“Physician, heal thyself.”

–Luke 4:23

Now that healthcare employers take disruptive workplace behavior seriously, and a major survey has indicated that physicians cause the majority of it, what are they doing to change the situation?

According to Dr. Barry Silbaugh, CEO of the American College of Physician Executives (ACPE), one effective method is based on the engineering concept of high reliability. “This sticks more with doctors because they think like engineers,” he says.

“There is a fair amount of overlap between disruptive behavior and medical malpractice,” Silbaugh says, although he knows of no studies examining the exact relationship.

With lives and health on the line, the healthcare field is following the aviation industry, which several decades ago brought in the principles of high reliability to improve behavior among pilots and crew in airplanes, where lives are also at stake.

The ACPE works with physicians all around the country, teaching them how high reliability applies to the practice of their profession. “We try to emphasize the knowledge and behavior competencies needed by physician leaders,” he says.

The most dangerous time for patients is when they are transferred from one department to another, such as the operating room to intensive care, Silbaugh says.  “Doctors need to learn how to behave and influence people,” he adds. “They must let go of autonomy and become part of a team” that feels free to ask questions about patients and their care without fearing attacks or reprisals.

Another huge issue for physicians is admitting that they are not perfect, that they will make mistakes. In addition, Silbaugh notes, the obsessive-compulsive behaviors that may have helped them through medical school start to work against doctors in the real world of actual medical practice.

“Medical schools use too much humiliation as part of their training,” Silbaugh adds. He says that when he speaks to doctors, he talks about the baggage they carry with them, and always cites poet Maya Angelou, who writes that people never forget how we make them feel. Amen to that.

The real issue, however, goes beyond behavior, which is visible and measurable, and is therefore usually the focus of improvement efforts. Behavior, in its turn, arises out of our feelings about self and our beliefs. The baggage, in other words.

Doctors, nurses, and other healthcare professionals dishing out disruptive, possibly criminal behavior do so out of low self-esteem. They feel bad about themselves and are insecure, and take it out on those around them. They also play politics, jockeying for position and recognition. All at the expense of patients and colleagues.

How do we heal feelings? How do we even find them within ourselves to address them? The low self-esteem and insecurities that prompt disruptive behavior are often not available to our conscious awareness. We cannot fathom why we act the way we do. It just comes out and blindsides us as well as those around us.

The irony of medicine today is that having devolved into a science devoted strictly to the physical, there is little accounting for the mental part of self, and no place at all for the emotional and spiritual aspects of our being.

Yet if physicians (and the rest of us) are ever truly to heal themselves or their patients, they/we must finally include the overlooked parts of self that cry out for succor. The emotional and spiritual are just as real and valid as the physical and mental sides of self, or our behavior. Feelings and beliefs are powerful and important.

Yet medical science ignores and leaves behind this entire half of self, rendering healthcare incomplete and ever more costly as a result.

These medical “professionals” relegate notorious TV physician Gregory House to strictly amateur standing.

A recently published survey of more than 2,100 U.S. physicians and nurses reveals that almost 98 percent of them have witnessed serious incidences of unprofessional conduct that crosses into criminal behavior while on the job in hospitals and other healthcare workplaces.

The kinds of actions cited are not merely the snide remarks that the fictional House directs at colleagues, friends, patients, and other unsuspecting targets. The abysmal conduct includes groping a radiology technician while she was taking an X-ray. A nurse spreading false rumors about a new physician to get him fired or disciplined. One enraged surgeon tossing surgical instruments about an operating room and another shoving a nurse into a trash bin head first. A different physician telling a nurse, “You don’t look dumber than my dog. Why can’t you at least fetch what I need?”

The most common grievance from the survey: degrading comments and insults, which nearly 85 percent of participants reported they had experienced at their organization. Other frequent complaints included yelling, cursing, inappropriate joking, and refusing to work with one another.

Most of the survey participants (67.2 percent) were nurses, and 32.8 percent were doctors. While there were reports of bad behavior among nurses, most respondents, nurses and doctors, cited physicians as the primary source of the problem. While most (56.5 percent) said the incidences occurred either monthly or several times a year, 30 percent said they occur weekly and 9.5 percent reported witnessing problem behavior daily. In other words, more than one-third of surveyed healthcare professionals encounter poor behavior as a regular part of their workday.

