Editor’s note: The following is the fourth in a series of excerpts from Being Well and Staying Competent: Challenges for the Surgeon, a guidebook issued in 2013 by the ACS Board of Governors’ Committee on Physician Competency and Health. The complete document is posted in the General Surgery community’s library in ACS Communities (login required).
Most health care professionals have witnessed their colleagues engaging in disruptive behavior with coworkers, relatives, patients, and other acquaintances at one time or another. However, it is imperative to make the distinction between being disruptive and advocating on the behalf of a patient. For example, when a physician assumes a firm patient advocacy position in a conversation regarding the long-term care facility placement of an elderly patient, this may be an appropriate and effective behavior. Conversely, when a physician angrily demeans a nurse in a crowded hospital hallway or raises his or her voice, shouting profanities in a committee meeting, these actions are inappropriate and disruptive. When physicians exhibit this behavior in such a setting, it may be a signal that a more widespread issue within the health care system requires attention.1 Disruptive actions listed in the American Medical Association Code of Medical Ethics, adopted in 2009, include: “any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or nonverbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.”2 Specifically mentioned are the following actions:2
- Physically threatening anyone [in the hospital]
- Making threatening or intimidating physical contact with another person
- Throwing things
- Threatening violence or retribution
- Sexual and other harassment
- Persistent inappropriate behavior, rising to the level of harassment
Specific inappropriate behaviors outlined in the code include, but are not limited to, the following: making belittling, sarcastic, or condescending statements; calling people names; using profanity; blatantly failing to respond to patient care needs or staff requests; and deliberately failing to return calls, pages, and messages.
As the complexity of medical care increases, the need for well-functioning partnerships between members of the medical team becomes more important. At the same time, the stresses, demands, and distractions for surgeons also continue to mount. As a result of the relatively high profile of physicians, disruptive behavior by these individuals is perceived to have a greater impact—and greater potential for disruption.
Despite physicians’ best efforts to work within “the system,” quite often surgeons are urgently contacted for an issue that ultimately does not qualify as an emergency. At other times, surgeons responding to a call arrive only to find that necessary preparations have not been made or equipment is not available for a procedure. Perhaps an important change in a patient’s condition went unrecognized, or the staff did not notify the physician of the change. Feelings of anger and frustration are understandable in these situations, but a physician must consider his or her response carefully.
Although little evidence is available to indicate that the frequency of disruptive conduct has increased in recent years, the issue is being increasingly studied, and physicians who display this behavior continue to be penalized. In 2008, The Joint Commission issued a Sentinel Event Alert, which stated, “Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more professional environments. To assure quality and to promote a culture of safety, health care organizations must address the problem of behaviors that threaten the performance of the health care team.”3 For example, Joint Commission-accredited hospitals are mandated to have defined mechanisms in place for identifying and addressing disruptive behavior.
Although the overall prevalence of this type of conduct is unknown, large-scale studies suggest that disruptive behavior occurs frequently. In a 2002 survey of 675 nurses at 50 Veterans Affairs (VA) hospitals, 86 percent of the respondents reported witnessing disruptive physician behavior—a finding supported by the results of other studies.4 Most of these incidents involved nursing staff or other health care professionals. In 2011, another survey of more than 800 physicians found that disruptive behavior occurs in more than 70 percent of hospitals each month.5 More than 10 percent of the physicians surveyed reported that these behaviors occur weekly. Similarly, in 2009, more than 2,000 physician executives acknowledged encountering behavioral problems with physicians in their institution.6
It is important to note, however, that “a single episode of disruptive behavior does not render a physician a disruptive physician,” according to experts on the topic.7 Current research suggests that it is generally a small percentage of physicians who are responsible for the majority of the inappropriate behavior. Most reports describe 3 percent to 5 percent of physicians exhibiting disruptive behavior; unfortunately, it appears that surgeons are among those most often identified as disruptive (particularly general surgeons, neurosurgeons, cardiovascular surgeons, and orthopaedic surgeons).5 Another important clarification is that most disruptive physicians are not impaired or suffering from a substance abuse pathology, but are likely exhibiting longstanding behavior patterns. In fact, fewer than 10 percent of physician behavior issues are related to substance abuse.8,9
Effects of disruptive behavior
The consequences of disruptive behavior can be significant, and may even affect patient care. Furthermore, these behaviors often result in diminished morale and productivity and create work environment disturbances due to increased stress and turnover of health care employees.1 Collegiality is impaired by disruptive behavior, leading to a less efficient and less functional team. A colleague on the receiving end of inappropriate behavior may be less likely to question orders, express concerns regarding discrepancies in patient consents, or notify the physician of other patient-related issues, thereby increasing the potential for medical error.
