Disruptive behavior is defined as any unprofessional behavior that has the potential to compromise patient safety and quality of care. The usual types of aggressive disruptive behaviors reported include yelling, anger, verbal abuse, bullying, harassment, condescension, or other types of demeaning, berating, belittling, or disrespectful remarks. More subtle disruptive behaviors include issues related to nonavailability, refusal to return calls, poor documentation, or noncompliance in adhering to guidelines, practice standards and expectations. Actual physical abuse is rare.
Disruptive behaviors have quality, economic, and cultural consequences. They negatively impact care relationships and can lead to compromises in patient safety and quality of care.(1-4) Delays in service, medical errors, and adverse events can have a significant impact on hospital economics.(5) They also can affect staff and patient satisfaction negatively, which can reduce hospital pay for performance value-based reimbursement that measure quality outcomes, satisfaction, and hospital readmissions.(6) The negative impact on the work environment causes staff morale to deteriorate, which can affect retention and recruitment—a real concern in the face of staff shortages resulting from the “great resignation” stimulated by the pandemic.(7,8) Organizations have made significant strides in trying to address this issue, but the problems still exist.(9,10)
Managing Disruptive Behaviors
Table 1 provides a list of recommendations that can help the organization reduce or minimize disruptive behaviors.
Raising Levels of Awareness
The first step is raising levels of awareness. Educating staff as to the types, frequency, and consequences of disruptive behavior helps establish the need for accountability. The organization must adopt a zero tolerance policy toward disruptive behavior. They must take action, given the economic, clinical, and emotional consequences of failure to act. A policy must be in place in the Code of Conduct that:
Describes unprofessional behavior;
Sets up a process for complaint or incident reporting and review; and
Lays out the steps needed to ensure behavioral standards, specifying ramifications for noncompliance.
The next step is training. To provide effective training it is necessary to gain a better insight into and understanding of the factors contributing to physician attitudes and behaviors (Table 2). I have divided these factors into two categories: internal factors and external factors.
Internal factors include values and perceptions related to age (generation), gender (including sexual identity), culture, ethnicity, and spiritual beliefs. These factors contribute to conscious and unconscious biases that become a core part of the individual’s personality.(11) These internal factors are deep-seated and account for many of the subconscious implicit biases that mold our values and perceptions and may be more difficult to change.(12)
External factors come from chosen (or accidental) life experiences. In the medical environment, medical school and specialty training are key contributing factors. Students learn in a high-pressure, high-stress hazing type of training environment that leads to low self-esteem and self-dependence. There is a significant degree of stress and burnout, which can lead to a fragile emotional state where trainees are reluctant to ask for or receive support.(13) Fortunately, many training programs are introducing support programs to help with this issue. The high levels of stress and burnout continue as physicians try to adopt to the high-pressure complexities and intricacies affecting the changing culture and work dynamics of today’s practice environment.(14) (The impact of stress and burnout is discussed in more detail in the section on enhancing physician well-being). The good thing about the external influences is that they are more amenable to change through appropriate training.
Depending on the situation at the organization, suggested programs might include diversity or cultural competency training; training in emotional intelligence; harassment, anger, or conflict management training; and improving overall communication and team collaboration skills. The whole purpose is to enable the physician to get a better understanding of what drives their behaviors, the needs of others, and modifications needed to improve care relationships and patient outcomes.(15)
The next step is to provide support. Support can be divided into three categories: logistical (administrative); clinical; and behavioral.
Logistical support refers to redesign efforts that help to ease some of the physician’s nonclinical administrative responsibilities. Issues related to work capacity and productivity expectations, performance of nonclinical tasks, schedule commitments, coding and documentation requirements, and compliance with the EMR all take time away from patient care and are a major source of frustration and physician agitation. System-wide issues account for more than 80% of staff frustrations.(16) Administrative support can help by reducing administrative tasks and responsibilities, reducing committee or on-call requirements, providing more training in the EMR, or by providing scribes to help with EMR input and documentation. Clinical support can be provided by using physician assistants or nurse practitioners to handle routine matters and free up time for the physician to focus on more complex cases. The use of care coordinators, case managers, or navigators can help ease some of the scheduling and logistical responsibilities for guiding the patient through the full spectrum of care. Behavioral support requires a more individualized approach.
Individualized coaching and mentoring programs have been extremely successful in enabling the physician to better adjust to practice pressures.
