Changing the surgical culture, one apple at a time

Imagine the following scenario: a surgeon is finishing up a complicated case near the end of the day. He is exhausted and hungry. The scrub technician is fresh out of training and is nervous to be working with this particular surgeon. When asked for a hemostat, the technician passes a DeBakey forceps. The surgeon throws the instrument onto the Mayo stand and berates the scrub tech for not paying attention. The surgeon’s tirade is just loud enough to get the attention of the entire operating room (OR) staff, and care of the patient grinds to a halt.

Sound familiar? This fictitious example probably strikes a chord with most, if not all, of us who have worked or trained in the American medical system, regardless of discipline. Few professions in the 21st century tolerate such outbursts the way medicine does. Imagine what would happen to a board member at a Fortune 500 company who repeatedly exhibited similarly disruptive behavior. The employment of that executive within the company would probably be short-lived.

Counterproductive culture of intimidation

The prevalence of bad behavior in the health care profession is high. In a survey of more than 2,500 executives, nurses, and physicians, greater than 90 percent of respondents said they had witnessed disruptive behavior.1 Although the majority of health care professionals may not exhibit disruptive behavior, the aphorism “one bad apple ruins the whole barrel” rings true. In an era of quality controls and checklists, it would appear unacceptable that a nurse would choose not to alert a surgeon in the OR that a step has been missed or an error committed. However, that individual may feel it best to remain silent for fear of repercussion or reprimand.

In health care, the culture of intimidation is often perpetuated down the chain, as that same intimidated individual turns around and bullies a resident or medical student. Students and trainees are often the victims of disruptive behavior. It is astonishing to witness some of these unprofessional interactions between health care practitioners, especially when they are the same individuals providing care to our loved ones. The community of health care professionals must question why this bad behavior continues to be tolerated.

Although the medical and surgical professions have begun to address disruptive behavior over the past decade, the need for continued improvement at medical institutions throughout the country is tremendous.

The American Medical Association (AMA), in its Code of Medical Ethics, states that “personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care constitutes disruptive behavior.”2 Furthermore, in 2003, the American College of Surgeons’ (ACS) Board of Regents approved a Code of Professional Conduct, which calls upon Fellows to “respect the knowledge, dignity, and perspective of all other health care professionals.”3

The AMA and the ACS adopted these principles with the realization that it is our responsibility as physicians to protect the safety of our patients and provide high-quality care. Eliminating the intimidation and disruptive behavior that will undermine the delivery of high-quality patient care is paramount. According to a survey conducted by the Institute for Safe Medication Practices, 49 percent of clinicians reported that after experiencing intimidation or mistreatment, they changed the way they asked questions regarding medication orders and sought order clarifications.4 Of the respondents who had concerns about medication orders, 40 percent said they would remain silent or have a colleague discuss the issue with the intimidating prescriber.

The financial impact of disruptive behavior has been described in a recent article.5 The effect is evident at multiple levels, ranging from adverse events to the increased risk of litigation. The loss of human capital secondary to bullying can be significant; a recent survey showed that one-third of nurses left work after being subject to intimidation. Nurse attrition results in significant financial consequences, with direct costs of recruiting a new nurse ranging from $60,000 to $100,000.4 This figure does not account for the additional costs of orientation and training or the time needed for employees to adapt to a new work environment.

Surgeons must lead

Perhaps more than any other discipline, surgery requires a commitment to fostering a culture of patient safety. Typically, it is the surgeon who sets the tone for how things are going to run in an OR, during a trauma resuscitation, and during other patient encounters. As other members of the health care team look to surgeons to lead by example, our behavior can completely change the dynamic of patient care in either a positive or negative manner. It is clear that a functional team improves patient care, so now more than ever, our leadership is needed to address this prevalent problem.6

Leadership in this arena must come from the top down with a zero-tolerance policy for disruptive behavior. Disruptive behavior violates our code of conduct as physicians, erodes worker morale, imperils patient safety, results in negative financial consequences, increases loss of human capital, and heightens the risk of liability litigation.

The hierarchy of medicine that has been the prevailing culture for centuries might have something to do with disruptive behavior. The time has come to flatten the hierarchy and work together as one body, for our goal is the same—to deliver safe and high-quality medical care. As surgeons, we must take the lead in driving this process.

A number of centers have taken the initiative to develop centers of professionalism to address these issues among clinicians. Although The Joint Commission initiated a professionalism standard in 2009 requiring a disruptive behavior policy to be in place as part of the accreditation protocol for hospitals, policies must be enforced and applied consistently across disciplines. Enriching the work environment to provide a safe, collegial, and positive atmosphere has multiple benefits—perhaps the most important of which is fostering an environment that will enhance the safety and quality of patient care.


  1. Rosenstein AH, Russell H, Lauve R. Disruptive physician behavior contributes to nursing shortage. Study links bad behavior by doctors to nurses leaving the profession. Physician Exec. 2002;28(6):8-11.
  2. American Medical Association. Code of Medical Ethics. Current Opinions with Annotations. 2006–2007. E.9.045: Dealing with the disruptive physician colleague. Available at: Accessed February 20, 2013.
  3. American College of Surgeons’ Code of Professional Conduct. Available at: Accessed February 20, 2013.
  4. Institute for Safe Medication Practices. Intimidation: Practitioners speak up about this unresolved problem (part I). ISMP Medication Safety Alert Acute Care Edition. March 11, 2004;9:1-3. Available at: Accessed February 20, 2013.
  5. Rosenstein AH. The quality and economic impact of disruptive behaviors on clinical outcomes of patient care. Am J Med Qual. 2011;26(5):37.
  6. Sakran J, Finneman B, Maxwell C, Sonnad S, Sarani B, Pascual J, Kim P, Schwab C, Sims C. Trauma leadership: Does perception drive reality? J Surg Ed. 2012;69(2):236-240.

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