November 2010
Feature Story

Anne Ford

For anyone thinking that sticky laboratory personnel situations eventually and magically resolve themselves, James S. Hernandez, MD, MS, has a message: “Hope is not a plan.”

That is, when a colleague is displaying inappropriate or troublesome behavior—such as not meeting performance standards, engaging in sexual harassment, showing signs of substance abuse, or just being a jerk—it’s unhelpful to minimize the severity of the situation and refuse to intervene in the hopes that things will get better on their own. But many physicians, including pathologists, do exactly that.

“As physicians, we’re in a sense like the military—we’re a band of brothers and sisters, and we don’t want to see one of our fellow pathologists fail,” Dr. Hernandez says. “So we have a lot of compassion for our colleagues; we don’t want to turn them in or get them in trouble. But at the same time, we don’t want to cause patient harm. It’s not something that should be ignored.” Dr. Hernandez is assistant professor of laboratory medicine and pathology at the Mayo Clinic College of Medicine, Rochester, Minn., as well as medical director of laboratories and chair of the Division of Laboratory Medicine at the Mayo Clinic in Arizona, Scottsdale.

That common conundrum was the impetus for “PUMP: The Pathologist of Uncertain Malignant Potential, or How to Understand and Manage Difficult Colleagues,” a presentation given Sept. 28 by Dr. Hernandez, Paul Bachner, MD, and Debra A. Katz, MD, at CAP ’10 in Chicago. Dr. Bachner, a past president of the CAP, is professor and chair of the Department of Pathology and Laboratory Medicine at the Chandler Medical Center at the University of Kentucky in Lexington. Dr. Katz is vice chair for education in the Department of Psychiatry at the University of Kentucky in Lexington.

After giving individual talks on different aspects of interacting with troublesome coworkers, such as recommended communication styles, common psychiatric issues among physicians, and the role of medical directors in these situations, the three physicians discussed several fictitious case studies with the audience. Each study presented a different scenario involving a difficult colleague, and each prompted plenty of discussion about the most appropriate course of action. The recommendations and comments that ensued may be helpful to pathologists dealing with PUMPs of their own.

Case Study No. 1

A. Ignore it—self-preservation is key, and you don’t want a bad reputation.
B. Go to your boss’ office and insist that he stop this behavior immediately.
C. Gather more documentation and talk to the histology supervisor directly.
D. Defer to human resources.

“Ignoring the situation and looking the other way is probably the worst thing to do, because the chief’s behavior is going to be rewarded by tacitly not doing anything,” Dr. Hernandez says. And while a few people might opt for confronting the boss directly—“There are some people who can do that, you know,” says Dr. Bachner. “My vice chair, if I were behaving like that, he’d come in and tell me”—most of us wouldn’t. That leaves talking to the histology supervisor yourself or getting HR involved, either of which may be a valid choice depending on your institution.

Of course, there’s always another option, Dr. Bachner notes wryly—asking yourself, “How much do I like this job?”

Case Study No. 2

You recently hired a 32-year-old new pathologist. You are a 60-year-old with 30 years in practice. The new pathologist comes in at 9 AM and frequently leaves at 3:30 PM, saying she needs more work-life balance. Recently, while assigned to the frozen section room, she left the service uncovered, and a colleague had to do a frozen section for her at 5:15 PM. What do you do?

A. Fire her and begin recruiting for a new pathologist.
B. Tell her she is on probation until she improves her work ethic, and report this to HR.
C. Hope for the best the next time she is on call.
D. Review with her the guidelines for the expectations of the practice and hold her accountable.

To anyone who thinks this is a clear-cut case of simple laziness, Dr. Bachner points out that “there really are generational differences” in terms of the hours during which people are expected to work, the flexibility of hours, and the like. He adds, “I must say I find that my younger pathologists are pretty much hard workers, though they may not be as compulsive about their work as those of us who are of a different generation.”

Dr. Hernandez says: “I don’t think she really knew what the expectations are. Perhaps they weren’t clearly spelled out to her. Perhaps she had been like that in her residency or fellowship, and no one had said anything.” In situations such as these, he recommends option D—sitting down with the young pathologist and going over exactly what is expected of her in terms of practice, education, and research. “If people don’t know the expectations, they can’t be held to them,” he points out. “And the person has to be given a chance to improve her behavior.”

“Immediately firing her would, in my view, be difficult to defend,” he continues. “A chair may be in the position to fire somebody, but what would be the perception of the pathologist who takes that person’s place? ‘My predecessor was fired capriciously—do I really want to join that group?’”

