Physician Behavior and Safety

Managing Disruptive Physician Behavior–A Patient Safety Concern

By Rena Courtay RN, BSN, MBA, CASC

‍

I have spent the last 28 years working alongside physicians, most notably surgeons. As you can imagine, this experience has provided me with quite a few anecdotes about physician behavior. These experiences led me to delve into this topic a bit deeper to really uncover the consequences of this behavior and discuss constructive ways to address it in a healthcare organization. Obviously, our most paramount concern is taking care of our patients and making sure this care is safe and does no harm. Disruptive physician behavior is a practice pattern of personality traits that interferes with a physician’s effective clinical performance. The disruptive behaviors negatively impact the persons with whom the physician interacts(Journal of Medical Regulation, 2013). Does this sound like it is conducive to great patient care?

Let’s review some examples of things that fall into disruptive behavior. These can range from degrading comments or insults all the way to causing personal injury by throwing things or actual assault.  Things in between such as discriminatory behavior, inappropriate joking, profanity, retaliation, and spreading malicious rumors all fall into the bucket of disruptive behavior. There can be a refusal to cooperate with other providers or to follow established protocols. Incompetence and substance abuse are also categorized as a disruptive behavior. What do all these things have in common? They take focus off the care of the patient and can jeopardize the safety of the patient in numerous ways. These traits also can intimidate the staff around the physician. They become anxious and guarded and are not at their best when caring for patients. They may also fail to act in the best interest of the patient by not questioning the physician about an order, a policy or protocol that they have a concern about. The behavior often continues because no one is courageous enough to report and/or address the behavior.

This problem is so pronounced that almost 60% of providers have encountered and are concerned about some of these behaviors (QuantiaMD, 2011). The data shows that this behavior does happen most frequently in the operating room and that surgeons were the most likely physicians to exhibit the behavior.  This is in part due to their underlying driven personalities and the desire for perfection in the OR. Surgery is certainly not a stress-free profession and we all know one mistake can result in a very bad outcome for the patient.

I have encountered a lot of different scenarios over the years and will just share a few. I had a physician leader who was always engaging in off-color jokes and other explicit conversations. This made some staff uncomfortable and there were complaints to the Corporate Human Resources Department. Also, patients had reported overhearing the dialogue and we had some staff threatening to resign.

Another scenario involved a surgeon always arriving late and there were no H&P’s on the charts. He would rush the staff in pre-op and pressure them to send the patient back to the OR without the H&P. The staff were intimidated, and this led to documentation not being properly checked and the implantation of a wrong interocular lens (IOL). A third situation involved an orthopedic surgeon who was frequently volatile. He had an occasion where he was yelling at patients in the pre-op, screaming obscenities in the operating room and even throwing instruments. The OR staff and the CRNA were in tears and refusing to go into the room for the next case. This is an obvious safety issue for the patient on the table in the operating room.

The fourth scenario will probably be common to many of you. A busy surgeon has over 30 operative reports pending dictation. Multiple attempts have been made to correct this by the staff. Requests for medical records cannot be completed. The center is unable to bill and the icing on the cake is when CMS cites the center for not following its own policies and procedures. In addition, it is highly unlikely that someone’s memory is that good, so they resulting operative report may not be as accurate as it would have been if done timely.

All these examples have negative consequences. These include adverse clinical events, staff resignations, verbal and physical confrontations, culture deterioration, loss of patients from practice, and patient and staff complaints. Further repercussions are more severe such as disciplinary action, legal action (civil and criminal), Equal Employment Opportunity Commission (EEOC) complaints, loss of staff privileges and reports to the Board of Medicine and/or National Practitioner Data Bank (NPDB). However, most important are the consequences to patient safety which could be medical errors, other adverse events and even mortality.

What are some best practices to deal with these types of behavior? Most important of all, you must deal with the problem and learn to address behaviors as they occur. These things do not usually correct themselves, so you cannot bury your head in the sand. It is not something that someone will “outgrow”. We all have a responsibility to provide a safe environment for our patients and an environment for our employees that is free of harassment and discrimination. You should adopt professional behavior standards whether they are in the form of bylaws, rules and regulations or policies and procedures. Excellence should be recognized as well as bad behavior should be addressed. Ensure that your team is empowered to have full freedom and support to report incidences as well as the confidence that they will be addressed.

There are a few important steps to having a corrective feedback conversation with a physician. Inform him/her of the session ahead of time and provide a private, respectful atmosphere. Negotiate an agenda and have all the facts of the issue documented. If possible, it is helpful to have another physician leader there with you for the conversation. Start by asking the physician for his/her own assessment of the situation being discussed. It is very important to get this perspective before sharing your own observations and findings. Then ask the physician for strategies for improvement and review the expected improvements, any monitoring that will occur and the consequences of not improving.

These strategies should assist you in confidently handling behavior issues that arise. Most importantly, this approach will enable you to improve the environment at your facility and allow you toprovide the highest quality of care for the patients that you serve.

References

•Holmes, J.(2016, May 1) Dealing with Disruptive Physicians. Retrieved fromwww.mgma.com. Accessed 1/8/18.

•MacDonald, O. (2011) Disruptive Physician Behavior. Retrieved from: www.quantiamd.com/q-qcp/QuantiaMD_Whitepaper_ACPE_15May2011.pdf.

Accessed 12/22/17