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Disruptive Physician Behavior: Fact vs. Frenzy

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By Alan Rosenstein, MD

The Joint Commission has recently proposed in its 2009 Accreditation Standards that hospitals develop and implement a Code of Conduct policy and provide appropriate education and processes that address disruptive behaviors.

Many think the decision is long overdue, while others have expressed concern that it was just another way for administration to weed out physicians who are openly vocal in expressing contrary views to administrative policies and decisions.

Disruptive behaviors include any inappropriate behavior, confrontation or conflict ranging from verbal abuse to physical or sexual harassment. Unfortunately, they’re all too common in the health care arena, and they affect staff morale as well as patient safety.

I have been researching disruptive behaviors for 10 years, starting in the era of growing concerns about the nursing shortage to see if there was a relationship of between physician disruptive behavior and nurse satisfaction and retention.

In one study, more than 90 percent of the 2,500 survey participants (physicians, nurses and senior level administrators) witnessed disruptive behaviors in physicians and more than one-third were aware of a nurse who left the hospital specifically because of physician disruptive behaviors.

What we learned from this research was how serious an issue it really was and more importantly, the impact it had on staff relationships, communication efficiency and patient outcomes of care.

The second phase of our research focused on not only physician disruptive behaviors, but also disruptive behaviors in nurses and other hospital employees. We also assessed the relationship of disruptive behaviors to human factor issues affecting decision making, task fulfillment and performance (stress, frustration, concentration, communication and information transfer) and the linkage between disruptive behaviors and negative outcomes of care (adverse events, errors, compromises in quality or patient safety and mortality).

Once again we were astounded by the frequency and significance of our findings and in particular the acute and downstream negative effect of these incidents on patient care and patient safety.

Our recommendations for action include:

  1. Raise awareness
  2. Conduct an internal assessment
  3. Developing and implement behavioral policies and procedures that outline and reinforce appropriate professional code of conduct standards
  4. Assess potential underlying factors that may precipitate disruptive events and provide appropriate educational courses (diversity training, sensitivity training, conflict management, assertiveness training
  5. Provide tools that improve communication efficiencies and team collaboration (SBAR, team collaboration training, improved language/ linguistic skills
  6. Implement an effective and consistently applied reporting and follow up system that assures that all incidents be addressed with appropriate action and feedback as part of the loop
  7. Have a consistent criteria based system for addressing chronic disruptive behaviors to include multidisciplinary review and follow up recommendations that may include counseling and/ or suspension of privileges
  8. Use a clinical champion to foster the cause
  9. Secure leadership support and endorsement
  10. Reinforce the importance of the end goal which is to improve patient safety and quality as an integral part of the organizational culture and other patient safety, quality and risk management programs.

The historical issue of the reluctance of management and clinicians to address other physicians who bring patients into the hospital and are a major source of revenue makes addressing this issue difficult. Also, traditional monitoring and credentialing activities focus on demonstration of clinical or technical competence. We have not really been trained on the merits of communication competency. If you do nothing, you run the risk of staff dissatisfaction and its associated repercussions on staff recruitment and retention, risks to compromises in patient safety and quality outcomes of care, risks to your reputation, and even financial liability.

So what should you do? First, develop the business case around patient safety. Many physicians are not aware of the downstream effect of many of their actions and their primary goal is always to provide optimal patient outcomes of care. Focus on health care complexity and the opportunity to improve understanding, communication and collaboration as way to improve efficiencies and outcomes of coordinated health care delivery rather than taking a primary punitive confrontational approach.

Make sure you have criteria, guidelines, standards and processes in place that address critical issues of concern to help thwart the potential concerns about a hospital witch hunt. Be up front in addressing and following up on physician complaints and issues brought to your attention. Get a better understanding on what makes people react the way they do. With increasing diversity in the medical marketplace providing educational and training programs on culture and ethnicity, generational issues and ways to improve communication and collaboration skills.

Alan Rosenstein is the medical director and a vice president at VHA West Coast, a health care consulting firm. He reported no conflicts of interest related to this post.

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12 replies »

  1. “Disruptive Behavior”? Yes, we all know that physicians, as well as others, are capable of it. But, is this label SEVERELY ABUSED to get rid of some doc the administrators or other docgtors don’t like?

    The Center for Peer Review Justice has in it’s files hundreds of such cases where a doc is tagged with that label and then the hospital and others get IMMUNITY and because of the Health Care Quality Improvement Act of 1986, the doc only has PROCEDURAL due process and not substantive ( facts) due process.

    A lawyer can not change the very limited amount of rights a “Disruptive Doctor” has.

    There ARE solutions!!!! http://www.PeerReviewSolutions.org, for example.

    Richard Willner
    The Center for Peer Review Justice
    http://www.PeerReview.org

  2. The description of Swantine’s friend above who has been targeted by her HMO is a case study in sham peer review. The is well describe by Lawrence Huntoon, MD on the Association of American Physician and Surgeons website. Don’t be a victim of sham peer review. Protect yourself. Bring a friend to any “emergency” meeting you are called to with administrators. Record the interaction on your dictaphone. If allegations are made against you but you cannot have access to the complaints in writing watch out. You are about to become a victim. Get legal advice early. Demand access to records. Notify your department head and other colleagues. Sometimes this is used to fire employeed physicians who are low producers. I have personally see a physician firing who was labeled disruptive without recourse or intervention to correct behaviour.