This disruptive behavior negatively impacts patient safety and saps workforce morale, according to Dr. Barry Silbaugh, CEO of the American College of Physician Executives (ACPE), which conducted the survey. “It’s nothing new,” Silbaugh says about the conduct brought to light by the poll.

Indeed, anyone who has family or friends in the healthcare field has heard plenty of similar horror stories. I attended college with a registered nurse who graduated from the last nursing diploma class admitted to the profession. She was back in school to obtain the four-year degree that had been just been established as a requirement to become a nurse. It was the early 1970s.

My college classmate often regaled me with toe-curling tales about how she spent much of her time on the job trying to keep interns and residents from harming patients because of their inexperience and/or arrogance. Her view was confirmed by a good friend from later in life who is also a registered nurse and reported much the same situation. Both women are no longer working as nurses, which is hardly surprising.

Then there is the report from the hospital trenches about a different surgeon well known among his colleagues for temper tantrums. One time during a procedure he threw a scalpel. The sharp knife hit something and ricocheted back at him, slicing into his palm and ending his career in the operating room. Instant karma?

While the situation has festered for decades, it has taken on fresh urgency for several reasons, Silbough explains. The first is the current national emphasis on healthcare reform. Despite notable improvements at certain organizations, he says, the majority of healthcare systems still struggle with disruptive behaviors by doctors, nurses, and other medical professionals.

Another reason for renewed interest in solving the problem is a requirement instituted at the start of 2009 by the Joint Commission, the most highly regarded medical accreditation organization. Hospitals and other healthcare facilities must now show a written code of professional conduct to earn Joint Commission safety accreditation.

According to those who replied to the questionnaire, the fundamental issue behind much of the behavior problem is lack of respect between doctors and nurses. And there is good news in all of this. Members of the profession and professional groups like the ACPE are finally starting to talk openly about the problem and address it, instead of keeping it as healthcare’s dirty little secret. And there are actions that members of the healthcare field can take to reduce the problem.

The insurance industry whines constantly that runaway, frivolous medical malpractice lawsuits and excessive payouts are the cause of rising U.S. healthcare costs.

We’ve already disposed of that pernicious myth in a previous column. Now it’s time to focus on the insurance industry’s own shoddy business practices and just plain old greed. Carriers having problems with medical malpractice payouts have primarily themselves to thank for their woes.

Let’s do a simple analogy. When a person wants to buy auto insurance, the first thing the insurance company does is use that person’s driver’s license to obtain the person’s driving history. Too many accidents or moving violations on the record, and the insurer declines to issue a policy.

This is a business process known as underwriting. The insurance company gathers information to make an informed decision about whether or not a person is a good candidate to take the risk of issuing that person auto insurance. The record of the person’s driving behavior is a major component of that assessment.

A similar record exists in the case of physicians and other state-licensed healthcare providers. It’s known as the National Practitioner Databank (NPDB). Overseen by the Bureau of Health Professions within the Department of Health and Human Services, the NPDB tracks certain information about physicians and all licensed healthcare providers in every state. It was set up by 1986 federal legislation and began operating in late 1990. By law, medical malpractice insurers are required to report to the NPDB every payment they make on behalf of any licensed healthcare practitioner tracked by the NPDB.

According to Maryland resident Bob Oshel, associate director for research and disputes at the NPDB for 15 years before retiring a year ago, federal law does not allow malpractice insurance companies to query the databank directly.  But, he points out, there is nothing in the law that prohibits insurers from requiring that a physician or other licensed practitioner self-query the NPDB and then provide a copy of the report to the insurance company as part of the underwriting process. (The cost for an individual record is $4.75.) This is the professional equivalent of the driver’s license record, and there is a legal way to obtain it up front, before any malpractice insurance policy is ever issued.

Oshel also says that in most states, roughly 2 percent of all licensed practitioners account for more than 50 percent of all malpractice payouts. Malpractice insurers thus may cut their payout risk in half simply by requiring the NPDB record as part of their underwriting process, then refusing to issue malpractice insurance in those cases where that record shows a risky pattern of professional behavior.

