Sex, lies and the ‘intentionally difficult doctor’

By the time a doctor reaches an employment tribunal, any type of court, disciplinary panel, referral to the General Medical Council, grievance, or even mediation, that whatever the judgement one outcome is certain – the relationship between employer and employee is broken.

Trust seeps away.

Like a death in a family, whatever the employee might be going through, the world isn’t interested and keeps rotating. The organisation moves on, even when there has been catastrophic organisational failure.

But the employee remains trapped, internalising the trauma in a way that is the opposite of therapeutic. 

Social media and a community of fellow sufferers ensures irrecoverable cognitive dissonance. Friends and family often need to intervene and stop the spiral down the path of no return.

These experiences and outcomes are not because of a lack of policies. 

Not fit for purpose

The 2003 Maintaining Higher Professional Standards policy guides how all HR departments address issues of conduct and capability. It is not fit for purpose – designed by multiple stakeholders with opposing aims and impossible timelines. Procedures are poorly delivered, so process failures become the focus and the hoped for get out of jail card. 

The process has three possible outcomes: first written warning; final written warning; dismissed. The warning letter enters the employee file and in effect puts the doctor on probation. Without a remediation plan, this leaves the trust holding the sword over a doctor’s future.

Even lawyers who make a healthy living in this treacle agree that MHPS needs radical reform.

Even lawyers who make a healthy living in this treacle agree that Maintaining Higher Professional Standards policy needs radical reform

Describing challenging doctors as “divas”, as the GMC recently did, does not enable the understanding needed to address the complete absence of a formal and effective pre-MHPS governance system. 

As in the medical model, a definition of “difficult doctors” enables a diagnosis, which in turn permits interventions. 

There are, broadly, two types of “difficult doctors”.

Type A: The unintentionally difficult doctor

• Not uncommon 

• Falls into difficulty without intent

• Typically, a reaction to external factors – family, health, stress, line relationships, resources

• Can become misunderstood and isolated by colleagues

• Typically has insight and welcomes support

• Left unattended risks cognitive dissonance 

Type B: The intentionally difficult doctor

• Is everywhere, but thankfully not common

• Keeps the medical director awake at night

• Acts with deliberate intent

• Generates pain to secure gain – money, sex, power, resisting accountability; medicine has its fair share of pathologies from divas to triadics (psychopathy, Machiavellianism and narcissism)

• Deliberately isolates from colleagues, avoiding meaningful collaboration – be scared of the “superhero” 

• Has insight and stays difficult enough to keep people away 

• Left unattended will damage colleagues, destroy teams and harm patients

A few of the type Bs surface in the media. Many more don’t, reaching retirement without a blemish or scar to show for their actions, except on the staff, and patients. A stark organisational failure of governance.

Type As should not reach the panels. Type Bs must not be exited quietly – the medical director’s duty of care is to the staff and patients beyond their building. Type Bs must reach the panels and need a different governance that generates the guardrails to protect staff, patients, and the profession.

Prevention

The journey of being difficult to the activation of the MHPS policy will not be prevented by appraisals which we now know are not fit for purpose. That requires a governance framework that defines and measures medical professionalism using reliable data.

There are ways of doing this. The framework must include effective systems, processes and capabilities. The team should employ clinical/occupational psychologists working to support the type A, and guard-railing the type B. 

All this work must find its way to the board as a routine report. 

Part one of this report would describe the trust’s “difficult doctors”, which are most easily identified as those who are the subject of meetings between the medical director and GMC and NHS Resolution PPA handlers.

The report should include demographics; incidents of poor behaviour; grievances; failing teams; employee investigations of all types, including fraud, disciplinary panels, GMC referrals, and outcomes; as well as issues of conduct and capability. 

The framework must include effective systems, processes and capabilities. The team should employ clinical/occupational psychologists working to support the type A, and guard-railing the type B

Part one is for the open board and would describe the numbers, processes, challenges, resources and resources needed.

If the board doesn’t get this data, it will, as many do now, remain ignorant of the real world of managing doctors, issues of professionalism, and the efforts being made by the medical director, human resource teams and more, and the deep cultural and behaviour issues being faced up to.

Part one also means transparency to the staff, the taxpayer, regulators and the profession.

Part two is for the private section of the board meeting. It would detail the narratives under the types and numbers in part one.

Here the board, filled with its professionals from other walks of life, can have the raw debates needed to understand and be more supportive of this genuinely difficult work. Work that can also be dangerous to the careers of those that try and do the right thing to protect patients, colleagues and teams damaged by the type Bs.

The Care Quality Commission should look for the evidence of good medical professionalism governance before gauging how “well-led” a trust is.