  3. Ms Porto,
    As this issue becomes more prevailant in hospitals I suspect you will find more and more physicians who are concerned by these new requirements. Comments such as yours saying “I have heard the argument that this will be used against physicians who rail against the system and frankly I am not sympathetic to this” are quite possibly the reson for that. This fear is very real, especially as the arena of healthcare becomes more and more politicized.
    I’ve been in practice for 6 years and in that time I’ve had one incidence where my behavior was questioned. After this single episode of “disruptive behavior” I had to present my case to peer review, the medical executive committee, and then a special review board. This all occurred about two months after giving up my block time and moving the majority of my cases to a competing hospital. When I finally got a chance to plead my case to the hospital CEO she said “What difference does it make, you’re not doing enough cases here to matter anymore anyway.” While you mention the safeguards that are put in the system for physicians who feel unfairly targeted, you can’t account for the lost time that is required to deal with these situations, especially for those of us in solo practice. I think you should be more receptive to physicains expressing their doubts about these new requirements.
    Oh, and in case you were wondering, my “disruptive behavior” was asking the charge nurse how much time and thought she had placed into the decision to move an adult with HIV related pneumocystis pneumonia into a room with my pediatric patient whom I’d admitted with inherited immunoglobulin G deficiency. Apparently she thought my tone was demeaning. Still trying to figure out how my demeaning tone placed my patient as greater physical harm than her incompetence.

  4. I’ve been a psychotherapist for a fair number of years now and my wife is a clinical social worker. We’ve both seen disruptive professionals in all the disciplines – doctors, nurses, psychologists, social workers, therapists, and administrators; in each category, they have been a small minority, thankfully. We do need a way to weed them out, and we also need that mechanism to have safeguards built in so that it isn’t abused to get rid of whistleblowers or staff who stand up to the institution in advocating for patients, clients, and their families.
    Prevention is always better than damage control, and we should be doing more in the training of all our fields to first, identify people who are just temperamentally unsuited for the work and redirect them before they ever get through school and get licensed.
    Second, and this is something I learned in earlier parts of my life in the military and in management, the attitudes and values of the people running the organization trickle down and quickly permeate every part of it. An important part of having members of all our professions treat the people we serve the same way we’d want to be treated is for the executive leadership to treat staff at all levels that way. When I see situations where line staff are shorthanded and underpaid while the top brass are pulling down hundreds of thousands of dollars a year, it’s not hard to figure out where a ‘disruptive’ atmosphere can originate.

  5. An excellent commentary on the issues and recommendations for action. This is a real issue that impacts healthcare on many levels. I am glad to know that the Joint Commission included it in its 2009 accreditation standards.

  6. Dr. Rosenstein,
    My friend is a physician with an exemplary 20 year record and is currently in the midst of a battle with a huge HMO which dismissed her for being such a disruptive physician. She was not disruptive but she had reported some unlawful or otherwise problematic procedures that had slipped into practice had not been corrected. That alone brought her into focus and the culture of backstabbing took over! The past 2 years have been unbelievable. Instead of just calling her disruptive, they altered certain medical records to conform to their allegations, filed complaints with the state medical board, named her as a security risk and summarily dismissed her. Ironically, for 6 months, between the first allegations and the final dismissal, she continued to be in charge of her department while on duty (I hesitate to say which dept.) and treated many patients. They KNEW she was actually harmless and that the accusations were false. False is not a strong enough word. ‘Created from thin air’ is more accurate for most of the charges. They really went for the jugular vein in this case, using the idea of the ‘disruptive physician’ as the reason.
    The initial hearings are almost over and then the trial will begin. Because the HMO has so much power, many things were automatically waived including the oversight of a “cumis attorney” which is often used in cases of insurance companies where there may be a conflict of interest. Of course, there is HUGE conflict of interest when the rules of this type of judicial review allows the HMO to choose both plaintiff’s and defendant’s attorney.
    The physician has quite a lot of support evidence and witnesses on her side but none have been deposed or subpoenaed.
    The physician was never, ever disruptive, but was a quiet, serious doctor who cared about her patients.
    I believe that the term “disruptive physician” is being overused and has now become a handy label to slap on any doctor who doesn’t want to plod along, covering up the flaws and legal errors in the hospital practices and procedures. It is serving to quiet physicians alright, but at considerable cost to the health of patients. We need physicians on OUR side, not physicians too afraid to speak up for fear of being labeled disruptive!

  9. As a member of the Joint Commission’s SEntinel Event Advisory Group and a champion of its efforts in this area, I would like to add a few comments to Alan Rosenstein’s excellent posting: 1) the requirements in the JC’s standards as well as the guidance in the alert released in July of 2008 clearly state that this applies to everyone, not just physicians. 2) the work of Alan Rosenstein and ISMP clearly show that the behavior in question is not limited to physicians. 3) although physicians are not the most frequent disrupters, their behavior tends to have the largest impact because of their relative power in the organization. 4) the focus of these efforts is on behavior that imperils patient safety, something everyone should be concerned about, regardless of the source. 5) I have heard the argument that this will be used against physicians who rail against the system and frankly I am not sympathetic to this. If a physician is protesting in such a way that patients are put at risk of harm, they should be rightly disciplined. Also, physicians have a lot of rights that are codified in law as well as in institutional bylaws. Much more so than anyone else in healthcare. In my experience, physicians are not hesitant to engage lawyers and to litigate when they feel unfairly targeted. There are enough safeguards for physicians in the system, but almost none for patients being injured by these behaviors.

  11. HAHAHAAA, as my teenage daughter would say, to “a”!!! You must be a doc – I’ve seen a few of those administrators myself! In fact, they are behind the current hospital building binge (and other things) which is driving healthcare costs even higher!
    As for arrogance and ass-hole like behavior, I am afraid administrators don’t have it over (some) doctors on that one. As a pathologist I had to deal with too many of them with both titles! But thanks for the good laugh!

  12. how about disruptive administrators
    those who destroy clinical departments thru incompetence, inexperience, and just plain egotistical stupidity?
    what about arrogance, and general asshole-like behavior?
    got a regulation for that?