There’s not much incentive for the industry to tighten its underwriting when it comes to medical malpractice insurance, however. The premiums are huge and the actual risk of making a payout extremely low. In addition, Oshel says, the gap between an incident of malpractice and a payout averages more than four years nationally, and in some states can be as long as seven years.  That’s a lot of time to collect interest or other investment dividends on that money before having to fork it over.

In short, do not believe a word the insurance industry says about a supposed medical malpractice crisis. Its members could cut their already low exposure risk in half, if they weren’t so busy collecting inflated premiums to notice.

Even worse is the outrage of permitting a special interest’s group mere financial interest to rob American citizens of their constitutional right to their day in court when they have been maimed or their loved ones murdered by medical malpractice.

(Cross-posted at The North Star National, where StoneScribe is a political columnist.)

Never let pesky facts get in the way of a profitable myth. The myth in question: runaway medical malpractice lawsuits are causing outrageous hikes in U.S. healthcare costs.

Here’s the reality: Medical malpractice total costs were 0.6 percent of all U.S. medical costs in 2008. Actual medical malpractice lawsuit payouts have fallen to less than 0.2 percent of this country’s total healthcare spending. And the actual number of medical malpractice payouts in 2008 was the lowest since the federal government began keeping national records.

These numbers come from a report published in July by Public Citizen that analyzes medical malpractice payout data from the National Practitioner Databank (NPDB). Overseen by the Bureau of Health Professions within the Department of Health and Human Services, the NPDB tracks certain information about physicians and all licensed healthcare providers in every state. It was set up by 1986 federal legislation and began operating in late 1990. By law, medical malpractice insurers are required to report to the NPDB every payment they make on behalf of any licensed practitioner tracked by the NPDB.

In other words, the NPDB affords a reality-based look at medical malpractice costs versus convenient myths. “The facts flatly contradict the argument that medical malpractice costs have much, if anything, to do with the rise in health care costs,” the Public Citizen report states.

We keep hearing “tort reform” bandied about as a significant healthcare cost savings, however. Could it be that those singing this tune over and over want to evade all financial responsibility for their errors? “The costs of caring for these [medical malpractice] injuries are often borne by American taxpayers rather than those responsible for the injuries,” Public Citizen notes.

Even worse, the incidence of medical malpractice is rising sharply even as legal action is dropping.  A decade ago, a landmark Institute of Medicine study estimated that as many as 98,000 hospital patients were dying annually due to avoidable medical errors. A Hearst Newspapers study earlier this year estimated the number of annual medical malpractice deaths now at 200,000.

Yet the total number malpractice payouts, on behalf of physicians and all other healthcare providers tracked by the NPDB, has declined from 17,964 in 1991 to 14,157 in 2008.  Those raw numbers from the publicly available portion of the NPDB do not take into account increases in the U.S. population or in the ranks of physicians during those 17 years. The drop in malpractice payouts has been steep.

In the rare event that a malpractice payout takes place, it is not for frivolous reasons. Last year, 32.8 percent of payouts were for death; 5.3 percent were for brain damage or quadriplegia requiring lifelong care; 10.9 percent were for major permanent injury, and 15.5 percent were for significant permanent injury. That represents 64. 5 percent of total medical malpractice compensation in 2008. Just 1.3 percent of payouts were for emotional injury only.

One proposed alternative to lawsuits is “no fault” compensation for patients who suffer adverse medical events regardless of whether the injury or death was preventable (a common definition of malpractice). But Public Citizen points out that to keep the costs of these tribunals, sometimes called “health courts,” equal to the current system, only about one-third of those injured could be compensated and the amount of payment would have to be limited to no more than $100,000 for non-economic damages and no more than a two-thirds replacement for lost wages.

“Far from being broken, the current medical malpractice system works well,” says Joanne Doroshow, cofounder Americans for Insurance Reform and executive director of the Center for Justice & Democracy.

Indeed. The current system makes it possible for those injured by medical malpractice or the loved ones of those killed to have their day in court, as provided by the U.S. Constitution. Even so, it’s obvious that many of those who should be paying for their medical mistakes are literally getting away with murder and doing next to nothing to improve their medical practices.

Instead of limiting patients’ access to courts, we should let the trial hounds loose on these hospitals and physicians unless and until they clean up their acts.

(Cross-posted at The North Star National)