Leadership skills in the OR, Part II: Recognizing disruptive behavior

Editor’s note: This article is based on the panel discussion, The Pitfalls of Leadership in the Operating Room (OR), which took place during the 2011 Clinical Congress in San Francisco, CA. It is the second in a two-part series.

The term “disruptive surgeon” conjures the image of an individual prone to angry outbursts, swearing, or throwing instruments. The American Medical Association’s Code of Medical Ethics defines disruptive behavior as “personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care.”1 With this broad definition of disruptive behavior, physicians and nurses may be unaware that their behavior may fall into this category.

Raising the bar

In the past, surgeons were not expected to show empathy, and explanations were offered for bullying and other forms of overbearing behavior. Communication skills were not emphasized, and personality quirks were tolerated to retain talent. The surgeon was the enfant terrible. And so it was. The range of accepted behaviors we would now question without hesitation extend from the odd but innocuous— Nobel Laureate Alexis Carrel’s insistence on black surgical gowns, black drapes, and a black operating theater—to exhibitions of temper, objectionable humor, and demeaning forms of address.2

In an American College of Physician Executives’ survey, greater than 30 percent of more than 1,600 respondents reported that they observe disruptive behavior at least monthly.3 Despite the relatively frequent occurrence of disruptive behavior, only an estimated 3 to 4 percent of physicians are referred for remediation for unacceptable behavior.4 This discrepancy reflects the challenge of identifying more subtle forms of disruptive behavior.

There has been a great deal of emphasis recently on the repercussions of bullying, both in the workplace and in American society at-large.5 Workplace bullying may be categorized as sabotage (typically involving passive-aggressive behavior), verbal abuse, or conduct that is threatening, intimidating, or humiliating.1 These behaviors have been linked to loss of concentration, reduced team collaboration, failure to comply with system processes, and reduced information transfer. As a consequence there may be increased potential for patient harm such as wrong site surgery and medication errors.6 In a survey of more than 2,000 pharmacists, nurses, and other health care professionals conducted by the Institute for Safe Medication Practices, 88 percent of those surveyed had encountered condescending language or voice intonation, 87 percent encountered impatience, 79 percent dealt with reluctance or refusal to answer questions, 48 percent were subjected to strong verbal abuse, 43 percent experienced threatening body language, and 4 percent reported physical abuse. Almost half (49 percent) of all respondents indicated that their past experiences with intimidation had altered the way they handle order clarifications or questions about medication orders. Almost 50 percent of clinicians felt pressured by an intimidating prescriber to dispense medication despite unresolved safety concerns. Additionally, 40 percent of the respondents reported that at least once during the prior year, when they had concerns about a medication order, they assumed that it was correct or asked another professional to talk to the prescriber, rather than interact with the particularly intimidating prescriber.7

Professional standards

On July 9, 2008, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)—now known as The Joint Commission—announced that disruptive or inappropriate behaviors would be considered sentinel events. These behaviors included intimidation and disruptive acts that might foster errors, contribute to poor patient care, increase costs, and discourage teamwork. These actions encompassed verbal outbursts, threats, or passive-aggressive behavior, regardless of the underlying cause and whether they might be attributable to stress, personality, emotional pressures, or abuse of authority. Although The Joint Commission intended to put these rules in place on January 1, 2009, full implementation has been delayed because of the need to address a number of ambiguities and unintended consequences. For example, there was concern that strong advocacy for patient safety could be considered disruptive behavior. Also, the term “disruptive behavior” could be used in a setting in which patient behavior could unsettle the care environment. In a revised policy, set to go into effect July 12, 2012, the term disruptive behavior has been replaced with “behavior that undermines a culture of safety.”8

These guidelines require that health care organizations create a code of conduct that defines acceptable and unacceptable behavior and establishes a formal process for managing unacceptable behavior. Institutions are urged to educate all health care members about professional behavior, including telephone interactions and etiquette. All members of the team are to be held accountable for implementing desirable behaviors. Codes of conduct are to be enforced consistently and equitably.

The American College of Surgeons (ACS) has long-standing standards pertaining to professional behavior and relationships, which residents and fellows should read and discuss with their mentors/mentees at the beginning of and during training. The scope of these standards can be determined by reviewing the following excerpts from section I, part A, numbers 4 to 6, and section III, part B, of the ACS Statements on Principles:9

I. Qualifications of the Responsible Surgeon

A. Competencies
4.    Interpersonal and Communication Skills that result in effective information exchange and effective interaction with patients, their families, and other health care professionals.
5.    Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
6.    Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively utilize system resources to provide care that is of optimal value.

