In my job as a consultant for stressed-out physicians, I hear all kinds of stories about practices gone astray. Here are three recent ones:

• Dr. Taylor's problems at work bothered him most at night, when he struggled to sleep. His colleagues, the doctor felt, were arrogant and consumed with greed. Dr. Taylor, in turn, was filled with resentment.

• On Dr. Garcia's first day at his new practice, another physician pulled him aside to talk about a colleague's clinical incompetence. This badmouthing, it turned out, was a typical conversation held with all new members.

• In Dr. Miller's office, the senior partner insulted anyone who praised others or even offered a hug after a partner survived a difficult call schedule.

All of these doctors, whose names have been changed, have two things in common: They were all part of dysfunctional practices, and they all came to my office at the Center for Professional Well-Being for help. With some coaching, they were able to improve their lives, and I wanted to share the solutions for family physicians who might be in similar situations.

A common problem

All of us at some point have encountered dysfunctional individuals. Everywhere they go, havoc follows. A dysfunctional practice is marked by that same chaos, and it comes with a human cost.

I define a dysfunctional practice as one that enables inconsistencies and interpersonal abuses, harming the emotional and professional health of those who work there. It is a toxic work environment.

Such an office can include poor organization, tyrannical or impotent leadership, and demoralizing attitudes. Conflict is the norm. Complaints pervade conversations. Gossip and unclear communication seem to be the rule. This behavior heightens turnover, undermines morale, reduces cooperative behavior, diminishes productivity and increases the risk of substandard care. Physicians and others leave prematurely or try to adapt, which usually generates enough stress to cause burnout. In extreme cases, I've seen it advance to the point of disability.

Causes of toxic practices

Toxic practices are the result of multiple converging factors (see “Causes and Consequences of Toxic Practices”); however, three causes are most common:

First, no one is truly in charge of the practice. Toxic practices are fueled by ignorance and fear because their leaders don't know how to promote a mature, interdependent practice. Individuals' expectations for one another are not identified or validated. Ownership of a problem is usually pushed onto associates. Disruptive partners don't respect the manager, do not accept coaching and usually are not confronted because of their status.

Second, because no one is clearly in charge, the ambiguity takes over. Individuals with strong control issues see the practice as their personal fiefdom and use their power to intimidate others into an authoritarian model. These individuals may resist others' input because of cultural or personality reasons. These people may use toughness or tyranny to escape their own fear of being controlled by someone else. They are seen as despots who view all relationships as disclosing weaknesses. Their fears cause them to feel no sense of compassion for their co-workers (who are perceived as dangerous). Their co-workers, in turn, reflect no compassion and isolate one other.

Third, the practice has no sense of unity or purpose. The practice remains ineffective because the organizational teamwork that would produce a clear vision and realistic objectives is unknown. Any attempts at practice efficiency are sabotaged by those who control by maintaining disorganization. They view clarification, measurable objectives and ownership of responsibilities as a threat.

Dangers to your patients

A dysfunctional practice, like a dysfunctional family, breeds unhappiness. Disrespect and distrust fill the air. But while a dysfunctional family sometimes can hide its troubles from the world, a dysfunctional medical practice cannot.

Your patients will sense that something is wrong. In a worst-case scenario, their care could suffer, despite your best efforts to preserve your clinical integrity. Even if their health remains fine, your patients will transfer out of your practice or become hypercritical.

Some of the patient-related problems are easy to spot. Difficult patient requests become too troublesome and are ignored. Even routine patient requests may be neglected. When patients do hear from the practice, communications are often curt.

Less obvious problems might pose the most danger to your patients. They can suffer when positive feedback is missing or performance appraisals are put off. Observations or hunches that can sometimes solve a mystery illness are not swapped in a dysfunctional practice. Even the benefits of attending CME programs are not shared in partner meetings.

A day in the strife

A dysfunctional office can wear out its members in endless ways, whether they're new to the practice or have been around for years.

Disorder rules. Policies and roles are either not clarified or are changed at a whim. Expectations are unclear and unrealistic. Discussion of the vision and development of an agreed upon strategic plan is avoided. Employees are subjected to impulsive requests, have no sense of stability and feel compelled to conform to arbitrary control. Their professional self-esteem is dependent on unpredictable forces. They take out their stress on other colleagues, patients or family members.

Physicians avoid perfectly appropriate discussions about clinical care differences or dangers because they're afraid of conflict or being shamed. Mistakes may become more prevalent. Each physician maintains his or her own style to the detriment of office efficiency and quality patient care.

Staff ideas are rarely heard or elicited. Morale decreases. Staff quit, leaving the practice understaffed. Loyalty is rewarded regardless of merit. The staff emulates the attack mode of the leaders. Reduced cooperation and inefficiency permeate the practice. What's best for the practice becomes secondary to keeping your job.

Those with innovative ideas keep them to themselves because of the implied threat of personal attack. Trial and error isn't allowed.

Faultfinding becomes the unintended obsession. Planning for the future, or efficiently managing the present, is not a priority. In such a practice, the physician who routinely is late, writes illegibly or controls the environment with his or her “good” or “bad” days is allowed to persist.

In a dysfunctional practice, peer appraisal and civil disagreement are not sanctioned. Greater anxiety is promoted. Denigration of topics such as stress management and well-being are put down and put off.

