Dealing Fairly with Disruptive Physicians

From time to time, physician leaders must deal with a disruptive physician colleague. Interacting with a disruptive physician can be emotionally draining and time-intensive for the physician leader and the organization. Disruptive physicians might pose legal challenges as well.

In our opinion, most physician leaders are not sufficiently trained to manage disruptive physicians. In fact, an organization might simply decide to terminate a disruptive physician without attempting to rehabilitate him or her or providing due process because of the time and cost issues.

Disruptive behavior is defined by the American Medical Association Code of Ethics as:

“. . . any abusive conduct, including sexual or other forms of harassment, or forms of verbal or nonverbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.”(1)

Additional examples of disruptive behavior include use of profane language, name calling, sexual comments, racial/ethnic jokes, outbursts of anger, throwing equipment, criticizing other caregivers, comments that undermine a patient’s trust in other caregivers, intimidating behavior and failing to adhere to organizational polices.(2)

Disruptive physician behavior appears to be a continuing and serious problem. More than 70 percent of physicians surveyed in 2011 noted that disruptive physician behavior occurred at least once a month in their organizations, and more than 10 percent indicated that the disruptive behavior occurred daily.(3) Disruptive physician behavior is on a continuum of behavior and can entail minor profanity to outright assault.(3)

What’s particularly disturbing is that 90 percent of the physicians surveyed believe disruptive physician behavior affects patient care. Even more concerning, 25 percent of the surveyed physicians actually admitted to disruptive behavior at least once in their practice lifetimes.(2,3)

Small Percentages, Big Problems

Current data suggests that, in most work settings, only a few physicians are responsible for most disruptive behavior (3 to 5 percent).(4) In addition, while drugs and alcohol can have a direct impact on a particular physician’s behavior, it has been shown that only a small fraction of disruptive physicians are impaired by drugs or alcohol (estimated at 10 percent).(5) That being said, even a small fraction of disruptive physicians on a medical staff can have a profoundly negative impact on the culture and working relationships within the organization.

Disruptive behavior might also pose economic consequences to an organization, such as the potential for lawsuits, attrition of the workforce (particularly nurses), reduced patient satisfaction and loss of cohesive team interaction, which reduces efficiency and productivity.(4,6) Most important, this behavior often has a negative impact on patient care. Optimal patient care depends on several components, including team interaction, communication, team coordination, and mutually understood goals and objectives.(7) Unfortunately, if a disruptive physician is present these components of team interaction may not be achievable.

Physician leaders are expected not only to address disruptive behavior, but prevent it. They will need to develop a systematic approach to the problem.(4) An initial step in this approach includes educating the entire workforce on what constitutes disruptive behavior. In addition, the workforce needs to clearly understand the consequences of engaging in disruptive behavior. Consequences should be graded on the severity of the disruptive behavior. For example, the use of tainted language is less egregious than sexual harassment.

What drives a physician to display disruptive behavior? Physicians are inherently good people who want to serve and help their fellow man. If this were not the case, they would not have gone into the profession and spent many formative years preparing to do so. There appear to be two overarching factors that contribute to the development of disruptive behavior: external and internal factors.(8) External factors that affect physicians’ behavior are the stresses of training, the rigid health care hierarchy, health care reform, work-related stress, burnout, work environment, adverse events, litigation, personal issues and debt. Internal factors that affect physicians’ behavior are age, generational issues, gender, sexual orientation, culture, ethnicity, spirituality, geography, life experiences, mood and personality.(8)

Both the external and internal factors shape our moods, our emotions and how we react to our environments and individual circumstances.(8) In addition, both age and generational factors mold our individual perceptions of the environments in which we live and work.(8) These factors, among others, shape our individual work ethics, commitment and loyalty to institutions, our response to authority, and our views relative to work-life balance. Physician leaders should be aware of these contributing factors and the role they might play with their medical colleagues.