III. Interprofessional Relations

B. Discrimination or Harassment
The ethical practice of medicine establishes and ensures an environment in which patients, staff, colleagues, students, residents and all other individuals are treated with respect and tolerance. Discrimination, harassment, or creation of a hostile working environment…is inconsistent with the ideals and principles of the American College of Surgeons.

In the context of these standards, it becomes important to develop a surveillance system to detect and receive reports of unprofessional behavior, and to initiate training programs in which institutional leaders become conversant with organizational strategies to address intimidating and disruptive behavior. The importance and the gravity of disruptive behaviors must be emphasized, together with potential opportunities for improvement.

Identifying disruptive behavior

Disruptive behavior clearly includes angry outbursts, yelling, publicly degrading team members, cursing, and being physically abusive. Passive-aggressive behavior includes hostile e-mails, derogatory comments about the institution or individuals, inappropriate joking, and sexual harassment. Although less obvious, patterns of disengagement and/or withdrawal—such as avoiding meetings, failure to return calls, and delinquent chart notes—may also be disruptive.10 Frequently reported problem behaviors include degrading comments, refusal to follow established protocols, and failure to cooperate with other providers. All of these disruptive behaviors provoke stress, frustration, and loss of concentration, which impede transfer of vital information and can compromise patient safety and quality of care. Disruptive behavior also leads to nurse dissatisfaction and may lead to increased turnover.11

Tension occurs on a daily basis both inside and outside of the operating room (OR). In a study on communication in the OR by Lingard and colleagues, pairs of trained observers tallied a diverse range of communication events including jokes, stories, commands, questions, social chat, rebukes, and silences.12 The researchers found that each surgical procedure included between one and four high-tension events. These high-tension events sometimes extended beyond the OR to the scrub sink, the next room, and the front desk.

In a follow-up study, Lingard and colleagues created short videos that portrayed high-tension events occurring within the OR. When these videos were shown to nurses, surgeons, and anesthesiologists, the observers largely agreed on the intensity of the conflict. However, the different disciplines had differing perceptions about which character in the video was responsible for creating the tension and to what extent each character played a role in resolving the tension. Surgeon observers more frequently attributed the tension to the actions of the nurses or anesthesiologist. The anesthesiologists and nurses, however, identified the surgeon as the source of tension. The complexities involved in dealing with unprofessional behavior are illustrated by the differences in these perceptions. How does one know where to draw the line between reasonable reactions to stress and unacceptable behavior?

The institution’s role

Developing a comprehensive approach to addressing disruptive behavior starts with the recognition that addressing the well-being of physicians and staff can help individuals ameliorate the effects of stress before it compromises their work performance. Behavior lapses are often related to stress. A second component is to establish a shared understanding of what constitutes disruptive behavior. Team members should be taught to identify and be accountable for addressing unprofessional behavior as it occurs. They also need clear processes for reporting disruptive behavior that eliminate fear of retribution against whistleblowers.

Institutions should have a transparent and consistent system for dealing with individuals who demonstrate poor behavior. The pervasiveness of disruptive behavior is related, at least in part, to the culture of an institution. Institutions that have a lenient policy on disruptive behavior may foster an environment that allows further disruptive behavior.

Physician dissatisfaction and distress pose significant costs to the individual and the institution. Increasing patient care demands along with decreasing institutional support and financial reimbursement can overwhelm even the most committed practitioner. Excessive stress may lead to physician burnout, which includes symptoms of emotional exhaustion, cynicism, and a sense of depersonalization in relationships with coworkers or patients.13 Other potential contributors to unprofessional behavior include substance abuse, unresolved feelings of guilt or shame after patient complications, family or personal problems, and persistent frustration due to poor clinical or administrative support systems. Workers who are burned out may experience a breakdown in their sense of community and believe they are treated unfairly.13

Over the past decade, Vanderbilt University Medical Center, Nashville, TN, has developed a model for addressing unprofessional behavior. A fundamental component of this program is “actively valuing wellness, both as an individual and as a leader who supports others’ wellness.”4
Complaints of disruptive behavior must be addressed promptly and fairly, regardless of the status of whose behavior is in question. In institutions without a formal program to deal with disruptive behavior, managing behavior issues may fall to a chairman or a division chief. It is important for someone in a leadership position to take the time to investigate an alleged complaint.

Redonda Miller, MD, vice-president for medical affairs at Johns Hopkins Hospital, Baltimore, MD, noted that there are always two sides to every story: “The accused physician may want to focus on who was right and who was wrong. The leader should help the individual understand that there are professional and unprofessional ways to respond, even if another individual was in error” (personal communication with Dr. Halverson, March 2012). One must not assume that all problems can be ascribed to one individual. The discussion should include the potential inciting events and system issues that may have precipitated the situation. It is important to invite the physician’s view and, together, examine potential solutions. The leader should express appreciation for the physician’s willingness to talk and to acknowledge his or her perspectives. Any discussion of this nature should aim to maintain trust and respect, minimize distractions, balance empathy and objectivity, and anticipate the range of responses that may ensue.

