How to Recognize—and Stop—Inappropriate Physician Behavior

Disruptive physicians are a problem across all medical specialties, and otolaryngology is no exception. A 2011 survey of 800 physicians found that disruptive behaviors occur in more than 70% of hospitals each month (QuantiaMD.com, May 15, 2011). These actions, if not addressed, have been linked to lower satisfaction for patients and their families and can affect not only physician reimbursement but also physicians’ risk management experiences and malpractice lawsuits (JAMA. 2002;287:2951-2957).

Disruptive behavior in hospitals can also endanger patient safety. The Joint Commission issued a sentinel event alert in 2008 that requires hospitals to have a code of conduct and a process for managing disruptive and

inappropriate behaviors (The Joint Commission. July 9, 2008). In 2000, the American Medical Association issued guidelines on what constitutes troublesome actions and how to handle them (American Medical Association. December 2000).

Defining Disruptive

“The definition of a disruptive doctor has narrowed over the last couple of decades,” said Robert T. Sataloff, MD, DMA, professor and chair of the department of otolaryngology at Drexel University in Philadelphia. “Behaviors that would have been classified as idiosyncratic 10 to 20 years ago are now seen as disruptive.”

There may be a fine line between being disruptive and just being a jerk, but treading that line can bring problems to the practice. “Some physicians are just not people pleasers that you want to socialize with; they may be curt, arrogant, unfriendly, or not effective communicators,” said Judith Holmes, JD, of Judith Holmes and Associates, and co-creator of Master Series Seminars, LLC, both based in Denver. “But those who won’t win congeniality awards do not necessarily fit the model of the disruptive physician.”

Bad Behaviors

Holmes said that abusive and demeaning behaviors are the most likely to cause problems. These would include:

• Making threats;
• Shouting or throwing things;
• Making condescending comments;
• Criticizing a colleague in front of a patient or other staff members;
• Vocalizing sexually inappropriate comments;
• Touching a colleague in a sexual way;
• Verbally harassing or mocking a colleague, which can lead to legal liability if it involves a person’s age, race, gender, disability, religion, pregnancy, or other protected category; and
• Refusing to comply with established policies and procedures.

It is important for a physician practice to have policies and procedures in place, preferably before there is a problem, that not only outline the types of behaviors that will not be tolerated, but also describe the interventions that should be undertaken if rules are broken and delineate the consequences that will be enforced if those interventions fail. “One of the best ways to deter bad behavior is to implement a comprehensive code of conduct,” said Holmes. “This should include a clear policy defining unacceptable behaviors and should have a clear disciplinary policy outlining the procedures used to deal with complaints.”

A code not only sets expectations for acceptable behavior but also details how exceptions to proper behavior will be handled, thereby helping the practice by ensuring that all incidents are handled similarly. Giving one physician great latitude while coming down hard on another opens up legal issues that are best addressed early. Likewise, in order to decrease the likelihood of successful claims of discrimination or personal animosity, decisions about enforcing consequences for inappropriate behavior should not be made by only one person, when possible.

Document, Document, Document

“Documentation and follow-up is a very important part of the process,” said Leigh Olson, owner of Nova Consulting in Denver and co-creator of Master Series Seminars. “We find practices have rules and protocols, but there are no consequences when they are not followed. The rest of the office sees rules are not being followed and it sets a precedent, making it harder to enforce any of the rules.”

Many places offer information on how to set up employee codes of conduct, along with policies and procedures for handling breaches. Practice management associations, The Joint Commission, and the hospital with which your practice is affiliated can suggest ways to word these documents.

Although you can use a generic code for a starting point, Holmes recommends that the final product be written with input from each team member so that they have “buy in,” instead of having it imposed from on high, and that the code be vetted by an employment attorney before it is implemented.

Legal Considerations

Once a disruptive physician is identified, the first suggestion from a legal standpoint is to determine whether there is an underlying health or medical issue causing the behavior. If what is happening relates to depression, substance abuse, or another disability that falls under the purview of the Americans with Disabilities Act, there may be some obligation to provide a “reasonable accommodation” for treatment.

“If there is a possible disability issue, that would be a good time to get an employment attorney involved,” said Holmes. “This doesn’t mean that a practice must tolerate a physician who is using alcohol or drugs while working. In that situation, a zero tolerance policy would require immediate termination.”

A number of interventions must be considered. Give the physician an opportunity to discuss the complaints and tell his or her side of the story in a confidential process. “Frequently, the doctor doesn’t realize that his or her behavior is offensive or inappropriate,” said Dr. Sataloff. “Having someone point out the behaviors helps to make the doctor more aware of how his or her interactions affect others. When they are open to criticism and willing to change behaviors, this approach is usually successful and sufficient.”

It is generally suggested that disruptive physicians be counseled by someone outside of the practice. This helps eliminate concerns about internal practice politics and can lessen the physician’s defensiveness. Make sure to hire someone who has a good understanding of the law and is sensitive to the personal interactions within the practice.

“I really don’t think that the dynamics of these concerns are very different whether we are talking about academic medical centers, large groups, or small practices,” said Dr. Sataloff. “The friendships and relationships are very similar across these settings. All types of physician settings can experience these problems.”

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Kurt Ullman is a freelance medical writer based in Indiana.