Disruptive Behaviors Among Physicians

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Disruptive Behaviors Among Physicians

Luis T. Sanchez, MD
Physician Health
Services,
Massachusetts Medical
Society, Waltham,
Massachusetts.

Concerns regarding the “disruptive physician” have been reported in the medical literature for at least the past 30 years. Recently, there has been the perception that the problem is increasing, although it is unclear if this is because of increased awareness or greater surveillance or because more physicians are acting unprofessionally. A report from 2006estimated that 3% to 5% of physicians had demonstrated behavior that interferes with patient care or could be expected to interfere with the process of delivering quality care.1 Disruptive behavior has been described as “disruptive behavior by a physician, sometimes 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.Itencompasses behavior that adversely affects morale, focusand concentration, collaboration,and communicationand information transfer,all ofwhich can lead to substandard patient care.”2

The purpose of this Viewpoint is to enhance the understanding of physicians and physician leaders regarding the problem of disruptive behavior, to provide guidance about how best to address physicians with behavioral problems, and to discuss the importance of physician leaders developing a medical culture of safety with clear expectations and standards.

In 2008, the Joint Commission provided amore detailed description of “acceptable, disruptive and inappropriate behaviors.”3 Problematic behaviors were described as overtverbal anger and physical threats, aswell as passive behaviors suchas refusing to doassigned tasks and being uncooperative. The Joint Commission also noted that themajority of health professionals were well meaning and care about patients, but those who display intimidating behaviors canerode an institution’s culture of safety. Effective July 1, 2012, the Joint Commission revised this description, removing the term “disruptive and inappropriate behavior” and replacing it with “behavior and behaviors that undermine a culture of safety.”4

A 2008 report of a national survey of 2846 nurses, 944 physicians, 40 administrative executives, and 100 listed as “others” in 102 hospitals found that a significant percentage of respondents felt stressed and frustrated, recalling a loss of focus in their work as a result of disruptive behaviors by others. Two-thirds reported that disruptive behaviors by others were correlated with an adverse event, 71% with the occurrence of medical errors, 51% with compromises in patient safety, and 71% with compromises in quality.5A 2011 questionnaire surveyed 523 physician leaders and 321 staff physicians in a variety of health care settings regarding disruptive behaviors such as degrading comments or insults, refusal to cooperate with others, and speaking loudly, characterized as “yelling.” Almost three-fourths (598 [71%]) of responding physicians reported that they had witnessed disruptive behavior within the previous month, and 219 (26%) of those surveyed reportedly had been disruptive at one time in their career. Disruptive incidents were of higher frequency in surgical, anesthesia, and obstetrics and gynecology specialties and occurred more often in the stressful and intensive areas of the operating room, intensive care unit, and emergency department.6

Starting in 2009, the Joint Commission Standard LD.03.01.01 required hospitals to defineelements of performance, including a code of conduct that defined acceptable, disruptive, and inappropriate behaviors and a process for managing these behaviors.7 Most hospitals have done so, although some physicians may be unaware of the policy, consider that the policy lacks clarity, or observe other physicians who display problematic behavior with no consequences.

The Accreditation Council for Graduate Medical Education’s 6 core competencies form the basis of another set of professional standards. The 6 core competencies include patient care, medical and clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and system-based practice. These standards are the basis for the Ongoing Professional Practice Evaluation (OPPE) and the Focused Professional Practice Evaluation (FPPE) that the Joint Commission instituted in 2002.8 The OPPE provides a continuous evaluation for credentialing and privileging physicians, whereas the FPPE is used if specific concerns arise that would benefit from focused attention.

By having an ongoing set of evaluations, institutions are required to establish a code of conduct, develop a reporting system, educate and train staff, and have a mechanism for problem resolution. The system requires that institutions begin to develop a culture in which physicians are aware of the standards and set an expectation that theywill be required tomeet these standards.Inaddition, physician leaders’ commitment to professional behavior will in time effectively convey to the staff that the values of the institution are well defined, expected to be upheld, and are being demonstrated by leaders.