As unimpeded communication becomes more difficult, patient safety is also compromised. In a survey conducted at 102 VA hospitals with 4,530 participants, 67 percent of respondents said they felt that disruptive behavior was linked to adverse events, 71 percent saw a link to errors, and 27 percent saw a link to patient mortality.5
Patient and family satisfaction deteriorates as a result of disruptive physician behavior.10, 11 These occurrences may lead to complaints to the medical staff office, and multiple complaints may serve as an indicator of a disruptive physician. A review of complaints to state medical boards indicated that 36 percent of these reports were related to inappropriate physician behavior.12
Disruptive physician behavior also has economic consequences, including slowed patient throughput as a result of decreased efficiency, increased employee turnover leading to additional hiring and training expenditures, elevated costs for hospitals because of increased errors and adverse events, and an additional financial burden for physicians resulting from liability claims.13
How to address disruptive behavior
Because of the significant consequences associated with disruptive physician behavior, it is important that health care institutions and the profession address this problem. The following approach should provide a systematic and effective approach for reducing and deterring disruptive behavior.
The first step in addressing disruptive behavior is prevention. Hospital systems should develop a clearly outlined approach for making all employees, including physicians, aware of what constitutes disruptive behavior, as well as the consequences of any transgressions. It is essential that health care professionals understand that the codes of conduct/standards apply to all patient care team members.
To address the issue of disruptive behaviors, most hospital systems have incorporated specific language in their medical staff bylaws. This behavior falls under the category of “professionalism,” requiring health care professionals to display a minimum standard of behavior toward colleagues, employees, and patients.14 Any violation of the tenets of professionalism may serve as justification for taking action to address this behavior. The definition and expectations of professional behavior have some expected variance across health systems, but there are common components, including the following:
- Expected behaviors should be clearly defined
- Consequences for divergence from these behaviors should be delineated
- Repercussions should be in accordance with the severity of the incident
- Consequences for repeat behaviors should increase in a step-wise fashion
- Clear communication should occur and be documented after each and every reported incident
It is imperative to recognize that the individual displaying disruptive behavior(s) and the individual(s) on the receiving end of such behaviors may perceive these behaviors differently. Some physicians may claim that whether the behavior is positive or negative is in the eye of the beholder. Therefore, a code of conduct that is equally applied to all health care professionals is essential in order to establish a well-defined foundation to support any conduct-related conversation or disciplinary action. It also is essential to include due process in the code of conduct. Complaints should only be considered valid if a verification process is in place. In a report issued by the American Association for Physician Leadership (formerly the American College of Physician Executives), code of conduct bylaws should include an appeals process, along with an option for a fair hearing.15 For physicians, acknowledgment (and signing) of the code of conduct is frequently part of the credentialing process.
If a health care professional witnesses unwanted behaviors, they should identify and report the act in a timely and professional manner. Disruptive behaviors may be viewed as diminishing the strength of the health care team and, therefore, detrimental not only to other staffers and the physician involved, but, ultimately, to patient care.10 Identifying disruptive behavior is the cornerstone of promoting better patient care and encouraging long-lasting, meaningful relationships among all hospital staff. Most institutions recommend that reports of unfavorable physician behavior be directed at either the medical staff director/administrator or human resources. It is crucial that behavior standards are universally applied and that no perception of favoritism occur (that is, higher tolerance for inappropriate attitudes or actions exhibited by prominent or highly productive physicians). Identification of disruptive behavior must be done in accordance with defined criteria and must not be applied arbitrarily. Formal mechanisms, including detailed reporting, should be in place for documenting these events, alongside policies to protect those colleagues who are reporting them from retaliation; some individuals may otherwise be hesitant to report misconduct for fear of the repercussions.
