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Dealing With Disruptive Physician Behavior (Part I): Scope of Problem, Antecedents of Disruptive Behavior, and Primary Prevention

Elizabeth Becker, LCSW
William A. Norcross, MD

Although most of us conceptualize the problem of the disruptive physician as centering about an individual physician, the dilemma is actually  systemic, cultural, and multifactorial. The challenge of dealing effectively with disruptive physicians is that they may be very competent from a strictly technical point of view, bring in large amounts of money to the hospital, and deliver services that may be difficult to replace. Some observers have suggested that the culture of some residency programs actually models, teaches, and reinforces disruptive behavior to its learners1.

The problem would be ameliorated if hospitals and medical groups had clear, specific expectations for physician communication, leadership, and behavior and held their colleagues accountable for adhering to these standards. The medical staff policies and procedures should not only be clear in describing behavioral expectations, but should have a specific plan for investigating departures from the standard, options for remediation, and unambiguous consequences for recurring misbehavior. Such policies would be especially effective if they were reviewed and signed by physicians at the time of applying to or joining the medical staff, and were accompanied by a brief educational program that taught communication skills and hospital behavioral expectations.

For disruptive behavior to be tolerated, it requires a work environment and hospital culture that allows, sustains, and ultimately reinforces such behavior. Disruptive physician behaviors have been enumerated elsewhere1, but the consistent outcome of such behavior is poor workplace morale, high staff turnover, and a climate of fear and distrust. Such an environment splinters the healthcare team, potentially impacting patient care. Divisive and disruptive behavior also decreases effective communication, contributes to medical errors, and is associated with patient dissatisfaction and complaints. Ultimately, trust in the leadership of the medical staff and hospital is undermined through the tolerance of obviously dysfunctional behavior. Staff and physician colleagues begin to devote more time to avoiding triggering the noxious behavior of the disruptive physician than they do to patient care. While no study to date has examined the effects of disruptive behavior on clinical performance, everyone who deals with this issue firmly believes that it causes poorer medical and surgical outcomes than would be found with a well functioning team in a supportive work environment.

Rosenstein performed a large convenience sample survey of nurses, physicians, and hospital executives, reporting the results of the first 1200 responses in June 20022. Although there is much data in the study (and it is ongoing), salient findings for the purposes of this article were that the respondents most commonly reported that 2% to 3% of physicians demonstrated disruptive behavior, with such behaviors most commonly being reported to occur once or twice each month or weekly. The average rating of all respondents (n=1155) to the inquiry how serious an issue disruptive behavior was at the hospital was a 7 on a Likert scale of 1 to 10. Of 1043 respondents who answered a question regarding barriers or resistance to the reporting of disruptive physicians, the most common responses were: “fear of retribution,” “the belief that ‘nothing ever changes’,” “lack of confidentiality,” “lack of administrative support,” and “physician lack of awareness or unwillingness to change.”

With respect to disruptive physician behavior: an ounce of prevention is worth a pound of cure. Each hospital that hopes to create a work environment of excellence must have a critical mass of physicians and staff who consistently demonstrate good communication and interpersonal skills, personal leadership, mutual respect and trust, and teamwork on a daily basis. These skill sets are considered fundamental for effective team functioning. Such a hospital creates a culture of excellence in which disruptive behavior is unacceptable. The Medical Staff Policy and Procedure document of every hospital should clearly and specifically proscribe disruptive behavior, and the document should spare no pains in detailing the specific behaviors that are unacceptable. The authors should keep in mind that in addition to the “classical” expressions of disruptive behavior (e.g., yelling, belittling, throwing instruments, etc.), that passive-aggressive behaviors (e.g., ignoring staff questions, failure to respond to paging, etc.) may be equally disruptive to the work environment. The document should clearly describe how allegations of disruptive behavior will be investigated, the disciplinary steps that will result from persistent misbehavior, a remedial plan for dealing with motivated physicians, and the consequences to the physician if he does not participate in remedial efforts or fails to achieve a satisfactory level of remediation. The disciplinary sequence for severe, persistent disruptive physician behavior should ultimately result in dismissal from the medical staff. Failure to deal with disruptive physician behavior quickly, firmly, and clearly, actually results in positive reinforcement to the physician, as he quickly learns that such behavior is accepted and that there are no consequences. For this reason, every hospital should have a policy that ensures that all employees are able to report disruptive or unprofessional behavior in a manner free from intimidation or retaliation. In fact, the hospital should expect and require employees to report such behavior.

