Advice on Dealing with Malignant Personalities?

[SedRate]

I've been working at a rural regional trauma center part time and I've had the unfortunate pleasure of being consulted by an unprofessional and disrespectful ED director. For example, arguing with me to admit a pt rather transferring for higher level than can be provided in their small town, or arguing against admission to the trauma service for at minimum a trauma eval. This guy actually documented in a pt's chart, "provider was pleasant but not helpful." Further, this guy berated me in front of my attending regarding another situation for "giving pushback instead of just admitting the pt" despite the fact the pt actually didn't need surgery or admission and was actually discharged home, but that's a whole other story and you can add lack of support by my attendings as well. (Apparently, there's some history of bad blood between the previous group and the ED, which the director admitted to, and we're locums so there's no interest in improving relations. I could go on but you get the idea.)

Anyways, I've never experienced so much disrespect in my career thus far so I'm at a loss. I'm pursuing other opportunities so I only have a few sets of shifts left, but I'm expecting to be on shift with this ED director again at some point. Any advice on dealing with these types of malignant personalities? Trying to do the right thing and killing them with kindness and professionalism has only gotten me so far with this place, apparently. I've dealt with some a-hole surgeons but this guy takes the cake. 

[Joelseff]

Have you spoken with your attending? I would also possibly involve HR if you can't get anywhere with your supervisors. Or, since you're on your way out, just kill them with kindness till your last day.

Edited January 7, 2023 by Joelseff

[CAAdmission]

I don't kill anyone with kindness any more. I meet them with an icy but cordial combo of "I'm not sure who you think you are talking to" and "I'm not sure how you are accustomed to dealing with people, but you need to immediately change your attitude when you interact with me, because I'm not going to tolerate this."

If they respond with anything other than respectful interactions and their behavior warrants, I'd go nuclear with anyone who will listen - HR, medical board, impaired providers organization. 

When I was young, I'd put up with some stupidity. Not any more. 

[ventana]

^^^. This. 

[SedRate]

2 hours ago, Joelseff said:

Have you spoken with your attending? I would also possibly involve HR if you can't get anywhere with your supervisors. Or, since you're on your way out, just kill them with kindness till your last day.

I have a couple dozen attendings -- all locums. The attending at that time when I was berated is brand new outta residency and did nothing. I've asked my lead PA and another attending and they just shrug their shoulders with indifference and say, "Things are a little different around here." I gave my director a heads up about the interaction around the petty chart comment since it involved a transfer and the ED director said he's "going to have to have a couple meetings about this," and my director said they're not worried about my conduct, I did the right thing and to not worry about it. Nothing about the ED doc's behavior... 

I guess I will just keep doing my thing and tell him his behavior won't be tolerated. 

[SedRate]

1 hour ago, CAAdmission said:

I don't kill anyone with kindness any more. I meet them with an icy but cordial combo of "I'm not sure who you think you are talking to" and "I'm not sure how you are accustomed to dealing with people, but you need to immediately change your attitude when you interact with me, because I'm not going to tolerate this."

If they respond with anything other than respectful interactions and their behavior warrants, I'd go nuclear with anyone who will listen - HR, medical board, impaired providers organization. 

When I was young, I'd put up with some stupidity. Not any more. 

Thanks. I've been pretty well respected and had good attending support for most of my career, so this is all pretty new... Time to start working on a new communication style.

[CAdamsPAC]

I have told Docs who feel compelled to denigrate me that they are no longer part of my professional life, I will not work with them, nor will I even speak to them or acknowledge their presence in the department. As you are leaving this position and the doc isn't in your line of supervision, game on! 

 

P.S. Just to throw a grenade into the fire, mention to your HR manager "Hostile Workplace" and "Constructive Discharge" as factors in departing your position. I'm pretty sure they will want to speak with this problem doc.

Edited January 8, 2023 by CAdamsPAC

[SedRate]

3 hours ago, CAdamsPAC said:

I have told Docs who feel compelled to denigrate me that they are no longer part of my professional life, I will not work with them, nor will I even speak to them or acknowledge their presence in the department. As you are leaving this position and the doc isn't in your line of supervision, game on! 

 

P.S. Just to throw a grenade into the fire, mention to your HR manager "Hostile Workplace" and "Constructive Discharge" as factors in departing your position. I'm pretty sure they will want to speak with this problem doc.

Thanks for this advice. I will definitely respond differently if this happens again. 

I'm private practice so I'm hesitant to even mention any of this in my leaving since everyone else in my group just accepts it and the director has admitted to me how turbulent the hospital is... They've had a few PAs and surgeons leave last year and I can't imagine why. 