Dysfunctional practices do not reward collaboration and interdependence. In cardiology or radiology practices, invasive and noninvasive specialists are pitted against each other. Prestige, income generation or case selection reinforce differences rather than blending into a whole group.

Helpful solutions

Breaking the cycle of dysfunction within a medical practice takes great time and effort, but it can be done. Here are some strategies that, though they may sound simple, have helped other practices.

1. Communicate openly and regularly. If you want to begin healing a toxic practice or ensure one doesn't deteriorate, your first step is to open clear and honest lines of communication. The pervasive disorder in a dysfunctional practice leaves no time or opportunity to consider important practice issues. At a time when doctors should be asking critical questions such as “What's not working well within our practice?” and “What will happen if we can't agree on a common vision?” they're not even asking one another “What are you up to this weekend?”

If you don't confront your communication woes, outsiders will. Patient advocacy groups are demanding better interpersonal skills from their doctors. Attorneys will hold the practice liable for tolerating disruptive behavior by members.

I recommend training your practice members in assertive communication, which involves a commitment to promoting equality in human relationships. Everyone is presumed to have an opportunity to win, and no one is set up to lose. Individuals communicating assertively act in their own interests, clearly expressing their issues and personal priorities. Assertive individuals respond to praise or anger honestly. They do not deny the rights of others to say what they feel and do not support unfair criticism of others. These skills can be taught.

A key part of communication is giving and receiving feedback. Management consultants Drs. Irwin Rubin and Raymond Fernandez stress the importance of having effective feedback systems.¹ Clear feedback promotes a clear vision and a plan for carrying out the practice's mission and goals. In a healthy group, ownership and responsibility can be spelled out. Performance appraisals are expected and implemented. Individuals who are underperforming are helped or dismissed.

2. Clarify expectations. The next step is to establish written policies that spell out your practice's expectations for all employees. To make it easier logistically, it's best if a small group works on establishing your office's professionalism criteria and then presents it to the entire practice.

I often recommend that these small groups set up a retreat to begin their discussions. Working outside of the toxic environment is the best way to think clearly and assess what needs to change.

When your subgroup meets, you need to define three sets of expectations:

Behavioral – how members are expected to make the office a better place to work;

Practice – how members are expected to make the office a better place to be a patient;

Interpersonal – how members are expected to interact with one another.

These expectations will differ slightly from practice to practice, but I have provided some sample criteria to get you started in “Establishing expectations.”

When your subgroup has agreed upon your practice's professional criteria, it's time to present your policy to the group. It's up to you whether the subgroup's work will be presented as the new law of the land, or whether you'll allow room for debate. Either way, the next phase of your transition to a healthy practice promises to be the real test.

3. Establish a protocol for grievance resolution. Even if everyone signs off on your new office policy, there are bound to be conflicts that it alone cannot resolve. For these times, it is critical to learn negotiating skills and conflict management. In some cases, you might need to hire mediators. Conflict is rarely irresolvable; by using dispute settlement skills, amicable resolutions can usually be reached.

A grievance process needs policy enforcement. Internal and external parties need to be comfortable with conflict resolution as a process. Where no dispute resolution process exists, seniority, productivity quotients, style or disruptive behavior favor abuse. Sometimes administration has to insist on a grievance policy because of intimidation or misuse within the program. I've seen cases in which the practice administrator gave up on ever getting the partners to agree because it was “a doctor problem.”

Long-standing or late-stage problems may need evaluation by a third party who understands the culture of medical practices.

4. Invest in your group. Back up your practice's words with bucks, setting aside the necessary time and money for training and development. Encourage physicians to attend not only CME events but also courses in personal or professional development, such as spousal communication, parenting, coping with medical malpractice and stress management.

You should also spend some time each year away from the practice as a group. Retreats devoted to the essentials of a healthy practice (cohesion-building, effective teamwork, etc.) are another way to promote training in conflict management.

A last resort

Unfortunately, there may be times when all the confrontation and communication in the world won't cure a toxic practice. If you're in such a situation, it's time to develop an exit strategy.

With all the opportunities out there for family physicians, it may be wisest to begin self-care and look for another work situation. You'll probably feel guilty for leaving the practice understaffed temporarily, but why stay in a hostile environment?

It can take time, but you will find a healthier practice situation. The AAFP Placement Services program may be a good place to start: https://www.aafp.org/careerads/.

The road to recovery

These days, Dr. Taylor is sleeping well, Dr. Garcia no longer has to endure badmouthing, and Dr. Miller is free to compliment his co-workers.

Getting to where they are today wasn't easy. Disruptive individuals are difficult to confront and hard to change. But by getting their practices to focus on their problems, whether caused by individuals or a collective ignorance of unprofessional behaviors, they now work in offices that are at least trying to foster a collaborative and synergistic culture.

If you work in a dysfunctional practice, don't be afraid to dream of an office where morale is high and turnover is low, where everyone feels empowered to suggest, create and take responsibility.

Others probably feel the same way you do. Take a chance and begin talking to your colleagues about improving your practice. The alternative is more time in a toxic environment. Practices that correct deficiencies and encourage assertive communication, conflict resolution and a professionalism policy promote optimal health for patients and providers.