Hospitals try to calm doctors' outbursts

Medical road rage affecting patient safety, group says

By Liz Kowalczyk
Globe Staff / August 10, 2008
The Boston Globe

During an operation at a Salem hospital last summer, an orthopedic surgeon, frustrated by a pair of scissors that wouldn't cut, threw them and narrowly missed a nurse.

In many hospitals, outbursts from a top surgeon who generates significant revenue or a star researcher who wins huge grants often have been tolerated. But in this instance, North Shore Medical Center disciplined the doctor who threw scissors and required mandatory team training for all operating room staff under a recent policy requiring physicians to treat their colleagues with "civility and respect."

North Shore is part of an emerging effort to crack down on what some call healthcare road rage. The push is inspired by a growing body of research suggesting that swearing, yelling, and throwing objects are not just rude and offensive to co-workers, but hurt patients by increasing the likelihood of medical errors.

The national group that accredits healthcare organizations issued a safety alert to hospitals last month, saying outbursts threaten patient safety because they prevent caregivers from working as a team. The organization, The Joint Commission, for the first time is requiring all hospitals, nursing homes, and other healthcare facilities to adopt "zero-tolerance" policies by Jan. 1, including codes of conduct, ways to encourage staff to report bad behavior, and a process for helping and, if necessary, disciplining offenders.

Dr. Peter Angood, chief patient safety officer for the commission, said most hospitals have tolerated healthcare road rage to the point where it has become an accepted part of the culture. That can be particularly true, others said, in high-stakes surgery, a field that can attract high-intensity physicians who are used to being in charge.

The typical attitude, Angood said, is "let's not irritate the physicians or else they're going to take their patients to another hospital."

Some surgeons have escaped discipline even after frequent offenses. At Saint Vincent Hospital in Worcester, orthopedic surgeon Peter Mulhern repeatedly yelled at colleagues over six years - including calling one nurse a "lame-brain" and "an idiot" for seeking additional consent prior to a patient's surgery - before the hospital suspended him in late 2002, according to the state Board of Registration in Medicine, which licenses physicians.

The last straw: He threw two 10-pound sandbags, used to position a patient's arm, to the operating room floor; one hit a nurse's foot, according to the board.

It was the ninth complaint about Mulhern, who moved to practice in Georgia after his suspension. Current administrators at the hospital, which is under new ownership, said they are not sure why the situation was allowed to continue for so long. Mulhern, who completed an anger management program, did not respond to a request for a comment.

Dr. Anthony Esposito, chief of medicine, said that a case now goes to the medical executive committee for a decision after a person has three outbursts. As for Mulhern's nine episodes, he said, "the number is absolutely unacceptable."

In calling for a new policy, the Joint Commission cites several studies linking bad behavior to errors. For example, one survey found that some nurses and pharmacists had avoided consulting with a prescribing doctor because they did not want to interact with that particular doctor.

"The number one issue in the errors that occur is bad communication," said Angood. "The industry needs to put a stop to this."

Many hospitals have already adopted civility policies, including Massachusetts General Hospital, where leaders of the hospital's patient safety initiative saw a link between errors and disruptive behavior, said Jeff Davis, senior vice president for human resources.

But policies are just a first step. Specialists say a key issue is making sure staff members are comfortable reporting colleagues' outbursts without fear of retaliation.

At North Shore's Salem Hospital, nurses did report Dr. Murray Goodman when he threw the scissors. Fran O'Connell, head of the hospital's nurses' union, said tension was high in the operating room because Goodman was running late for two surgeries to correct carpal tunnel syndrome and the two nurses were new.

"The scissors didn't cut to his liking; he was trying to cut suture material. He said they were dull. He tossed them across the room. One of the nurses had to dodge the scissors," O'Connell said.

O'Connell said nurses were frustrated because they felt the hospital was slow to take action - and when the hospital did discipline Goodman, administrators would not tell nurses the details. Dr. Marc Rubin, who implemented the civility policy when he became chairman of the surgery department two years ago, said the specifics of the discipline are confidential. Goodman declined to comment.

North Shore spokeswoman Laura Fleming said administrators learned from this incident. When the civility policy was expanded to the entire medical staff this year, it was streamlined so that cases that can't be resolved informally reach the medical staff professional conduct committee, a group of doctors and administrators that makes disciplinary decisions, more quickly.

"These incidents happen because the OR environment is so high stress," said Rubin. "Surgeons hold patients' lives in their hands, yet they're dependent on equipment and people who are outside their control. This incident was over a year ago and there has not been another incident with this physician."

Most hospitals don't track how many doctors, nurses, and other employees engage in disruptive behavior. But administrators at Vanderbilt University Medical Center estimate that 4 percent to 6 percent of doctors and nurses have repeated outbursts. Vanderbilt, which has one of the most extensive programs to track and deal with such behavior, began focusing on the problem a decade ago when administrators found that physicians who were sued often were more likely to have abusive outbursts. The medical center now advises 34 healthcare facilities on addressing the problem.

Some leaders in the field believe the number of doctors and nurses acting out is rising. Angood said Joint Commission surveyors hear about the issue constantly when they visit hospitals, where frustration is escalating amid growing financial pressures.

"You're looking at a very stressed out industry," agreed David Yamada, a Suffolk University law professor who specializes in employment issues including workplace bullying. "You have an industry in crisis where people are having to do much more with limited resources. That combination can be a potent one."

But others believe that the problem is not necessarily getting worse, but, rather, that the patient safety movement has focused more attention on the conditions that lead to medical errors, encouraging staff to report bad behavior more often and hospitals to respond more quickly.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

© Copyright 2008 Globe Newspaper Company.

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