 As disruptive behavior continues, a maladaptive culture develops that “allows” for disruption and creates a “niche” for the physician. Nurses and other staff begin to spend more and more time trying to avoid the situations that trigger the disruptive behavior. A small group of “favored” nurses (those who have proven tolerant or adapted to the disruptive behavior) evolves and may actually take sides in a sick dynamic against the majority of the staff who are intolerant of the misbehavior. Typical battle cries of the disruptive physician include: “I’m only interested in quality of care!” “I’m passionate about excellence, but misunderstood!” “I wouldn’t get mad if we had competent nursing staff!” We have consulted in one hospital in which the birthday gift for each member of the operating room nursing group was a full week in which they were not scheduled to work with the disruptive surgeon! While this may seem strange to most readers, cultures develop insidiously and over the course of years. Aberrant systems and relationships come to be regarded as the norm. The negative fallout from this type of toxic culture commonly has a more widespread consequence, spreading beyond the borders of the hospital into the larger medical community. Gossip and distrust lead to an erosion of confidence in the clinical program and perhaps even the entire hospital, with a consequent decline in referrals and admissions.

We recommend that at the time a physician first joins the medical group or hospital medical staff, he should participate in a one-day orientation program that carefully reviews the Medical Staff Policy and Procedure document. The program should also include brief training in communication. The physician must sign the Medical Staff Policy and Procedure document, indicating his understanding and agreement to comply. Regular social and teambuilding activities involving the medical and hospital staff help develop personal relationships, communication, and empathy. Although the problem of disruptive behavior can be recalcitrant, we have consistently witnessed improvement when the index physician begins to know his staff colleagues on a personal level.

Every hospital would do well to build the leadership capacity within its nursing staff, medical staff, and administration. There are a variety of sources for this training, but State and local medical societies frequently offer educational programs in this area. In dealing with the physician culture of a hospital or medical group, the Chief of Staff occupies a critical position. Over 5 years of offering onsite consultation to hospitals with problems of disruptive physician behavior, the most common response to the question, “Why did you consult with us now?” was: “This year we have a strong Chief of Staff.” In anticipation of her/his forthcoming tenure as Chief of the Medical Staff, the hospital should give strong consideration to sending the physician to a program that will teach her/him about the position and develop her/his leadership skills. An excellent program in the State of California is Essentials for New Medical Staff Leaders offered regularly by the Institute for Medical Quality (http://www.imq.org).

In its extreme manifestations, disruptive physician behavior is not difficult to detect, but in its beginning stages, especially when taking place in a hospital culture that tolerates or accommodates such behavior, it can be a challenge to characterize. While confidential reporting of a specific incident might seem desirable, it is very difficult to achieve. Retaliation by the reported physician must be strictly forbidden, and consequences in place, if it occurs.

An interesting tool that has been used in the corporate world for decades, but has only been introduced into medicine recently, is the 360º-assessment (“360”), a series of survey instruments evaluating the clinical performance and professionalism of the index physician that are typically completed by patients, staff (nurses, OR personnel, receptionists, etc.), physician colleagues, the physician himself/herself, and the physician’s supervisor (e.g., Department Chair, Chief of Staff). The “360” is easy to complete, provides much data, and gives feedback from the people who form the “sphere” of the physician’s professional environment. The survey instruments typically ask the respondent to respond by way of ranking the physician’s performance compared to the other physicians you know. The UCSD PACE Program and the Division of Family Medicine, UCSD School of Medicine uses the tools and processes created by the College of Physicians and Surgeons of the Province of Alberta for their Physician Achievement Review (PAR) Program. They are available in the public domain at http://www.par-program.org. A “360” allows for specific feedback for all physicians, not only those identified as manifesting disruptive behavior, and can help detect deficiencies in communication skills or unprofessional behavior that may not have previously been appreciated by medical staff leadership.

(Part II will address the “treatment” of established disruptive physician behavior.)

References:

  • Kissoon N, Lapenta S, Armstrong G. Diagnosis and therapy for the disruptive physician. Physician Exec 2002; Jan-Feb: 54-58.
  • Rosenstein AH. Nurse-Physician relationships: Impact on nurse satisfaction and retention. AJN 2002; 102: 26-34.

 

 
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