Addressing disruptive behavior in a relaxed, informal setting with either the medical staff executive or in conjunction with a physician mentor is most likely to result in a desirable outcome. The degree and pattern of behavior may be a predictor for a positive outcome. For example, for a physician who has an unusual, uncharacteristic outburst, a private conversation with a colleague may be most appropriate. The physician with an ongoing pattern of unacceptable behavior may best be addressed by physicians in leadership—either within the department structure or via the institutional physician executive structure. Unfortunately, such a physician may have long-established behavior patterns and lack insight into his or her behavior.10 In these cases, changing the counterproductive and damaging behavior patterns is likely to require prolonged and intensive counseling. Physicians in this position generally must be mandated to enter counseling programs, as they are unlikely to seek assistance voluntarily.
In a structured format, the physician’s behaviors should be discussed and include specific documentation. The physician should have an opportunity to self-evaluate. Relevant cultural factors also should be addressed. A plan for future actions should be developed, agreed upon, and documented with stepwise progression up to and including dismissal from the medical staff, if the disruptive behaviors continue. Consequences of continued/repeated inappropriate behavior should also be explained to the physician. The conversation should be documented and the physician’s progress monitored. The ultimate goal of these actions is focused on two outcomes—improved patient care and a physician who embodies optimal behaviors and capabilities.
As part of the corrective plan, a monitoring program should be put in place. Established behavior patterns may be resolved incrementally, and while relapses are not uncommon, improved conduct is expected. If the behaviors persist, the agreed-upon penalties should be implemented. The monitoring period will vary, but it should extend at least six to 12 months to encourage the maintenance of appropriate behavior. Most state medical boards provide or contract with formal programs for the evaluation and rehabilitation of physicians who exhibit disruptive behavior, and these are available to hospitals as an option for resolution. These programs can be found on the website of the Federation of State Health Programs and the Federation of State Medical Boards (see sidebar). These programs provide the offending physician an opportunity to confidentially undergo rehabilitative counseling or behavior modification without jeopardizing his or her licensure.
In an era in which quality care and patient safety are high priorities, the surgical profession can no longer tolerate disruptive behavior in or out of the operating room. These behaviors should be addressed early on and in a stepwise fashion to reduce their impact and presence, to maintain the morale of other members of the health care delivery team, and to protect our patients’ well-being.
- Williams MV, Williams BW, Speicher M. A systems approach to disruptive behavior in physicians: A case study. J Med Lic Disc. 2004;90(4):18-24.
- American Medical Association. 2011 AMA Code of Medical Ethics. Opinion 9.045–Physicians with disruptive behavior. Available at: www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9045.page. Accessed January 12, 2015.
- Rosenstein AH, O’Daniel M. A survey of the impact of disruptive behaviors and communication defects on patient safety. Jt Comm J Qual Patient Saf. 2008;34(8):464-471.
- Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. Am J Nurs. 2005;105(1):54-64.
- MacDonald O. Disruptive physician behavior. May 15, 2011. Available at: www.quantiamd.com/q-qcp/Disruptive_Physician_Behavior.pdf. Accessed December 9, 2014.
- Johnson C. Bad blood: Doctor-nurse behavior problems impact patient care. Physician Exec. 2009;35(6):6-11.
- Reynolds NT. Disruptive physician behavior: Use and misuse of the label. J Med Regul. 2012;98(1):8-19.
- Porto G, Lauve R. Disruptive clinical behavior: A persistent threat to patient safety. Patient Safety and Quality Healthcare. Lionheart Publishing Inc. July/August 2006. Available at: www.psqh.com/julaug06/disruptive.html. Accessed December 9, 2014.
- Leape LL, Fromson JA. Problem doctors: Is there a system-level solution? Ann Intern Med. 2006;144(2):107-115.
- Hickson GB, Federspiel CF, Pichert JW, Miller CS, Gauld-Jaeger J, Bost P. Patient complaints and malpractice risk. JAMA. 2002;287(22):2951-2957.
- Daniel AE, Burn RJ, Horarik S. Patients’ complaints about medical practice. Med J Aust. 1999;170:576-577.
- Patel P, Robinson BS, Novicoff WM, Dunnington GL, Brenner MJ, Saleh KJ. The disruptive orthopedic surgeon: Implications for patient safety and malpractice liability. J Bone Joint Surg Am. 2011;93(21):e1261-1266.
- American College of Surgeons. Statements on Principles. Available at: www.facs.org/about-acs/statements/stonprin. Accessed December 9, 2014.
- Papadakis MA, Teherani A, Banach MA, et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005;353(25):2673-2682.
- Weber DO. Poll results: Doctors’ disruptive behavior disturbs physician leaders. Physician Exec. 2004;30(5):4,6-14.