Editor’s note: The American College of Surgeons (ACS) Board of Governors (B/G) has conducted an annual survey of its domestic and international members for more than 20 years. The purpose of the survey is to provide a means of communicating the Governors’ concerns to the College leadership. The 2018 ACS Governors Survey, conducted in August 2018 by the B/G Survey Workgroup, had a 91 percent (263/289) response rate.
Two of the survey’s topics focused on disruptive and impaired physicians, and this article outlines the Governors’ feedback regarding these issues.
How do we define disruptive or impaired behavior? Inappropriate and disruptive behavior on the part of physicians and other hospital staff is more than a teamwork issue; these behaviors also present a serious threat to patient safety and quality of care. According to the American Medical Association (AMA), the relationship between patients and physicians is based on trust and should serve to promote patients’ well-being while respecting their dignity and rights. Disrespectful or derogatory language or conduct on the part of either physicians or patients can undermine trust and compromise the integrity of the patient-physician relationship. It can make members of targeted groups reluctant to seek care, and create an environment that strains relationships among patients, physicians, and the health care team.
Disruptive behavior by a physician, often called abusive behavior, generally refers to a style of interaction by physicians with others—including hospital personnel, patients, and family members—that interferes with patient care or adversely affects the health care team’s ability to work effectively. It encompasses behavior that adversely affects morale, focus and concentration, collaboration, and communication and information transfer—all of which can lead to substandard patient care.
As delineated by Ernest Amory Codman, MD, FACS, more than 100 years ago, physicians have a responsibility to monitor hospital activities for quality and safety concerns. This responsibility includes monitoring the medical staff and the actions of its members. When dealing with impaired behavior, physicians have defined metrics to recognize this conduct. For example, does the physician test positive for certain substances? What is the physician’s blood alcohol level? Most states in the U.S. have programs in place to assist impaired physicians who are in need of treatment. These programs also provide guidelines for medical administrators on how to credential and monitor the impaired physician.
Evaluating, monitoring, and credentialing the disruptive physician can be a more complicated process. What is a disruptive physician? Most surgeons would agree that a physician who throws objects and uses physical force and/or abusive language should be labeled disruptive. Threatening violence or retribution or engaging in sexual harassment also is commonly viewed as disruptive behavior. In other scenarios, the appropriateness of using the disruptive label can be more difficult to determine. While some direction can be garnered through resources such as the AMA Code of Medical Ethics and the Ethics Panel at the World Medical Association, the parameters of what actions constitute disruptive behavior should be decided locally by the organized medical staff. The medical staff should clearly define which actions are intolerable and how the disruptive physician will be held accountable. Accordingly, the physician should be afforded due process when any medical staff disciplinary action is taken. For example, in the weeks and months leading up to the start of a sport’s season, coaches, referees, and players receive instructions on how penalties will be called and managed. Physicians should be given similar consideration. Several resources are available to help clarify what constitutes disruptive behavior (see sidebar).
The 2018 ACS Board of Governors (B/G) Survey revealed that 7 percent of Governors have been labeled a disruptive physician, including 5 percent (2/41) of the International Governors, 6 percent (13/212) of the U.S. Governors, and 40 percent (4/10) of the Canadian Governors. Interestingly, when all the Governors were asked if they knew of a surgical colleague who had been labeled as disruptive, 83 percent answered affirmatively.
The survey also focused on to whom the disruptive surgeon posed a threat. The survey revealed that 46 percent of the time, the threat was to colleagues, 32 percent to patients and their families, and 35 percent to themselves (see Figure 1).
Figure 1. To whom did the disruptive physician pose a threat?
Governors were asked if they knew of a colleague who was inappropriately labeled disruptive; 41 percent answered affirmatively (see Figure 2).
Figure 2. Have you known a surgical colleague who was inappropriately labeled disruptive?
Interestingly, only 52 percent of the hospitals/facilities where Governors practice defined disruptive behavior in their bylaws. However, 74 percent of the Governors said their practices either had policies and procedures or a program to address disruptive behavior (see Figure 3).
Figure 3. Does your hospital/practice/facility have policies and procedures or a program to address disruptive behavior?
Governors also were asked whether they had encountered circumstances when the label of disruptive behavior had been used to curtail opposition to a policy or change; 49 percent did not believe it was applied in this manner.
Finally, 83 percent of the Governors agree that disruptive behavior is an important issue that the College should continue to address (see Figure 4).