A variety of different types of behavioral support resources are available. As discussed previously, more advanced training in stress management, anger management, conflict management, or time and project management can help the physician better adjust to the intensity of stressful practice situations. Diversity training, training in emotional intelligence, and training in communication skills and team collaboration provide a better understanding of values, perceptions, and priorities of all involved, which will help improve care dynamics. Mindfulness and resiliency training have become a popular way of teaching the physician coping skills to better manage a stressful event.(17,18) Individualized coaching and mentoring programs have been extremely successful in enabling the physician to better adjust to practice pressures.(19) In some cases, more intense behavioral modification may be needed. This may include individualized therapy, referral to outside specialty programs, such as PACE: UC San Diego Professional Boundaries Physician Assessment and Education Program and Vanderbilt Comprehensive Assessment Program, or management of substance abuse, if that is an issue.(20) We must remember that the individual physician can only do so much; we need to look to system redesign for the ultimate solution.(21)
The next step is intervention. The first attempt is made through a more casual, informal approach. In most cases, the physician didn’t recognize that their behavior was disruptive, and when alerted about the incident and the recognition of possible downstream negative consequences, most physicians will readjust their behaviors accordingly. Many have referred to this type of conversation as a “coffee time” chat. These conversations should be conducted in a neutral setting by an individual who has experience in conflict management. For resistant physicians, or where there has been a trend of complaints, a more formal intervention process is needed.
Formal interventions involve a direct discussion with the physician about the chronology and severity of complaints. These interventions must establish accountability and conclude with a recommended course of action and ramifications for noncompliance. At the first level, recommendations may include participation in diversity, harassment, anger management, or stress management programs. The next level is to recommend individualized coaching, counseling, or therapy. The delegated individual, specialized task force, or subcommittee responsible for follow-up needs to be updated on the physician’s progress and must continue to monitor the physician’s response. More extreme cases are referred to the Medical Executive Committee and Governing Board for review and action. A final recourse may involve sanctions including reduction of privileges, not recredentialing, or termination. At this stage, a number of different legal implications must be considered.(22)
Stress and Burnout and Physician Well-being
The onset of the pandemic led to a growing amount of stress and burnout in healthcare providers. Recent surveys have shown that more than 50% of physicians admit to working under high stress and burnout conditions, which has affected their emotional and physical well-being. Nearly 25% of physician report clinical depression,(23) and 20% of physicians have become so dissatisfied and frustrated that they have left their position, looked for new careers, or retired prematurely.(7,8)
There is an assumed direct cause-and-effect relationship between stress and burnout and disruptive behavior. A recent survey conducted by Medscape provided observational data suggesting that stress and hardship triggers physician misconduct.(24) Other than this report, it is difficult to find objective data to support this conclusion. There are several reasons for this. First, it’s not something that anyone is proud of, so it is unlikely that anyone would want to publicize these data. Incident reports are held confidential, and meeting minutes are protected under peer review confidentiality. There is also a reluctance to report given a pervasive “code of silence” or fear of retaliation or other repercussions that may adversely impact the work environment or concerns about job security. Current surveys ask questions about degree of stress and burnout and how this affects culture and the work environment, but do not ask about the occurrence of disruptive behaviors or associated adverse events. Maybe it’s time to do so. We need to work on reducing aggravating factors. As mentioned previously, the external factors are more amenable to resolution, and most of the solutions come from system-wide adjustments rather than just trying to enhance physician resilience. We need to improve work–life balance and overall well-being.(25)
System-wide adjustments relate to aggravations and frustrations due to excessive time demands, workload, and capacity, third-party interference, the amount of time spent on nonclinical administrative tasks, and frustration with EMR input and documentation. Potential solutions were discussed in the previous section. More extensive relationship management training, stress management, mindfulness, and residency training can only go so far. Many organizations have reinvigorated the role of their Physician Wellness Committee or have hired a Chief Wellness Officer to enhance physician well-being.(26) Physicians need to recognize the importance of rest, relaxation, setting limits, exercise, proper nutrition, and adequate sleep, and must be able to disconnect from their day-to-day work activities. We need to promote and support a more appropriate work– life balance, remind them of their purpose and intent, and reinvigorate their passion and joy for practicing medicine.(27,28)
The final step is for the organization to thank them for what they do. Show them you care. Provide helpful amenities, including childcare and food services for those on call, adding break rooms or meditation rooms, arranging the physician lounge and dining facilities so physicians can interact with each other, or plan outside social or recognition events.(29,30) Showing respect and recognition will increase satisfaction, improve engagement, and lower the likelihood for disruptive behaviors.
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