I've always been taught to not say anything negative if you are thinking of leaving so as to not place a target on your back and just leave once another job is lined up. But I'm hearing more folks recommend reporting this stuff to HR/admin... Would speaking up affect my references or paint a target? 

[JEFTU]

Forget HR, file a complaint with the medical staff office against the ED director. We've had physicians attend mandated counseling sessions / anger management because of their toxic personalities. Medical staff professionalism was a major focus of Joint Commission some time ago.

[CAdamsPAC]

11 minutes ago, SedRate said:

Thanks for this advice. I will definitely respond differently if this happens again. 

I'm private practice so I'm hesitant to even mention any of this in my leaving since everyone else in my group just accepts it and the director has admitted to me how turbulent the hospital is... They've had a few PAs and surgeons leave last year and I can't imagine why. 

I've always been taught to not say anything negative if you are thinking of leaving so as to not place a target on your back and just leave once another job is lined up. But I'm hearing more folks recommend reporting this stuff to HR/admin... Would speaking up affect my references or paint a target? 

If you put them on notice that you are not a patsy, they will tread lightly. This why  clearly stating this doctor created a " hostile work enviroment" will protect you. You say others are aware of this circumstance so the HR  folks need to CYA as others speaking up can sink them in court. The use of " constructive discharge" alerts them to your leaving is the result of the conditions making staying not an option, again HR will need to step up and address this doctors attitude and behaviors. You running scared from the situation is in their best interest.

[CAAdmission]

I spent a few years dancing around the poor behavior of other clinicians. When someone was acting like a digested food exit port, I used to just ignore them. I concluded that all this did was to reward them and perpetuate the behavior. 

Now I push back as hard as possible, not just for me but for everyone in the environment. We need to make these people uncomfortable. If they represent a large profit center for your organization it can be tricky, but if enough of a stink is made they will eventually be chased away as a risk management strategy.

[SedRate]

9 hours ago, CAAdmission said:

I spent a few years dancing around the poor behavior of other clinicians. When someone was acting like a digested food exit port, I used to just ignore them. I concluded that all this did was to reward them and perpetuate the behavior. 

Now I push back as hard as possible, not just for me but for everyone in the environment. We need to make these people uncomfortable. If they represent a large profit center for your organization it can be tricky, but if enough of a stink is made they will eventually be chased away as a risk management strategy.

Thanks for sharing your experience and perspective, and I agree. I'm usually pretty good at defusing these kinds of situations and calling people out in a professional way, but this guy seems to be an outlier and has caught me off guard more than once. I appreciate knowing this has happened to you all in some way, and it's not something we have to endure. 

[Mayamom]

On 1/7/2023 at 3:57 PM, Joelseff said:

Or, since you're on your way out, just kill them with kindness till your last day.

this is probably your best option.  if they offer an exit interview you could state your experience at that time.

[ohiovolffemtp]

Here's the approach I tend to use (I'm coming from the ED side, not the consultant/surgery/hospitalist side):

1. I present the patient: S/S, vitals, results of PE, imaging, labs, etc then why I want the patient admitted.
2. If there's push-back, ask the consultant what they're concerns are and how we can address them.
3. If the consultant's concerns aren't something I can fix in the ED, I say so and then specifically ask if we can proceed and have the consultant address those concerns after admission.  Examples:
   1. Patient transfer and hospitalist say pt needs ICU and intensivist says they don't.  My response, "the patient's needs are beyond what my facility can provide.  Can you sort out which unit once they get to your facility?"
   2. Patient is a transfer to my facility from an outside hospital but has to stop at my ED for a screening to make sure nothing major was missed, but outside hospital only consulted the surgical specialty and not the hospitalist at my hospital.  My response, "I'm sorry the OSH didn't do things right, but I can't fix that.  The patient is here now - will you take them and we can work the process issues later".
   3. Consultant doesn't want to take the patient.  My response, "here's what I'm concerned could happen if the patient goes home/stays at my facility vs goes to your better equipped facility/etc.  How should we address that?"

The general theme is to focus the discussion on the specifics of the case and then not backing down on the specifics.  I'm a nocturnist, so I can't fix system or process issues at 3AM and often tell whosever on the far end of the phone line that.