Figure 4. Level of importance for the College to continue to address the issue of disruptive surgeons
The impaired physician
Physician impairment is a public health issue that affects not only physicians, but also their families, colleagues, and patients. In this context, the AMA defines impairment as a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.
Almost all of the Governors (99 percent) said they had never been labeled impaired. However, 57 percent knew of a colleague who was impaired (see Figure 5).
Figure 5. Have you known a colleague who has been labeled an impaired physician?
Most of the Governors said they believe the impaired physicians pose the greatest threat to patients and families or to themselves (see Figure 6).
Figure 6. To whom does the impaired colleague pose a threat?
When a physician is found to be impaired, there are several different ways to address the situation, such as reporting the behavior to a supervisor, hospital, physician health program, and so on (see Figure 7).
Figure 7. If a colleague was found to be impaired, how was the situation handled?
Many of the respondents (more than 42 percent) said that impaired colleagues were reluctant to seek help because it might negatively affect their privileges or referrals (see Figure 8).
Figure 8. Are you aware of impaired colleagues who were reluctant to seek help because it might negatively affect privileges or referrals?
Interestingly, only 62 percent of bylaws for the hospitals/facilities where Governors practice define the behaviors of an impaired physician. A definition was more prevalently found in the bylaws of U.S. and Canadian practices than international practices.
Notably, most (58 percent) of the Governors’ hospitals/facilities educate employees on the ethical obligation to report impaired colleagues. Overall, 85 percent of the respondents agreed that the impaired surgeon is an important issue that the ACS should continue to address (see Figure 9).
Figure 9. Level of importance for the College to continue to address the issue of impaired surgeons
While less than 10 percent of ACS Governors report that they have been labeled disruptive, more than 80 percent know of a colleague who has borne that label. Because the definition of disruptive behavior is only codified in 52 percent of the bylaws of hospitals/facilities, it is important to ensure a definition is included in your institution’s bylaws, as well as the procedures to manage these behaviors, including ensuring due process for the physician. Fortunately, most of the Governors practice in institutions that have programs to address disruptive behavior.
More than half of the ACS Governors know of a colleague who has been labeled impaired. Unfortunately, many impaired physicians are reluctant to seek help. Being impaired poses a high threat to patients, families, and to the affected physician. Although 70 percent of North American-based and 56 percent of international hospitals/facilities have bylaws defining impairment, those institutions that do not should ensure that this language is defined in future revisions. Emphasis also should be given to the proper ways to report impaired behavior.
The impaired physician has medical condition(s) that should be addressed, regardless of whether they continue to operate. Surgeons have a responsibility to help their colleagues get treatment—for the good of the affected physician and for the safety of their respective patients. As surgeons, we are responsible for monitoring our colleagues who are affected by these medical problems and should follow Dr. Codman’s guidelines to ensure patients receive quality care that is delivered in a safe manner.
The physician exhibiting disruptive behavior offers a bigger challenge. While many physicians labeled as disruptive have truly needed help, the survey also revealed that more than one-third of Governors were aware of physicians being labeled as disruptive when they disagreed with policies at a hospital or system and/or disagreed with proposed changes. For those wrongly accused, surgeons must ensure medical staff policies, procedures, and bylaws protect due process. For those surgeons who exhibit disruptive behavior, we as colleagues need to provide them with assistance and training to get the train back on the track. The best treatment for disruptive behavior is to prevent its development. Prevention can occur through a number of strategies, such as participation in an ongoing wellness program, improving surgeons’ emotional intelligence, intervention from a colleague, stress reduction activities, and so on. Establishing transparent rules for behavior, as well as the ramifications if the rules are breached, is a good start. These actions can help improve morale and stave off conflict resulting from disruptive behavior.
Documentation of events and interventions are an essential component of the resolution process. Clear communication also is critical in the prevention and management of disruptive behavior. As cases are reported, investigated, and adjudicated, differences of opinion can be part of the problem, and many stem from miscommunication. With prevention in mind, surgeons should be taught effective listening skills and work to improve their emotional intelligence to avoid conflict and escalating confrontations. Surgeons are natural problem solvers; given the appropriate tools and resources, they can handily deal with this challenge to improve their working environments.
Dealing with physicians who are either impaired and/or disruptive can be more challenging but surmountable with time and effort. The issues of disruptive behavior and impairment are important topics that the ACS should continue to address by developing new resources and information to help surgeons recognize and respond to these behaviors and/or medical conditions in their colleagues.
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