An isolated episode of non-egregious behavior should be addressed with an informal intervention (a “coffee cup conversation”). Most of the time, a single conversation is enough to prompt the individual to modify his or her behavior. Allegations of sexual boundary violations, physical violence, substance abuse, or other egregious behavior, on the other hand, should be reported to the appropriate authorities for further investigation and action as appropriate.

In addition to specific reports of unprofessional behavior by members of the medical team, Vanderbilt catalogs unsolicited patient complaints as a mechanism for identifying problematic physicians. When asked about identifying more subtle forms of unprofessional behavior, Gerald Hickson, MD, associate dean for clinical affairs at Vanderbilt University Medical Center, stated, “We look for outliers. Over a one-to-two-year period, several physicians may have one or two patient complaints; 20 complaints regarding an individual indicates a problem” (personal communication with Dr. Halverson, February 2012). If a pattern in behavior is recognized, the next step is an “awareness intervention.”3 This involves having a peer share data with the physician. For example, Vanderbilt will assign a specially trained peer coach to the individual physician to explore the etiology of problems and to provide constructive feedback. This sharing of information may be followed by an action plan that includes peer coaching.

Georgetown University Medical Center in Washington, DC, has adopted a similar peer-support system. According to Stephen R.T. Evans, MD, FACS, vice-president of medical affairs, chief medical officer and professor of surgery at Georgetown, physicians often lack insight into how their words and actions affect others. “Having a colleague observe for a half-day of clinic can provide valuable insight and feedback,” noted Dr. Evans (personal communication with Dr. Halverson, February 2012).

Approximately 60 percent of physicians improve after the awareness intervention alone, whereas 20 percent will require additional intervention in order to improve. Some health care practitioners will choose to leave the institution. “This represents a loss for the institution because faculty recruitment requires a significant investment in time and money. Do the math,” explained Dr. Evans. Also problematic is the fact that the physician is likely to continue to display behavior problems at the new institution.

Role of the individual

Although nearly all clinicians have witnessed some form of disruptive behavior, many individuals are ill-equipped to deal with the issues. When encountering a high-tension situation, the first step is to stay calm, and ask what can be done to alleviate the friction. Inviting one of the individuals to step away from the situation may allow the emotional level to abate. Various strategies for addressing the problem may be employed depending on the circumstances. Common strategies include describing the situation or the unacceptable behavior and inviting suggestions from the involved individuals. Articulating the problem and possible solutions helps individuals reach a mutually acceptable resolution. The conversation should aim to determine what is right rather than who is right. Taking no action may imply tacit approval of the behavior. There are significant implications for novices who are exposed to this behavior, especially when it is not called out and corrected. The resultant behaviors can range from mimicry to withdrawal.

Surgeons often are challenged to change their own behavior. The first step toward change is to understand how one’s own behavior affects others. Changing behavior requires self-reflection. Feedback from a trusted colleague or 360-degree evaluations may provide a useful perspective.
Some individuals may lack insight into how their behavior is perceived. In some instances, individuals justify their behavior based on their circumstances. In Leadership and Self-Deception, the authors explain that when individuals behave in a way that they know to be unprofessional, their instinct is to justify the behavior. Typically, they do so by finding fault in others and seeing themselves as the victims. As people become more deeply entrenched in their own perspective, they come to expect unwanted behavior from others. When it does occur, it reinforces an individual’s justification of his or her own bad behavior.14

One must inventory internal and external stressors to assess how they are affecting work performance. Professional counseling may be necessary to improve stress management techniques and restore emotional equilibrium or to address problems such as depression or substance dependence. Continuing medical education courses are available that specifically address disruptive physician behavior.

The role of prevention

Promoting professional behavior is just as important as promoting surgical skills and domain knowledge, but in many respects it is more difficult. Whereas residents and fellows expect to be trained in surgery and surgical technique, surgical judgment, and surgical lore, professional behavior traditionally has been viewed as an ability that is absorbed rather than studied.

The most efficient way to prevent potential problems is by carefully choosing and training staff, residents, and fellows. In the selection process, it is helpful not only to screen for surgical skill and expertise, but also to look at elements of character, such as kindness and empathy, as well as communication skills and positive experiences in team environments. Authoritarianism, intimidation, excessive narcissism, or insecurity should be avoided. It is important to select for, and insist on, good manners.

In the course of surgical training and career development, it is important to include inculcation in leadership, negotiation, conflict resolution, and crisis management skills. Essential elements of an educational program should include helping trainees to identify disruptive behaviors, appreciate their effects on patient safety, and understand and locate the institutional resources available to address these issues. Finally, the surgical curriculum should provide information on strategies for stress management and maintenance of emotional well-being.

