffadvises protective steps: "Dismiss the patient, bar the husband fromentering the clinic, and call the police," he says. Pediatrician ToddD. Pearson, director of the Auburn, WA-based Center for Physician Renewal,recommends getting a restraining order and demanding on-site security ifthe situation is sufficiently alarming. Your group should have a policyon patient violence, so check it. And see what legal protection the clinicoffers you.

But our advisers also detect a communication glitch in your office. "Theadministrator didn't seem to understand that you had already talked to thepatient," says Frederic DeVall, a health care consultant in Kalamazoo,MI. "It's not clear whether the administrator wasn't listening or youweren't describing the situation effectively."

DeVall suggests getting help from the clinic in explaining the insurer'sdenial of treatment--a step that would spare you the role of sole ogre:"When the explanation had to be made a second time, someone from theinsurance department could have sat the patient and spouse down and said,'Look, here's what your insurance program pays for, and here's what it doesn't.'This is a communication problem more than anything else."

The new FP gets the problem patients

Q:One of my most difficult patients--a woman with a personality disorder--waspassed on to me by a more senior doctor in our family practice group. Hetold her, "I'm very busy. Maybe you should see the new doctor; he hasmore time."

He really wasn't too busy; he just wanted to unload this woman. She'snot the only difficult patient I've inherited from this doctor, either.I wound up dismissing her.

Discussion: The best way to deal with a problem patient is simplyto ask a favor, suggests Charlotte pediatrician George E. Linney, Jr., aformer medical director who now serves as vice president for the executivesearch firm Tyler & Company in Atlanta. "Approach a colleague inyour department and say, 'I have a patient I just can't manage. Would yoube willing to try?' In the case described here, of course, the older doctordidn't seek any favor. He just took advantage of his younger colleague."

A formal clinic policy can protect young doctors from such uncollegialbehavior, but from Linney's perspective, a group consensus on problem patientsis the better approach. "When I was a medical director," he recalls,"we'd discuss how to handle them, so we wouldn't have to dismiss them."

It's only reasonable that new doctors are going to have to take on somepatients they might not like in order to build a patient base, says diagnosticradiologist Peter E. Moskowitz, director of the Center for Personal andProfessional Renewal in Palo Alto, CA. "That's part of the quid proquo of starting a career. It happens in all professional settings.

"Let it happen several times before you complain," Moskowitzcontinues. "But if one physician gets abusive--he cavalierly refersall his throwaways to you--notify the chief of medicine. It's difficultfor a young doctor to confront a veteran one-on-one, so the offending doctor,the beginner, and the chief should meet to work things out."

"I'm not sure you can control 'dumpers,' " notes Suzanne Spencer."But other physicians know who they are. And they're not respected."

A new HMO brings a flood of sick patients

Q:I joined this group just when it started an HMO and set new overallproductivity guidelines. I'm supposed to average 15 minutes per patientvisit--not easy for a geriatrician.

Many of my new patients have just bailed out of other managed care plansand haven't seen a doctor in a while. They'll say, "Oh, I have highblood pressure," and then I'll discover they havn't had a cholesterolcheck or a prostate exam, or that they're diabetic and they need to seea podiatrist and an ophthalmologist. And their charts are very incomplete.

The group reviews my performance every six months, and each time thecompensation committee says I should be more productive. I've told themthat I have a large proportion of very sick patients. But the response is:"Yes, but you really have to step it up anyway."

With so many new, unhealthy patients, I just can't do that.

Discussion: "Change jobs," Moskowitz says firmly. "Yourvalues and practice style are in direct conflict with the group's. You'retrying to practice medicine conscientiously; the group seems more interestedin money. "Try to explain things, then say, 'So I need 30 minutes perpatient.' But that's putting your neck on the chopping block. If they reply,'Doesn't matter, see more anyway,' it's time to get out."

Orlikoff concurs, but recommends redefining the problem for the compensationpanel. "Suggest that in the long run, if the group emphasizes productivityover quality, it'll incur significant financial losses when patients bailout of the new plan," he says. "If the argument goes nowhere,you have a choice between staying and being an assembly-line doctor or leavingfor a more fulfilling and productive job elsewhere.

"And next time you join a group," Orlikoff adds, "checkthe productivity guidelines before signing up."