Case Study No. 3

Dr. M. is a surgical pathologist who has a reputation for being demanding but who has excellent skills. You trained under him and have now worked with him for five years. You have a friendly but professional relationship. Dr. M. mentions his wife has left him, and he is stressed. Dr. M. does not show up for work one day and cannot be reached. You end up covering but have trouble managing the clinical load and are stressed yourself. When Dr. M. does come to work, he seems to finish more quickly than usual and often disappears for several hours. Some days you notice he smells of alcohol. Several surgeons approach you to say they are concerned about Dr. M. They ask you to review all of the slides Dr. M. reads but to “please not mention this to him.” Dr. M. seems out of it but tells you he is just depressed due to his marital problems and chronic back pain. One day, Dr. M. yells at a lab tech and says he “just can’t take it anymore.” He disappears for the rest of the day, and you are called again to cover. You worry that confronting or reporting him in some way may “push him over the edge,” or that he might retaliate in some way toward you. What do you do?

A. Ignore it and hope it will go away when his marital situation is resolved.
B. Try to justify hiring an additional pathologist or negotiate a reduction in your workload to be able to cover for Dr. M.
C. Confront Dr. M. about his absences and address the workload discrepancies between the two of you.
D. Meet with your director of pathology and ask him to figure out a solution to the problem.
E. File a written report about Dr. M. with your local physician impairment program.
F. Document and discuss your concerns with your chair, the head of the group, or the vice president of medical affairs, and urge professional evaluation.

Scenarios such as these are particularly sticky, as Dr. Bachner discovered many years ago as a young pathologist. “We had a somewhat sim-ilar situation in a community hospital,” he reported in the presentation. “A couple of people came to me and asked me to double-read another pathologist’s cases. Being young, flattered, and ignorant, I agreed to do so. I should not have done so. That should have been a signal for intervention. I think early intervention is always the answer.”

Unfortunately, many colleagues of a person such as Dr. M. delay seeking help. “There’s always the hope that when the sun rises tomorrow, something will have changed,” Dr. Bachner said. “‘I’m a nice person, and I don’t want to do harm to someone else. He or she has a family. He or she is a good pathologist, and I won’t do any better with the next person.’ And you’re afraid of legal action. You’re afraid of retaliation. And there are circumstances where you’re even afraid of suicide.”

All the more reason to intervene as early as possible, before the situation escalates further. Early intervention minimizes the risk Dr. M. poses to patients and to himself. It also minimizes a factor that may aggravate the situation—gossip. “You know that surgeon [who asks another pathologist to review Dr. M.’s slides] is sitting up in the surgeons’ lounge sharing his opinion about Dr. M. with the anesthesiologist and the nurses and whoever else has stopped by for coffee,” Dr. Bachner points out.

“This is the equivalent of looking at a very, very tough pathology case,” Dr. Hernandez says. “There are so many red flags in this case that I think even the most experienced medical director would say, ‘I need to get some help here.’”

Rather than hoping Dr. M.’s behavior will improve on its own, working around him by trying to hire another pathologist, or confronting him directly, the wisest choice is likely documenting the troublesome incidents and sharing them with the department chair, group head, or vice president for medical affairs. “The rationale behind that is that the problems have reached a level of danger to the system and to him to warrant a professional evaluation,” Dr. Katz said in the talk. “His erratic behavior is consistent with substance abuse”—a problem with which eight percent to 14 percent of practicing physicians grapple, she pointed out. “There is an ethical obligation to report impaired colleagues. There’s generally a chain of command for internal reporting. If internal channels don’t work or don’t exist, most local medical societies have an impaired physician program.”

Case Study No. 4

Dr. Jane Plodder has been a member of the practice for more than 30 years. She is personable and well liked by colleagues, staff, and physicians. Although a reliable diagnostician and available to physicians when contacted, she avoids involvement in hospital and department activities, claiming that her activities with her grandchildren and local/regional theater groups are important to her and occupy her leisure time. Despite several promises to use cancer protocols per department policy, she reverts to lengthy narrative reports, omits relevant observations, and frequently fails to stage neoplasms. Her productivity is significantly less than that of her colleagues, and she shows little evidence of keeping up. You are the head of the group. What do you do?

A. Consult with the other pathologists.
B. Terminate Dr. Plodder with three months’ notice and start recruiting.
C. Review current productivity and quality performance metrics with the group and emphasize that all pathologists will be expected to conform to them.
D. Inform Dr. Plodder that her performance must meet the established standards of the practice.

