Expert says power differentials increase the chances of having “disruptive” physicians. Addressing offenders requires the proper approach.
Thanks to the cultural shift that has brought workplace behavior into contemporary conversation, there’s increasing attention on the work environments within health care — and the role that physician leaders must play in stamping out disruptive actions.
“Behavior that undermines the culture of safety is a disruptive behavior. It’s a very broad term and includes any type of conduct that is unacceptable and inappropriate” says Jacob DeLarosa, MD, author of The Disruptive Physician: How to Manage the Consequences of Being You.
DeLarosa separates disruptive behaviors into three categories, passive, aggressive and passive-aggressive.
- Passive behaviors often are difficult to spot. They include chronic lateness, not returning phone calls, inadequate charting, and not being prepared or not participating.
- Aggressive behaviors are more obvious. They include yelling at others or degrading others in public, swearing or physical threats.
- Passive-aggressive behaviors often are the most difficult to notice and manage. They include writing hostile notes, inappropriate joking, sexual harassment and blaming others for problems.
DeLarosa, who is board-certified in general and thoracic surgery, says disruption in surgical specialties often manifests itself as aggressive and passive-aggressive behavior, while disruption in medical specialties usually is passive and passive-aggressive. It’s usually men who exhibit such behavior, but women are not immune.
Codes of Conduct
Many health care organizations have outlined what constitutes disruptive behavior and the consequences of any behavior that undermines the culture of safety. Many of the codes of conduct were developed after a July 2008 Sentinel Event Alert from The Joint Commission, outlining behaviors that “foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments.”
An update in September 2016 recommended using the term unprofessional behavior rather than disruptive behavior.
They have always been there; it’s just not accepted anymore. It was part of the culture, because that’s how it was trained.
Jacob DeLarosa, MD, on unprofessional behavior by physicians
“If your hospital does not have a code of conduct defining acceptable behaviors and inappropriate behaviors, you need to create one,” DeLarosa recommends, adding that the profession is increasingly aware of the negative consequences of unprofessional behavior. “They have always been there; it’s just not accepted anymore. It was part of the culture, because that’s how it was trained,” he says, explaining that developing a thick skin was seen as necessary to work in the medical field.
“Whenever you have a power differential, you have the chance of being a disruptive physician. It’s important for physicians to remember there is a power differential between physicians and nurses, techs and other workers in a hospital. The person in the powerful position will often be seen as the instigator.”
In his book, DeLarosa uses the example of a new physician who overhears some nurses talking about going out for drinks. He says he would like to join them, with their permission. They agree, and he buys them drinks and participates in discussions about their personal lives. After the outing, one nurse reports feeling uncomfortable and complains about the doctor. During the subsequent discussion between the offending doctor and a supervisor, the new doctor says he was just trying to get to know the nurses better and did not realize his behavior was disruptive.
DeLarosa concludes any behavior ultimately can affect patient care. Personal discussions, failing to return phone calls and using rough language with co-workers can influence who is willing to work with a physician. “It comes down to safety, about providing quality care to the patients,” he says.
Role of Physician Leaders
Because workplace culture is changing, DeLarosa says physicians should be reminded about what is appropriate. He adds that it’s up to physician leaders to initiate it, possibly during an employee onboarding process or a required training.
“It is difficult if someone is not aware of the rules. After they’re aware of it and somebody does something, I think the first thing that happens is there needs to be a collegial intervention,” he says.
That intervention needs to come from someone the doctor respects, which is often a physician leader. The goal is to help the offending physician understand what happened, how people were impacted, and come up with a course of action to keep it from occurring again. The plan could include monitoring and should consist of follow-up conversations.
Not all disruptive doctors will be understanding. A doctor’s reaction to an intervention could stem from fear, DeLarosa explains. Physicians fear being labeled as a bad doctor, fear being sued, and fear losing patients. This fear could drive them to be self-protective.
“They want to know who accused them and retaliate. They’ll become angry, hostile and defensive,” DeLarosa says.
The solution often lies with the tone physician leaders take when approaching the subject with a disruptive doctor. Accusatory conversations do not work. “I think you have to be open-minded and listen to all sides before making judgment. You’ve only heard one side of the story,” he says.
Timing is important. “Interventions should happen immediately, as soon as something comes to the attention of a physician leaders,” DeLarosa advises.
Understanding the source of the behavior is also necessary. “As a physician leader, you have to know a person’s behavior comes from somewhere. Once you understand what the root is, and why it triggers them, that is how you are able to help that doctor.”
Often, behaviors come from mimicking what they saw during their training or even on medical television shows, which DeLarosa says show bad examples of how people should behave in a professional workplace.
If the behaviors do not change, physician leaders should consult their bylaws and escalate if required, either to hospital wellness committees or medical executive committees.
“You do not want to get there,” DeLarosa says. “We hope for the short fix, and sometimes it happens.”
Tiffani Sherman is a freelance health care journalist based in Florida.
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