When doctors are asked to work beyond their training

Q:In my group, we internists are encouraged to handle what the administratorsdecide are routine medical emergencies. We're discouraged from getting consultsfor acute MIs if the patients don't need specialist intervention. The cardiologistsare overworked, we're told; they'll give advice over the phone, but arereluctant to come in. Pulmonologists apparently are too busy, also; we'reexpected to handle pneumonia patients without a consult.

The clinic wants us to manage more things ourselves, and the administratorsthreaten to start calling us on how many consults we order. I don't knowhow much of this is hot air, but it's obvious when we phone for consultsthat cardiology isn't eager to hear from us.

Discussion: "This situation is a liability waiting to happen,"says DeVall. "The group's malpractice insurer might not cover themif something happens."

In Orlikoff's view, the problem isn't as much the expanded duties asthe lack of written procedures. "An internist's treating certain less-acutecardiology patients is acceptable if the cardiologists create written guidelinesto clarify when a patient requires a consult," he explains. "Gettingspecialists to write the protocols is another matter. You may have to volunteerto lead the effort."

DeVall also suggests further training for the primary care doctors. "Ifan internist is willing to get the extra training, and the group is willingto pay for it, it can be a win-win-win situation--for the primary doctors,the practice, and the patients--in terms of cost-effectiveness and continuityof care.

"But in this case," he notes, "it's a mandate, not anoption."

Pressure to work while temporarily disabled

Q:I'm a female pediatrician. Afer I had an operation, I was dischargedwith a catheter, which I had to wear for a week. I told the medical directorthat I had to take a few more sick days, and she said, "But when Dr.Smith had a prostate problem, he came in with his catheter. You just haveto wear pants." .

I pretended she was joking, ignored the sexism, and took two more daysoff. But the pressure made me very uneasy.

Discussion: "Follow the same standard you'd prescribe foryour patients," says Pearson. "The Hippocratic oath says, 'Dono harm.' You wouldn't put your patients' convalescence at risk. You shouldn'tput your own at risk, either."

What about the pressure from above? "Support from your surgeon wouldbe your best bet," says Linney.

If call wrecks your office schedule

Q:When I'm on call for the clinic, I'm on call for all the doctors whoare off or out of town.

I'm expected to see my own patients at the same time, and if one of themneeds to be admitted, I have to cancel some appointments. Many of thosepatients have been waiting for weeks or even months to see me.

The ER might call at 10 in the morning and say, "We have a heartfailure here." And I have to say, "Could you give him some a diuretic,and watch him until I get there at lunchtime?" But a lot of times Idon't trust the ER doctors. You can never be sure they'll follow up.

The older doctors aren't affected because they don't have to take callduring their office hours.

Discussion: "You should volunteer to lead a committee toinvestigate the call schedules," says Orlikoff. "If other doctorsfeel the way you do, document what's going on during call, develop a planto improve the schedule, and present it to the group's leadership."

Consultant Essex agrees. "Have the assistants on the office staffgather some data--how many people were turned away, how many people's scheduleswere disrupted. This will be ammunition for when you go to the practiceand say, 'We're going to lose patients, and there's a lot of risk if I haveto respond to calls like this.' "

Orlikoff adds: "If that doesn't bring a change, then consider forcingthe issue. Refuse to take call, perhaps. If the call schedules are inconsistentwith the group's written policies, legal action is an option. Neither approachwill win you friends, but you'll get rapid resolution--one way or the other."

Moskowitz, too, recommends enlisting fellow doctors, but suggests a morecircumspect approach. "The call situation's outrageous, and it's badmedicine," he says, "but one individual is not likely to win thebattle to change it.

"Go quietly to other young colleagues and, without revealing yourplans, assess whether they think this is a big problem. If enough peopleagree with you, band together and approach the senior partners. You mightsuggest a retreat to discuss the problem, perhaps with a neutral facilitator.

"Large groups have the resources to assign somebody to the hospital,so that no one has to cover both places simultaneously. If you can't findagreement within the group that the call schedule you described is unreasonable,you're working in the wrong place."

From time to time, we'll publish problems unique to group practice, alongwith suggested solutions. If you have a problem you'd like to see included,please send it to Group Practice Q&A, Medi cal Economics magazine, 5Paragon Drive, Montvale, NJ 07645 or fax it to 201-722-2886. You may alsoe-mail it to sue.preston@medec.comAll queries will be kept confidential.

. Group Practice Q&A: Advice for dealing with on-the-job problems. Medical Economics Oct. 25, 1999;76:86.