A Psychiatric Perspective

Looking at disruptive behavior from a psychiatric perspective, the differential diagnosis associated with it can be segmented into symptom disorders (Axis I disorders) and personality disorders (Axis II disorders).(9) Axis I includes bipolar, depressive, substance use, attention deficit, intermittent explosive, circadian rhythm disruption and dementia disorders. Axis II includes paranoid, narcissistic, passive-aggressive and borderline personality disorders. Furthermore, the addition of external stressors, personal or professional, to a physician’s life will magnify both, his or her personality and symptoms.(9)

It is thought that certain personality traits are more commonly seen in physicians who display disruptive behavior.(10) In particular, minimal sociability, low personal trust and low personal contentment are commonly seen. These physicians tend to prefer environments with minimal social interaction and exhibit low levels of emotional self-control. In addition, disruptive physicians tend to question the motives and agendas of others.(10)

Disruptive physicians might react strongly when untrue rumors are told about them and/or in times when they perceive they have been unfairly treated. In this regard, disruptive physicians can react impulsively in stressful situations.(10) Disruptive behavior, ultimately, is generally motivated by a physician’s need for power and control in relationships.(9) The need for control in a relationship is translated into acts of intimidation and thus, disruptive physicians generally are not good team players.

Developing a strategy to help physicians migrate through the stresses of the day potentially can reduce disruptive behavior. Training programs that consist of personality and relationship management along with developing personal skills and team collaboration might be useful.(8)

Individual counseling or coaching also can help rehabilitate disruptive physicians, and physician leaders should consider having individuals on staff who can help assist with coaching/counseling. Coaching helps physicians to become more self-aware, because it teaches them that their behaviors are a result of how they think about events and not the events themselves.(10) Improved self-awareness helps physicians think about their responses, how they affect others, and how they can modify behaviors in the future.(10) As a caveat, counseling might not be effective in those physicians who are defensive and unwilling to admit mistakes.(10)

Plans Need Support

Physician personality and relationship management training and support must be improved by health care institutions to help physicians deal with the stresses of the work environment. A 2014 stress and burnout survey of physicians showed 85 percent indicating their organization did not provide support to help them deal with burnout and stress.(11) Why does it appear health care organizations are not providing support and behavioral training for their physicians? Although there are a number of factors that play into this organizational resistance, the biggest factor might be the fear that physicians will not bring patients to their organization.(8)

Revenue generation, in an environment of reducing reimbursement, is a powerful roadblock for institutional inaction. Physician leaders should recognize that there are risks to inaction.(8) Organizational risks include loss of staff, poor patient satisfaction, reduced quality and patient safety, liability, diminished reputation in the community and others.

The causes of disruptive physician behavior are multifactorial and complicated. Prevention — including training, awareness, proactive response on the part of the institution, and appropriate interventions for disruptive physicians — should be considered. There are many strategies a physician leader should consider, including:(8,10)

1. Addressing issues within the organizational culture that might hinder acceptable behavior. Examples of a nonsupportive culture might include placing economic issues above patient safety and quality.

2. Providing educational programs designed to make physicians aware of the issues surrounding disruptive behavior and their responsibility to be professional at all times. Educational programs should be comprehensive in nature and cover a broad base of topics including, but not limited to, relationship training, diversity management, personality profiling, customer satisfaction training, stress management techniques, defining what the organization considers professional behavior, and anger management training.

3. Remembering physicians are independent thinkers and therefore might not be well-versed in team collaboration and communication. In today’s environment, medicine is a team sport, and high-quality patient care depends on exceptional functioning of the health care team. Training physicians in team dynamics and creating an organizational culture that values team behavior is important to consider.

4. Clearly defining the concept of individual accountability, and requiring all health care providers, including physicians to access and use a functioning incident-reporting system. In addition, organizations should have a risk management process in place, and physicians should be part of the process, maybe even leading the process.

5. Developing a robust and fair intervention and rehabilitation process for disruptive physicians that has a prevention component and an informal and formal disciplinary process. It should be guided by prospectively designed policies and procedures agreed upon by the physicians and the leaders of the organization.

