by Dr. Kenneth H. Cohn

We usually know him when we see him: Tightly wound, a product of pedigreed training programs, a high achiever, used to getting his way. Most healthcare organizations have at least one of him. He may be the cornerstone of an institute or service line. He is the alpha doc.

The question we face is, how do we capitalize on his expertise and charisma without dreading to work with him?

Based on my 500,000 mile journey working in 40 states, I offer the following strategies from healthcare professionals who face this challenge.

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I prefer to begin with humor because it is the least confrontational:

• Humor: The OR staff asked a Director of Nursing in Minnesota to address a spine surgeon's negative behavior and "get him off their backs." The 6'7" surgeon towered over the 5'1" nursing director. Upon entering her office, he began complaining angrily about what was wrong with the OR, when she interrupted him, "Doctor, please sit down so we can talk eye-to-eye!" He stopped and started to grin, then laughed, and sat down. (She had to remain standing to make eye-to-eye contact). He became affable, and they discussed what he needed, how the OR staff could help, and what he might do differently when dissatisfied. From that day on, he remained gracious and friendly and the staff stopped complaining about him (Cohn KH, Algeo S, Stackpoole K. "What Physicians and Administrators Can Learn from Nurses." In Cohn KH. Better Communication for Better Care, 69.)

• Healthy competition: In Collaborative Competition, I wrote that cardiologists at a Connecticut hospital reduced variation in procedure times and outcomes for their six-person group to within one standard deviation, decreased their vendors to two, and cut costs substantially, while improving clinical outcomes, in just four months. All of this occurred after their chief wondered aloud about posting their results with cardiologists’ names visible in the cath lab lounge if they did not make progress within six months. One of the cardiologists explained, "None of us wanted to be an outlier, except on the positive side."

• Social networking: In Collaborative Champions, I defined physician champions as outstanding clinicians who have earned the respect of their peers by caring for patients in a consistent and reliable fashion, delivering great clinical outcomes. They are the people we turn to when we need medical care. They are also seasoned professionals looking to leverage their knowledge and experience to improve care for their community. Physician champions may have leverage with alpha docs, especially if the champions refer patients to the alpha docs.

• Inside knowledge: Knowing about an alpha doc's outside interests may be another way to connect with him. A hospital CEO in Ohio found himself arguing unsuccessfully with an orthopedic surgeon about locating an ambulatory surgery center (ASC) on campus rather than having the orthopedist use a national vendor. With 25 percent of his bottom line at stake, and knowing that the orthopedist was a Civil War buff, the CEO said, "This is beginning to look a lot like Antietam," (the bloodiest single-day Civil War battle with over 22,000 casualties September 17, 1862), to which the orthopedist replied, "This is the first time you showed me that you knew anything." They developed a bond as a result of this skirmish that led to a jointly ventured ASC on campus and a lasting collaboration.

• Collegial data-driven feedback: In "Managing Difficult and Disruptive Physicians," Harmon and Lapenta discussed the use of 360-degree feedback to change behavior (in KH Cohn and DE Hough, editors, The Business of Healthcare, v.1, 80-81). In this process, the physician rates himself on a variety of motivating variables, such as "Treats people with respect" and disruptive variables, such as, "Gets sarcastic when asked important questions." The same survey is sent to the alpha doc's colleagues, and the two responses are compared. Such a survey also permits colleagues to offer suggestions confidentially, which a neutral facilitator reviews with the alpha doc to draw up an action plan.

In my two-day seminar on Practical Strategies for Engaging Physicians, I note that conflict is inevitable in a rapidly changing marketplace, and talk about how people surfacing and resolving conflict can lead to a sustainable competitive advantage. "Going to the balcony" is a widely used tool in diplomacy to escape the passions of the moment and focus on each party's interests rather than stake out antagonistic positions (Ury WL. 1991. Getting Past No. New York: Bantam).

In Crucial Confrontations, the authors point out that if we do not talk out our differences, we act out our differences. (Patterson K, Grenny J, McMillan R, Switzler A. 2005. New York: McGraw Hill.) People can confront alpha docs safely if they:

• Start from a position of safety.
• Maintain respect.
• Use contrasting to reassure what is not going to happen.
• Establish mutual purpose.
• End with a question.

Here is an example that clarifies the suggested steps: "I am concerned about a problem that is affecting all of us. One of our veteran OR nurses has asked for a transfer because she felt that the stress in the room was affecting her health. This is not a witch-hunt. I value your service to the hospital, just as I value hers. I would like to understand better if there is anything that I can do to limit the stress that builds up here. I welcome your suggestions. Is there a time next week that might be convenient for us to discuss the situation?"

What do you think?

• Do you have any stories about alpha docs that you can share?
• Based on your experience, what steps do you recommend?
• Upon what successes can we build that will allow us to provide patient care that is safe, effective, timely, efficient, and equitable, in line with the recommendations of the Institute of Medicine?

As always, I welcome your input.

Ken is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching and consulting on physician-hospital relations. Learn more about what he does by visiting http://healthcarecollaboration.com.

To learn more about this subject, please read Cohn KH. Turn Irritation into Inspiration: Six Ways to Put Physicians’ Perspectives to Work in Your Practice.