To Dr. Bachner, option A should be ruled out right off the bat. “I would not start by consulting with the other pathologists, because the minute you start to do that, you generate a rumor mill,” he says. “That’s why I’m always very careful about gathering more information. The very act of asking one of your colleagues, ‘What do you think about Jane Plodder?’ causes them to immediately go into a defensive mode or a very aggressive mode depending on how they feel about this person.”

“I certainly would not go to option B for any of a number of reasons, the main one being that I would have a sense that Dr. Plodder was salvageable,” he continues. “I think I would probably myself use a combination of C and D”—that is, first review expectations with the entire group, then meet with Dr. Plodder privately to emphasize that her performance must meet them.

Why both? Because, Dr. Hernandez says, “if the medical director were to just say, ‘Look, everybody, we have to all meet the same productivity standards, the person that message is meant for may not hear it or want to hear it, or may not be able to because of [his or her] personality traits. So it’s important to review it with the entire group, then have that separate meeting behind closed doors and hold that person accountable.”

Case Study No. 5

Dr. John Rake is 50 years old and joined your university department five years ago after having held a series of positions in academic and community settings. He is a funded investigator who is viewed as a competent surgical pathologist, a good teacher, and an amiable colleague. His attention to young female residents has been a source of gossip for some time. Two weeks ago, a first-year resident complained to the program director that despite her polite refusals, Dr. Rake continues to invite her to private slide-review sessions in his office after hours and on weekends. The program director is hesitant to go to the chair because the chair and Dr. Rake were residents together and are good friends. You are a tenured full professor but not close to the chair. What do you do?

A. Counsel the resident that she will be on another rotation in two weeks and to ignore it.
B. Provide the resident with university grievance policies.
C. Confront Dr. Rake about his behavior.
D. Encourage the program director to bring the issue to the chair’s attention.
E. Go to the chair yourself and insist that he do something.

“You would think that the climate in the world has changed so much that people wouldn’t do this kind of stuff, but they do,” Dr. Bachner says. “This kind of behavior tends to be repetitive, and three months from now, this person is going to find another object of his attention.” So option A is out. As for option B, “it puts the burden on the resident for dealing with this on her own, and residents are pretty low on the totem pole. They don’t want to be seen as a troublemaker. People start to say, ‘She brought it on herself; she shouldn’t wear short skirts,’ that kind of stuff.” And for most people, the self-preservation instinct is too strong to risk confronting Dr. Rake directly.

That leaves the options of encouraging the program director to go to the chair, and going to the chair yourself. Opinions on the best course of action differ. “Speaking as a chair, my preference would be to know about this right away and deal with it myself,” Dr. Bachner said in the Sept. 28 presentation. “Program directors, in many academic institutions, tend to be relatively junior people without a lot of institutional clout. This needs to be dealt with at a relatively high level.”

“The medical director is the captain of the ship and is responsible for setting a good environment to make sure there’s zero tolerance for harassment,” Dr. Hernandez agrees. At the same time, he adds, “I think the best answer is involving the program director. If somebody felt compelled to ignore the program director, it raises the question: What made you think you couldn’t go to that person?”

Of course, there’s always the worst-case scenario—that the chair brushes off the concern, and Dr. Rake’s creepy invitations persist. In that case, you’d have to decide whether you’re willing to escalate the issue by going to the dean’s office or human resources department. “This is a very difficult situation of speaking truth to power,” Dr. Hernandez says. “That puts this poor pathologist witnessing this in a very difficult position, but I think doing the right thing for the residents—and avoiding a lawsuit for the department—is important.”

Even if the chair does take the issue seriously, that may not put an end to Dr. Rake’s inappropriate behavior, Dr. Katz cautioned in the talk. “He may stop it with this resident, but he may move on to somebody else,” she pointed out. “There needs to be an ongoing evaluation of what his relationships with residents are like. He may be somebody who is exploiting people in other ways. This may be the tip of the iceberg. This index complaint can open up a whole other series of issues that the chair may not want to hear about, but that are ultimately the chair’s responsibility.”

A final word of advice from Dr. Bachner: “Thorough pre-hiring is the best preventative” against problem colleagues, he noted in the presentation. “Prevention always trumps therapy. It’s much harder to get divorced than it is to get married. Anyone who hires only on the basis of letters of recommendation is making a huge mistake. As an HR director I once knew said to me, ‘Never forget that when you walk into the supermarket, the smallest olive is labeled ‘colossal.’’’