Doctors with disruptive behaviours
Summary: While most doctors communicate well and adhere to the highest professional standards of behaviour, a small number do not, and some recurrently display disruptive or intimidating behaviour.
Sunday, 18 March 2018
Managing doctors with disruptive behaviours
Disruptive behaviour from doctors not only impacts the workplace, but patient safety as well. It is critical to have a management plan in place to deal with disruptive events as early as possible.
What constitutes disruptive behaviour?
Disruptive behaviour is defined as ‘any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.’1
While most doctors communicate well and adhere to the highest professional standards of behaviour, a small number do not, and some recurrently display disruptive or intimidating behaviour. It is unlikely that we will ever create a culture without any unprofessional conduct. What is needed is a culture that discourages the development of disruptive behaviours and that has no tolerance for episodes of poor behaviour.
Disruptive doctor behaviours include, but are not limited to:
- physical or verbal intimidation or challenge, including disseminating threats or pushing, grabbing, or striking another person
- physically threatening language directed at another person
- physical contact with another person that is threatening or intimidating
- throwing instruments, charts or other items
- threats of violence or retribution
- sexual or other forms of harassment including, but not limited to, persistent inappropriate behaviour and repeated threats of litigation.
Serious breaches of expected workplace conduct or performance can result in a disciplinary process which may lead to disciplinary action (including termination of employment). Disruptive behaviours may also constitute bullying (refer to Avant’s Bullying fact sheet for further information) or sexual harassment. This conduct may be dealt with through relevant employer processes.
Of significant concern is the link that has been shown between disruptive behaviours and how these behaviours impact on patient safety. There is compelling evidence that some behaviours contribute directly to medical errors and undermine a ‘culture of safety’.2
A 2012 American College of Physician Executives survey found that:
- More than 70% of respondents said disruptive doctor behaviour occurs at least once a month at their organisation; more than 10% said such incidents occur daily.
- About 77% said they were concerned about disruptive behaviour in their organisation, and 99% believed disruptive behaviour ultimately affects patient care.3
Managing disruptive behaviours is in everyone’s best interest – doctors, other health professionals and patients. There are several steps required in the management process. We have based our model on the work of Gerald Hickson.4,5
Steps for addressing disruptive behaviour that does not amount to a serious breach of expected workplace conduct or performance:
- giving feedback
- management notified-authority intervention
- addressing hospital/practice systems and processes.
Crucial to managing doctors with disruptive behaviour is giving feedback. Without feedback, disruptive behaviour can become accepted as the norm.
Whenever possible, doctors need to have the behaviour or event brought to their attention through an informal process. This is simply a way to say to the doctor, ‘we want you to know what the patient (or colleague) shared’. The individual doctor involved needs to understand that the complaint is based on the perception, which may or may not have merit.
Also gaining popularity as a form of feedback is the concept of a 360-degree review. This is a formal process in response to an individual’s behaviour, or as a hospital/practice initiative. It involves seeking feedback from colleagues at your level, above you in seniority and those who report to you. A survey of American surgeons found the process gave accurate feedback and contributed to behaviour change.6
Management notified-authority intervention
There needs to be a system in place where, if the informal chat doesn’t help to raise the doctor’s awareness of their behaviours and address them, the situation is escalated.
The management level responsible for the doctor should be responsible for the development of a formal assessment and management plan. This plan needs to define expectations and maintain accountabilities.
Addressing hospital/practice systems and processes
At a hospital or practice level, creating an environment that rejects disruptive behaviour involves the following five elements as part of that strategy:
- Leadership. The most important course of action for leaders is to make sure your organisation's code of conduct applies to everyone. Leaders should lead by example and follow the code of conduct, taking consistent action as required if the code is breached.
- Appropriate responses. There's a big difference between a doctor who behaves badly on a regular basis and one who has an isolated episode of bad behaviour. By creating a model to help staff match the right level of intervention with the behavioural event or series of events, staff members have a guide to deal with the behaviour.
- A credo, or doctrine, that all professionals believe in and live out. If those who work at your organisation follow this credo, they won't be afraid to tell a colleague who has stepped out of line that their behaviour is inconsistent with the organisation's beliefs and values.
- Surveillance systems. Surveillance methods can be anything from patient complaints, an employee satisfaction survey, or even a ‘hotline’ that allows staff to report a colleague's actions anonymously.
- Training resources. Few people enter the workplace trained to talk with colleagues about poor behaviour, so it's up to the CEO and other hospital/practice leaders to make sure an organisation's managers have the tools to conduct such talks.
The impact of disruptive conduct
Disruptive conduct by medical professionals threatens retention, increases the probability of burnout and promotes jousting (defined as one healthcare professional criticising another or an institution).
Early identification of disruptive behaviours, regular feedback and holding doctors accountable for their behaviour all help to improve workplace culture and reduce the impact on patient safety.
1. Schoppmann M. The law and the “disruptive physician”. American Academy of Orthopaedic Surgeons; 2015. Available from: aaos.org/news/aaosnow/aug11/managing6.asp
2. Wyatt R. Revisiting disruptive and inappropriate behavior: Five years after standards introduced. The Joint Commission; 2013. Available from: jointcommission.org/jc_physician_blog/revisiting_disruptive_and_inappropriate_behavior/
3. Gessler R, Rosenstein A, Ferron L. How to handle disruptive physician behaviors. Am Nurs Today 2012;7:11. 4. Hickson, G. Changing behaviour. MJA 2013. Available from: mja.com.au/insight/2013/30/gerald-hickson-changing-behaviour
5. Hickson, G et al. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors. Academic Medicine 2007;82:11.
6. Gawande, A et al. Can 360-degree reviews help surgeons? Evaluation of Multisource Feedback for Surgeons in a Multi-Institutional Quality Improvement Project. Journal of the American College of Surgeons 2015;221:4 Available from: journalacs.org/article/S1072-7515(15)00455-X/pdf