During the past year, the College of Physicians and Surgeons of Ontario (CPSO) has focused much of its attention on a physician who has long eluded regulatory action, even though his behavior may have posed a risk to patient care and created chaos in his workplace for a number of years.
This physician may be clinically competent; indeed, he may be technically superior. However, no one wants to refer patients to him. No one wants to assist him in surgery. He is the one who screams at nurses, belittles medical students and makes criticisms that go beyond the bounds of fair professional comment. However, he is not always loud. He can be the passive physician who will not answer the pager while on call, who does not show up at meetings and will not help find solutions to departmental problems. Indeed, this physician is not always male, but more often than not that seems to be the case.
Currently, there are clear processes to deal with physicians who commit fraud, sexually abuse a patient, need their clinical skills upgraded, need assistance with issues such as patient communication or record keeping and those who need assistance in dealing with substance abuse.
The disruptive physician, however, does not necessarily fall into these categories. As a result, his bad behavior can continue for years without apparent redress.
There is now, however, a waning tolerance for doctors who behave badly. Too much time and effort is spent responding to the morale problems caused by the disruptive physician. More importantly, there is a better understanding of the potential harm that disruptive behavior can pose to patient safety.
As the regulator for the medical profession in Ontario, it is the CPSO’s responsibility to take action. That is why we are taking the lead in developing a program that deals with these physicians. Our first step was to organize a brainstorming session and invite everyone who has a role to play: the health-care profession regulators, the hospitals, the medical schools, the medical associations and the administrators of the physician health program. We spent the day discussing the problem from all angles to ensure that we had a shared understanding of the situation. We agreed that our focus should not entirely be upon individual disruptive doctors, but also upon the interaction between their behavior and the situation in which it occurs. An analysis of disruptive behaviors, and programs that are designed to deal with them, must always include a dimension-like “setting” to account for this interaction. Behavior that is acceptable in the locker room is not acceptable in the operating room. The setting defines appropriate behavior.
We also devoted a good portion of the session listening to presentations from experts in the field of disruptive physician behavior. The day ended with resolve to draft a definitive statement that would make it clear that disruptive behavior is unacceptable and will not be tolerated.
The participants at this session were also divided into four working groups, each one charged with a unique assignment. The expectation is that when the project reconvenes later this year, each group will have developed thoughtful approaches for responding to disruptive behavior on one of the following levels: community/institutional, educational, physician health and regulatory. We can then, as a group, identify the key strategies that need to be developed for dealing with this very complex problem in whatever environment it arises, be it during medical school, or within a community practice or hospital.
It is worth pointing out that one incident report does not a disruptive physician make. Doctors, being fallible human beings who work in very stressful environments, will likely have the occasional angry outburst. This is not the behavior upon which we are focused. Rather, we focused upon multiple reports from a variety of such sources as nursing staff, physician colleagues or family members of patients.
A literature search and report commissioned by the CPSO and conducted by the Canadian Policy Research Network (CPRN) found that disruptive behavior affects everyone involved in the health care environment and is detrimental for all involved in the delivery of health care services. It can undermine practice morale, heighten turnover in practice, diminish productivity and increase the risk of substandard or ineffective care.
Indeed, almost all the material reviewed cited the general impact disruptive behavior could have on patient care. Specific concerns listed were: upsetting patients or undermining the patient’s confidence in the care being received; upsetting the staff enough that they refuse to continue working with the physician; delaying needed care as other physicians attempt to refer patients elsewhere; and increased risk of harming patients — distracting the physician or the staff enough that an actual error is made in the delivery of care.
Perhaps not surprisingly, it is often medical students who bear the brunt of a physician’s ire. Half of all medical students report experiencing some form of abuse during training, including being yelled at and belittled. Interestingly, those writing about disruptive behavior make the point that these behaviors may have been learned, even role-modeled, during medical school and residency training. Then, upon entering independent practice, these physicians simply behave in a way they have seen reinforced during their training period.
Traditionally, the health care professions have not been very good at dealing with disruptive doctors. It is not surprising. Most people prefer to avoid conflict and physicians are no different in this regard. Physicians often feel a sense of “breaking ranks” when reporting a colleague. Chiefs of staff may not want to suspend a doctor who is technically competent, especially in areas already suffering from physician shortages. Nurses may worry that their concerns will not be taken seriously and they will only further anger the doctor if they report an incident. Concerns over burden of proof and liability have become increasingly important as the nature of the health care environment becomes increasingly litigious.
Hospital administrators feel acutely uncomfortable dealing with the issue of disruptive physicians. Indeed, one researcher stated, “confronting a disruptive physician is the most dreaded task a physician executive faces.”
The CPSO recognizes that there will be obstacles to effecting the kind of cultural change that we envision. However, this is not a problem from which we can afford to shy away. As a regulator, the safe delivery of patient care is our top priority and all our actions in this new initiative will be fundamentally aimed at enhancing patient care and improving the processes for delivering that care. If a physician’s behavior has the potential to jeopardize the well-being of patients, then we need to address it quickly and effectively.