Once identified, disruptive behaviors cannot and should not be ignored. Ideally, the physician demonstrating disruptive behavior would be aware of the behavior and seek advice and support. But often that is not the case. Therefore, thosewho observe or becomeaware need to take steps to mitigate such behavior. Physician colleagues have a role in meeting with the physician, reviewing the noted behaviors and supporting the physician in changing the behavior or seeking assistance.Nonphysician medical staff and hospital employees need to be made aware of the provisions of the code of conduct as to reporting channels.

Persistent disruptive behavior despite these initial interventions becomes the responsibility of the department chair, medical staff president, or chief medical officer. Use of the OPPE or FPPE, or referral to peer-review-protected hospital committees or outside resources such as the primary care physician, therapist, and employee assistance programs, if available, could be indicated. Professional coaches experienced in assisting physicians with behavioral problems can also be a resource. If patient safety is compromised, then sanctions and licensing board reports need to be considered.

Wellness committees can provide peer support. Peer review– protected entities, including many state physician health programs, can have an important role in assessing physicians with problematic behaviors and providing corrective action steps. Physician leaders need to promote acceptable behaviors with a well thought through expected code of conduct or similar standard. A definitive process needs to be in place for assessing unacceptable behaviors and developing action steps.

In addition to focusing on the identified physician, it is important to recognize that the physician’s behavior could be a reaction to system problems within the institution, because the medical environment is becoming more stressful. For example, the increasing emphasis on productivity, shorter patient visits, and documentation are taking a toll on physicians, and the advent of the electronic health record is causing significant dissatisfaction for some physicians.9A priority of leadership needs to be preventing andminimizing physician behavior problems by having systems in place that foster collegiality,mentoring, respectful dialogue, and promoting the belief that all physicians within the institution are important.

Hospital leaders, medical staff presidents, and administrators must be able to identify physicians with disruptive behavior and have the ability to develop well-planned interventions for those physicians identified as having behavioral problems. Physicians must self-monitor and review their own case loads, responsibilities, and boundaries to avoid becoming overloaded and overwhelmed. Similarly, all medical institutions and medical practices should have good leaders, role models, and mentors who can guide physicians, prevent difficult behaviors from escalating, and address issues as they occur. Working together and developing physician leaders who have the trust of their colleagues will help foster a culture of medicine that serves all physicians, other health care professionals, and patients well.


ARTICLE INFORMATION

Published Online: August 21, 2014.

doi:10.1001/jama.2014.10218.

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

REFERENCES

1. Leape LL, Fromson JA. Problem doctors: is there a system-level solution? Ann Intern Med. 2006;144 (2):107-115.

2. American Medical Association Council on Ethical and Judicial Affairs. Physicians With Disruptive Behavior. Chicago, IL: American Medical Association; 2000. Report 2-A-00.

3. Behaviors that undermine a culture of safety. Sentinel Event Alert. 2008;(40):1-3.

4. Joint Commission on Accreditation of Healthcare Organizations. Leadership standard clarified to address behavior that undermines a safety culture.Jt Comm Perspect. 2012;32(1):7.

5. 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.

6. MacDonald O. Disruptive Physician Behavior. QuantiaMD website. http://www.quantiamd.com /q-qcp/Disruptive_Physician_Behavior.pdf. May 15, 2011. Accessed July 25, 2014.

7. Joint Commission Hospital Accreditation Standards; Leadership Chapter, Standard LD.03.03.01: LD-18.

8. Accreditation Council for Graduate Medical Education website. http://www.acgme.org /acgmeweb/. Accessed July 25, 2014.

9. Friedberg MW, Chen PG, Van Busum KR, et al. Factors Affecting Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. RAND website. http://www.rand .org/content/dam/rand/pubs/research_reports /RR400/RR439/RAND_RR439.pdf. 2013. Accessed July 25, 2014.

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