[ventana]

4 hours ago, ohiovolffemtp said:

Here's the approach I tend to use (I'm coming from the ED side, not the consultant/surgery/hospitalist side):

1. I present the patient: S/S, vitals, results of PE, imaging, labs, etc then why I want the patient admitted.
2. If there's push-back, ask the consultant what they're concerns are and how we can address them.
3. If the consultant's concerns aren't something I can fix in the ED, I say so and then specifically ask if we can proceed and have the consultant address those concerns after admission.  Examples:
   1. Patient transfer and hospitalist say pt needs ICU and intensivist says they don't.  My response, "the patient's needs are beyond what my facility can provide.  Can you sort out which unit once they get to your facility?"
   2. Patient is a transfer to my facility from an outside hospital but has to stop at my ED for a screening to make sure nothing major was missed, but outside hospital only consulted the surgical specialty and not the hospitalist at my hospital.  My response, "I'm sorry the OSH didn't do things right, but I can't fix that.  The patient is here now - will you take them and we can work the process issues later".
   3. Consultant doesn't want to take the patient.  My response, "here's what I'm concerned could happen if the patient goes home/stays at my facility vs goes to your better equipped facility/etc.  How should we address that?"

The general theme is to focus the discussion on the specifics of the case and then not backing down on the specifics.  I'm a nocturnist, so I can't fix system or process issues at 3AM and often tell whosever on the far end of the phone line that.

These are all great with rational people. 
problem is there is just some people that are not.  
Twice have I hung up/terminated/spoke strongly to a doc.  (Happens to be husband wife doc 1 time each).  Both times they knocked off their silly stupid antics afterwards. 

[sas5814]

for transfers I just say "EMTALA". That usually settles the issue since the doc and the institution can be financially liable.

I have bumped and rubbed with a bunch over the years. I was trying to transfer a patient with an intracranial blled to a big facility in Dallas. The neuro surgeon asked me why I was calling him. I said "he is bleeding in his head. You have a better suggestion?" Which got me "why are you calling me and not your physician?" "Because I'm in a 12 bed critical access hospital and I'd like to get him out of here. My SP is home in bed." That got me a "send him through the ER." and the phone slammed down. You can't fix assholes.

 

[kettle]

A few things I learned through the years working for the fire service as well as dealing with HR in private institutions are:

First attempt a solution between you two before going up the ladder with this issue.

Second, be completely aware that HR may turn on you. The harassing doctor may be the worst doctor in the world and have multiple complaints against them but as a fellow PA we are easier to replace than a doctor.

I truly wish you only the best and that the issue gets resolved and this doc changes their ways

 

Kettle 

[SedRate]

8 hours ago, ohiovolffemtp said:

Here's the approach I tend to use (I'm coming from the ED side, not the consultant/surgery/hospitalist side):

1. I present the patient: S/S, vitals, results of PE, imaging, labs, etc then why I want the patient admitted.
2. If there's push-back, ask the consultant what they're concerns are and how we can address them.
3. If the consultant's concerns aren't something I can fix in the ED, I say so and then specifically ask if we can proceed and have the consultant address those concerns after admission.  Examples:
   1. Patient transfer and hospitalist say pt needs ICU and intensivist says they don't.  My response, "the patient's needs are beyond what my facility can provide.  Can you sort out which unit once they get to your facility?"
   2. Patient is a transfer to my facility from an outside hospital but has to stop at my ED for a screening to make sure nothing major was missed, but outside hospital only consulted the surgical specialty and not the hospitalist at my hospital.  My response, "I'm sorry the OSH didn't do things right, but I can't fix that.  The patient is here now - will you take them and we can work the process issues later".
   3. Consultant doesn't want to take the patient.  My response, "here's what I'm concerned could happen if the patient goes home/stays at my facility vs goes to your better equipped facility/etc.  How should we address that?"

The general theme is to focus the discussion on the specifics of the case and then not backing down on the specifics.  I'm a nocturnist, so I can't fix system or process issues at 3AM and often tell whosever on the far end of the phone line that.

Thanks for sharing your perspective and approach from the ED side. I appreciate folks like yourself who take the time to have a constructive discussion rather than focus solely on dispo. And you made a great point: I think a large problem is system/process issues. This place tries to function like a trauma center when it's really a glorified community hospital. I'm sure that has put strain on the ED which spills over to its consultants. 

 

8 hours ago, sas5814 said:

for transfers I just say "EMTALA". That usually settles the issue since the doc and the institution can be financially liable.

I have bumped and rubbed with a bunch over the years. I was trying to transfer a patient with an intracranial blled to a big facility in Dallas. The neuro surgeon asked me why I was calling him. I said "he is bleeding in his head. You have a better suggestion?" Which got me "why are you calling me and not your physician?" "Because I'm in a 12 bed critical access hospital and I'd like to get him out of here. My SP is home in bed." That got me a "send him through the ER." and the phone slammed down. You can't fix assholes.

 

What an ahole. I had the pleasure of consulting a neurosurgeon who refused to talk with PAs for the most part. During my first interaction with him, he asked about rectal tone and I told him I didn't examine rectal tone as pt was GCS 15. He responded by saying I didn't perform an adequate exam and therefore would not discuss further and then hung up.

