Medical Staff Leadership Responsibilities and the Issue of 'Disruptive Physicians'

So concerned with this patient safety issue was the Joint Commission that in 2008 it issued a Sentinel Event Alert on this subject and implemented leadership guidelines and codes of conduct, which it imposed on all hospitals. It thereafter issued “White Papers” in which it underscored the scope of the problem and the safety concerns associated with it.

Inappropriate and Disruptive Behavior

In response to the release of the Joint Commission guidelines, the American Medical Association (AMA) drafted definitions of two broad types of physician conduct that correlate with the issues addressed by the Joint Commission: “inappropriate behavior” and “disruptive behavior.”

The former is defined by the AMA as follows: “Inappropriate behavior is conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. This behavior can have a detrimental effect on relationships between healthcare practitioners.” See American Medical Association Model Medical Staff Code of Conduct. This definition describes a wide array of behaviors that include, but are not limited to, the use of vulgarities and demeaning, condescending or disrespectful verbal or written comments. Passive behavior may also be inappropriate (and even disruptive). This includes a failure to cooperate in the course of the delivery of patient services and the performance of assigned tasks, or a failure to respond to telephone calls and pages. Notably, where inappropriate behavior is pervasive and sustained, it may be deemed elevated in severity and re-characterized as a form of “disruptive behavior.”

According to the AMA, “Disruptive behavior is defined as any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or nonverbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.” Id. Dr. Peter B. Angood, the former Chief Patient Safety Officer at the Joint Commission, characterized the conduct of disruptive physicians as the “the health care equivalent of road rage.” See “Arrogant, Abusive and Disruptive — and a Doctor,” by Laurie Tarkan, The New York Times (Dec. 1, 2008).

Disruptive behavior is a heightened form of inappropriate behavior marked by its severity and persistence and may include: physically threatening language; throwing objects (e.g., medical charts, medical instruments); outbursts of anger and shouting; vulgar, derogatory and disrespectful language, whether verbal or written (such as comments contained in a medical chart); a refusal to act cooperatively or collaboratively with regard to the delivery of patient services, including a refusal to perform needed tasks and a failure to respond to calls; and chronic lateness.

The consequences of disruptive behavior in the workplace are profound, and include diminished staff morale, diminution of the quality of patient care and a greater risk of medical errors. It can also lead to frequent staff turnover, increased risks of litigation due to complaints by staff and patients and a toxic work environment.

Effects on Medical Malpractice

Quality patient care is reliant on teamwork and communication between staff members; disruptive behavior corrodes those two critical elements, breaking down the trust between medical team members that is essential to quality care. Likewise, staff members who are on guard for disruptive behavior, or who are otherwise distracted by it, may suffer from performance problems or may even take on the disruptive physician's mindset and behavior.

Even the disruptive physician is exposed to a litany of outcomes that may be harmful to his or her ability to practice medicine, including: the reporting of the disruptive conduct to the local state's physician licensure agency; the loss of hospital privileges; termination of employment; a report to the National Practitioner Data Bank; or even criminal charges, if the conduct is extreme in nature (such as a physical assault). Additionally, cases are legion in which seven-figure verdicts have been awarded against disruptive physicians.

A Changing Culture

Fortunately, there has been a changing culture in the health care arena: Disruptive behavior that may have been countenanced in the past has increasingly become the subject of scrutiny and intervention. In part, this positive evolution has been the result of the widespread recognition of the need for physician leaders to intervene to achieve the goals of improved patient health and safety, diminution of litigation risks, enhanced institutional viability, and compliance with ethical and legal standards pertaining to health care providers.

Certainly, most disruptive physicians are not difficult to spot. Their disruptive actions tend to be (but are not always) highly visible and can transpire in front of multiple witnesses. Warning signs that disruptive behavior may be afoot include a higher turnover rate among staff working for that physician; the intensity and severity of staff and patient complaints about the physician; and even a physician's reputation among the staff (clinical and otherwise) and patients (who may indicate their dissatisfaction in patient surveys or onine physician reviews).

Taking Action

As a general matter, there should be an enforced institutional policy of zero tolerance with regard to disruptive (and inappropriate) behavior, and all staff members must be made cognizant of the internal complaint process. Such behavior should not be ignored and should be the subject of responsive and effective intervention, because where patient safety is at risk, an immediate response is in order. Passivity in the face of disruptive behavior is simply unacceptable.

Once a physician leader becomes aware of disruptive behavior, he or she has a range of pathways to respond to it — from the informal to the formal to the disciplinary to the regulatory.

Some milder forms of mitigation efforts may include physician colleagues speaking directly with the disruptive physician about his or her unwanted behavior, and offering ideas for remedying it. Re-education or other internal arrangements, such as a focused or ongoing professional practice evaluation, are also possible remedies. Further, wellness committees and state physician health programs may serve as a helpful resource in stemming wrongful behavior.

However, where the behavior is severe or persistent, and continues despite these lesser measures, formal institutional responses become necessary. In such cases, departmental chairpersons, medical staff leadership and the chief medical officer are duty-bound to institute corrective action under an institution's by-laws, medical staff regulations and fair hearing plan against the disruptive physician's privileges. This process can lead to sanctions, including restrictions or even termination of the offending physician's privileges, and reporting of such results to state licensing boards.

When responding to disruptive behavior — and simultaneously with the prophylactic and reactive interventions described above — an institution should also examine whether or not there are workplace conditions that may be stoking the disruptive behavior and serving as triggers for it. For example, it may be possible that the physician's workload is excessive, and the resulting toll and stress is the root cause of the unacceptable behavior. Although physicians are responsible to a certain degree for self-monitoring their workloads, this does not absolve the institution of that role and responsibility.

Conclusion

In sum, disruptive physician behavior negatively affects the quality of patient care. It leads to an increase in medical errors and avoidable adverse patient care outcomes, enhancing litigation risk and its associated cost. Disruptive physician behavior also demoralizes and alienates dedicated staff members, leading them to depart the medical institution. But the problem can be mightily dissipated if medical staff leaders act assertively and proactively, consistent with their leadership roles, in the effort to prevent disruptive behavior and to intervene forcefully when confronted by it.

***** Andrew Zwerling is a Partner-Director at Garfunkel Wild, P.C., and a member of the firm's Litigation and Arbitration Practice Group and Employment Law Practice Group, as well as an arbitrator for the American Arbitration Association and the American Health Lawyers Association.