6. Allocating funds in the budget for adequate staff support and training of the care team in disruptive behavior. Staff support should include behavioral modification programs and career counseling efforts to support those physicians who may need to change their specialties.

7. Making well-being programs available to physicians. These programs should target areas such as stress management, awareness and resilience training.

Consider A Conduct Code

Physician leaders should establish a code of conduct that applies to all members of the care team.(4) It should include a well-defined due-process clause and an appeal process with fair hearings. The conduct code should clearly outline what is and isn’t acceptable behavior, as part of the credentialing process for physicians. The credentialing process should have physicians sign off on the code of conduct, indicating that they have read and understand the provisions of the code.(4)

The code of conduct helps to create a positive culture within the organization by establishing expectations of appropriate behavior, and should be linked to the organization’s core values. Core values are the behavioral attributes that the leaders of an organization expect from all of its employees.

How should a physician leader respond to a disruptive physician? The best time to respond to disruptive behavior is the first time that it occurs.(12) Responding to the first troublesome behavior allows the physician leader to bring that behavior into the disruptive physician’s conscious awareness. Many physicians do not realize that they are being disruptive.

Generally, unless there is an egregious issue, the first recognized disruptive behavior may not require a formal action on the part of the physician leader or the organization. Listening to the disruptive physician and offering support is important at this stage of the process.(12) Physicians want to be heard, feel appreciated and valued, and they might be unconsciously seeking help.

If the problem continues, physician leaders should be alert to the possibility of substance abuse or a psychiatric issue underlying the disruptive behavior.(12) A structured intervention should be planned and managed by a physician trained in the process. Legal counsel should be involved at this point, documentation of the disruptive behavior should be organized and made available at the time of the intervention, and a corrective action plan, including an independent assessment of the offending physician should be prepared for the meeting with the disruptive physician.

A corrective action plan should include suggested remediation for the disruptive physician along with a monitoring plan. Last, a disruptive physician should be informed of the consequences if the corrective action plan is not followed or the disruptive behavior continues.

References

1. American Medical Association. 2011. AMA Code of Medical Ethics. Opinion 9.045-Physicians with disruptive behavior.

2. Porto G, Lauve R. A persistent threat to patient safety. patient safety and quality healthcare. July/August.2006; 3:16-24. https://psnet.ahrq.gov/resources/resource/4100.

3. MacDonald O. Disruptive Physician Behavior. QuantiaMD and the American College of Physician Executives (now the American Association for Physician Leadership). Quantia Communications, Waltham, MA, 2011.

4. Santin BJ, Kaups KL. The disruptive physician: addressing the issues. Bulletin of the FACS. 2015; 100(2):20-4.

5. Weber DO. Poll results: doctors’ disruptive behavior disturbs physician leaders. 2004. The Physician Executive. 2004; 30(4):6-14.

6. Rosenstein A. Nurse-physician relationships: impact on nurse satisfaction and retention. Am J Nurs., 2002; 102(6):26-34.

7. Rosenstein AH, O’Daniel M. Invited article: managing disruptive physician behavior. Neurology. 2008; 70(17):1564-70.

8. Rosenstein A. Human factors affecting disruptive physician behaviors and its impact on the business of medicine. J Bus Hum Resour Manag. 2016; 2(2), online publication, article number: JBHRM-2-012.

9. Reynolds NT. Disruptive physician behavior: use and misuse of the label. Journal of Medical Regulation. 2012; 98(1):8-19.

10. Hicks R, McCracken J. Personality traits of a disruptive physician. The Physician Executive. 2012; 38(5):66-9.

11. Physician stress and burnout survey. 2014. Cejka Search and Vital WorkLife. www.VITALWorkLife.com/survey/Stress.

12. Kaufmann M. Management of disruptive behavior in physicians. Ontario Medical Review. October 2005, pp. 59-64.