Stopping disruptive physician behavior

By Eric Berkman

Imagine a nurse being so intimidated by a condescending and abusive doctor that she decides not to contact him for an emergency while he’s on call.

Or perhaps a patient suffering from internal bleeding but refusing treatment when he sees his doctor screaming at the nurses. Or a doctor loudly refusing to listen to his nurses, undoing a course of treatment and causing the death of a patient.

While these scenarios may sound like a bad ER script, they’ve actually happened, according to anonymous comments submitted by nurses, technicians and physicians who responded to a national survey on disruptive physician behavior and the risks it creates in the clinical setting.

As a result of these risks, the Joint Commission announced a new standard in July addressing “behaviors that undermine a culture of safety.”

The standard requires accredited hospitals and health organizations to maintain a code of conduct that defines “acceptable and disruptive and inappropriate behaviors” and requires organizational leaders to create and implement a process for managing disruptive and inappropriate behaviors.

Doctors and health care lawyers welcomed the new standard, saying the failure of many hospitals to police the issue on their own has put patients in harm’s way and heightened the risk of liability due to bad medical outcomes or hostile work environments.

“With the improvement of health care in general and the demand that patients be provided good care, this has been recognized as an area that hasn’t really been addressed,” says Luis Sanchez, director of Physician Health Services, a subsidiary of the Massachusetts Medical Society that provides consultation and support to doctors struggling with mental health, behavioral and substance abuse issues. “Enforcing [rules] against bad behavior is no fun, but it must be done to promote good behavior.”

Experts suggest that organizations take steps to ensure that their conduct codes are effective by:

--Training medical staff on behavior in the health care workplace;

--Instituting an effective reporting procedure;

--Intervening in a supportive, non-punitive way; and

--Not using the code to discipline physicians for freely debating ideas about patient care.

The study

In the 2006 study of disruptive physician behavior, Alan Rosenstein – vice president and medical director of VHA West Coast, an affiliation of 1600 nonprofit hospitals nationwide – and co-author Michelle O’Daniel surveyed more than 5,000 anonymous respondents at more than 150 hospitals.

They discovered that 75 percent of respondents had witnessed disruptive behavior in physicians, 38 percent were aware of adverse events that could have occurred as a result of such behavior and 14 percent witnessed adverse events that were the direct result of such behavior.

“Though we found that only 3 to 5 percent of medical staff engage in disruptive behavior, this small percentage has an enormous impact on the entire organization,” says Rosenstein, a practicing internist who’s observed such conduct in the workplace.

Meanwhile, a 2003 study conducted by the Institute for Safe Medication Practices revealed that 40 percent of clinicians have remained silent while witnessing such behavior rather than question an intimidating colleague.

Both sets of findings indicate that disruptive and intimidating physician behavior poses far greater risk to clinical collaboration and patient safety than most people realized, leading to the new standard.

The scope of the problem

A “Sentinel Event Alert” that accompanied the standard defines disruptive behavior to include verbal outbursts, physical threats, refusal to perform assigned tasks or respond to pages and phone calls, use of condescending language and impatience with questions.

Physicians agree that the number one cause of this behavior among their ranks is stress. The typical doctor has too much to do with too little time and overly high expectations to meet. Plus, many are dealing with life-or-death situations. Meanwhile, tensions are exacerbated by nursing shortages and grueling productivity requirements in the managed-care environment.

These tensions can make physicians angry, leading to disruptive behavior – and potentially negative consequences.

For example, a hospital could find itself mired in harassment, discrimination or hostile-work-environment litigation if it were to consistently allow physicians’ abusive or demeaning behavior toward colleagues or subordinates to go unaddressed, says health care attorney Jim Hilliard of Connor & Hilliard in Walpole.

Disruptive behavior gets particularly serious when it occurs in patients’ presence, says Hilliard.

It can raise the anxiety level of patients who are already on edge. When it happens in psychiatric settings, where patients may be dealing with post-traumatic stress, it can cause them to experience the same sensations that drove them into the hospital in the first place.

“When it becomes an issue between clinical staff, patients feel like, ‘My God, I’m a third wheel here,’” he says.

Dealing with the problem

Norwood attorney Scott Liebert recalls an incident 15 years ago where a surgeon called in an anesthesiologist who was at home to perform a surgery that the anesthesiologist felt could wait until the morning.

They verbally sparred in the patient’s presence as the operating room was being set up, and once the patient was under anesthesia, the two started physically fighting.

“They were rolling on the floor in the OR,” says Liebert. “Cooler heads in the room prevailed and they completed the case. The patient was never aware. But still the hospital took formal action and reported it to the Board of Registration in Medicine.”

The fact is, as Rosenstein points out, hospitals have historically been reluctant to confront such situations head-on for a variety of reasons, perhaps most significantly the hierarchical nature of the hospital.

It’s natural that a hospital administrator will be hesitant to confront a prominent surgeon who produces a huge amount of revenue for the hospital about his abusive or intimidating demeanor, but it may need to be done for the sake of patient safety.

The inability of hospitals to police themselves is exactly what spurred the Joint Commission to act. But experts stress that the standard is very open-ended and any behavior policy will have little impact without certain steps being taken.

Mary Anne Badaracco, chief of psychiatry and chair of the medical executive committee at Beth Israel-Deaconess Medical Center in Boston, says medical staff at her hospital undergo constant training in acceptable professional behavior.

“All our departments are expected to have as part of their regular education meetings guidelines about physician behavior and health and how to approach a physician who we think is having difficulty,” she says.

However, a behavior code is useless if people don’t know to whom to report an incident or, worse yet, fear retaliation or feel doing so will be futile, says Rosenstein.

“We recommend a consistent process of handling every single complaint, and maybe even a multidisciplinary group to review every complaint,” he says.

At the same time, he adds, “people need to change the attitude of, ‘I can’t do this to this physician.’ The CEO instead needs to say, ‘I can’t tolerate this.’”

Supportive manner

Liebert says interventions need to be handled in a supportive manner rather than a punitive one.

If all a hospital does is punish, it creates an environment where people may be even more afraid to come forward with a complaint out of fear of getting someone powerful in trouble.

Instead, he suggests carefully investigating the situation. Perhaps a doctor is acting out because of an anxiety disorder that’s inadequately diagnosed, or a substance abuse problem.

“In a lot of situations, intervention early on can be in everybody’s best interest,” Liebert says, adding that referring a troubled physician to PHS, Sanchez’s organization, for assistance is often an excellent first step.

Finally, hospitals must ensure that their code is used appropriately to protect patient and staff safety.

“When evaluating disruptive behaviors we would hope that the process is done fairly and conclusions are based on a thorough, unbiased review of the situation with resulting actions based on the merits of the situation and not the individual involved,” Rosenstein says.

Questions or comments should be directed to the editor at: reni.gertner@mamedicallaw.com