Vanderbilt begins professional behavior education in the first year of medical school and includes educational programs through every year of medical school and residency. Scott Hultman, MD, recently reported the results of a survey of fourth-year medical students from the University of North Carolina, Chapel Hill. Respondents revealed that they considered professionalism the third most important competency after clinical skills and medical knowledge. They said that professional behavior could be “taught” and “learned.” Although survey participants claimed reading materials and lectures on the topic of professional behavior may be useful, the students reported that the most effective teaching tools are mentoring and modelling.15 As we teach future surgeons, it is imperative that our behavior is consistent with our stated rules of conduct.

Conclusion

Medical institutions and surgical training programs are entitled to have legitimate expectations of manners and civility from students and staff at all levels. Patterns of behavior matter and constitute a reasonable criterion upon which to evaluate physicians. It is important that surgeons undertake a leadership position in improving the medical workplace.


Additional resources

Vanderbilt Comprehensive Assessment Program for Professionals, Nashville, TN

Sierra Tucson Assessment and Diagnostic Program, Tucson, AZ

Professional Renewal Center, Lawrence , KS

Elmhurst Memorial Healthcare Professionals at Risk Treatment Services, Elmhurst, IL

Colorado Personalized Education for Physicians, Aurora, CO


References

  1.   American Medical Association. AMA Code Of Medical Ethics. Opinion 9.045—Physicians with disruptive behavior. Available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9045.page. Accessed March 30, 2012.
  2. Witkowski JA. Alexis Carrel and the mysticism of tissue culture. Med Hist. 1979;23(3):279-296.
  3. Weber DO. Poll results: Doctors’ disruptive behavior disturbs physician leaders. Physician Exec. Sep-Oct 2004;30(5):6-14.
  4. Hickson GB, Pichert JW, Webb LE, Gabbe SG. A complementary approach to promoting professionalism: Identifying, measuring, and addressing unprofessional behaviors. Acad Med. 2007;82(11):1040-1048.
  5. Stelmaschuk S. Workplace Bullying and Emotional Exhaustion Among Registered Nurses and Non-Nursing, Unit-Based Staff. The Ohio State University College of Nursing; 2010. Available at: https://kb.osu.edu/dspace/bitstream/handle/1811/45566/Workplace_Bullying_and_Emotional_Exhaustion_among_Registered_Nurses_and_Non_nursing_Unit_based_Staff_final.pdf. Accessed April 10, 2012.
  6. Jericho BG, Mayer D, McDonald T. Disruptive behaviors in healthcare. The Internet Journal of Anesthesiology. 2011;28.Available at: http://www.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-28-number-2/disruptive-behaviors-in-healthcare.html. Accessed April 10, 2012.
  7. Institute for Safe Medication Practices. Intimidation: Practitioners speak up about this unresolved problem (Part I). Available at: https://www.ismp.org/Newsletters/acutecare/articles/20040311_2.asp. Accessed April 2, 2012.
  8. The Joint Commission. Perspectives. 2012;32(1):7.
  9. American Collge of Surgeons. Statements on Principles. Available at: http://www.facs.org/fellows_info/statements/stonprin.html#anchor125636. Accessed April 3, 2012.
  10. Swiggart WH, Dewey CM, Hickson GB, Finlayson AJ, Spickard WA Jr. A plan for identification, treatment, and remediation of disruptive behaviors in physicians. Front Health Serv Manage. Summer 2009;25(4):3-11.
  11. Saxton R, Hines T, Enriquez M. The negative impact of nurse-physician disruptive behavior on patient safety: A review of the literature. J Patient Saf. Sep 2009;5(3):180-183.
  12. Lingard L, Reznick R, Espin S, Regehr G, DeVito I. Team communications in the operating room: Talk patterns, sites of tension, and implications for novices. Acad Med. 2002;77(3):232-237.
  13. Spickard A, Jr., Gabbe SG, Christensen JF. Mid-career burnout in generalist and specialist physicians. JAMA. 2002;288(12):1447-1450.
  14. Arbinger Institute. Leadership and Self-Deception: Getting Out of The Box. 2nd ed. San Francisco, CA: Berrett-Koehler Publishers; 2010.
  15. Hultman CS, Connolly A, Halvorson EG, Rowland P, Meyers MO, Sheldon GF, Drake AF, Meyer AA. Get on Your Boots: Preparing Fourth Year Medical Students for a Career in Surgery, Using a Competency-Based Curriculum to Teach Professionalism. Presented at the 7th Annual Academic Surgical Congress, Las Vegas, NV, February 2012.

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