 

6 hours ago, kettle said:

A few things I learned through the years working for the fire service as well as dealing with HR in private institutions are:

First attempt a solution between you two before going up the ladder with this issue.

Second, be completely aware that HR may turn on you. The harassing doctor may be the worst doctor in the world and have multiple complaints against them but as a fellow PA we are easier to replace than a doctor.

I truly wish you only the best and that the issue gets resolved and this doc changes their ways

 

Kettle 

I did try to have a constructive conversation with him as best as I could during the heat of the moment. I haven't interacted with him since so we'll see if it did anything. 

Thanks for your kind words. I have the same concerns you list as I've had a small taste of what you describe. Not from me submitting things to HR, but pettiness and straight up lying by a CT surgeon. Good riddance. 

[iconic]

Reading this makes me glad I don't have the pleasure of interacting with other specialists in psych 

[ohiovolffemtp]

1 hour ago, iconic said:

Reading this makes me glad I don't have the pleasure of interacting with other specialists in psych 

From the ED perspective, psyche is one of the harder specialties to deal with.  Most psyche facilities won't take any patient that has any abnormality in labs, vitals, etc.  Even if the patient has a documented history showing baseline hypertension, tachycardia, etc, most in-patient psyche facilities will refuse them.  At best, they seem to be willing to continue oral meds.  That causes major issues because often psyche patients are non-compliant with all of their meds: antihypertensive agents, hyperglycemia meds, etc.

[sas5814]

1 hour ago, ohiovolffemtp said:

From the ED perspective, psyche is one of the harder specialties to deal with.  Most psyche facilities won't take any patient that has any abnormality in labs, vitals, etc.  Even if the patient has a documented history showing baseline hypertension, tachycardia, etc, most in-patient psyche facilities will refuse them.  At best, they seem to be willing to continue oral meds.  That causes major issues because often psyche patients are non-compliant with all of their meds: antihypertensive agents, hyperglycemia meds, etc.

My wife was an inpatient psych nurse for years. She said the psych docs just aren't comfortable with IM type stuff and, like you said, would make just about any excuse if they patient had a lot of other health issues...which all of them did.. He last facility had an NP to manage the medical stuff but the psych doc was the one who had to take the transfer. "Call the NP and see if she is ok with this patient and then call me back." A big PIA for everyone.

[CAAdmission]

3 hours ago, iconic said:

Reading this makes me glad I don't have the pleasure of interacting with other specialists in psych 

That's a shame - the specialists are some of the people most in need of psych care.  

Edited January 10, 2023 by CAAdmission

[iconic]

1 hour ago, ohiovolffemtp said:

From the ED perspective, psyche is one of the harder specialties to deal with.  Most psyche facilities won't take any patient that has any abnormality in labs, vitals, etc.  Even if the patient has a documented history showing baseline hypertension, tachycardia, etc, most in-patient psyche facilities will refuse them.  At best, they seem to be willing to continue oral meds.  That causes major issues because often psyche patients are non-compliant with all of their meds: antihypertensive agents, hyperglycemia meds, etc.

It's a really unfortunate system but a lot of psych facilities do not have any medical resources and very limited medical formulary. Psych RNs do not give IVs so patients can only be on oral or injectable meds. Also a lot of the times they are depressed because of their medical issues.. that we obviously cannot resolve in a psych unit 

Edited January 10, 2023 by iconic

[SedRate]

13 hours ago, ohiovolffemtp said:

From the ED perspective, psyche is one of the harder specialties to deal with.  Most psyche facilities won't take any patient that has any abnormality in labs, vitals, etc.  Even if the patient has a documented history showing baseline hypertension, tachycardia, etc, most in-patient psyche facilities will refuse them.  At best, they seem to be willing to continue oral meds.  That causes major issues because often psyche patients are non-compliant with all of their meds: antihypertensive agents, hyperglycemia meds, etc.

I love when we get a polytrauma psych pt... Or TBI/dementia requiring a sitter...

They usually end up staying on service for weeks until they are basically completely healed because inpt psych refuses any pts requiring anything IV or have anything abnormal and SNF says no to anyone requiring a sitter.

[iconic]

3 minutes ago, SedRate said:

I love when we get a polytrauma psych pt... Or TBI/dementia requiring a sitter...

They usually end up staying on service for weeks until they are basically completely healed because inpt psych refuses any pts requiring anything IV or have anything abnormal and SNF says no to anyone requiring a sitter.

We certainly get dementia patients.. which are not really psych but there's nowhere else for them to go but wait for a state psych hospital bed. I've seen a few ladies wait for close to 6 months while being surrounded by schizophrenics.. yea. Their family thinks they will be able to get their assets, however, there's state law in our state that the state will actually take possession of their assets to pay for their care