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Bullies, bad attitudes, and misbehaviors

By S. Jay Jayasankar, MD

Acting out is risky behavior for physicians and patients

In 2006, a neurosurgeon in Oakland, Calif., allegedly became belligerent—verbally and physically abusive—when told that instruments brought in from another hospital needed to be sterilized before he could operate on a trauma patient. It took three deputies to restrain and arrest him. The patient was subsequently treated safely by another surgeon.

In Massachusetts, a surgeon and an anesthesiologist wrestled on the floor of the operating room (OR) while their patient waited, under anesthesia, for emergency surgery. After the fight, they completed the operation. The physicians were sanctioned; the patient, fortunately, had no ill effects.

A physician who displays an agressive or uncooperative attitude may inhibit positive teamwork by other members of the operating room staff.

Disruptive behavior: On the increase?
Although such egregious behavior is rare, less dramatic incidents just as threatening to patient safety seem to proliferate. Whether the prevalence of bullying or subtler disruptive behavior is actually increasing or simply more frequently recognized and reported is not clear.

Disruptive behavior has been observed in almost all members of the healthcare team—from physicians and nurses to pharmacy, radiology, and laboratory staff members. Physician behavior, however, may have the greatest impact because of the position of authority that doctors hold as members of the healthcare team. A team member may, from fear of intimidation or patronization, withhold valuable or even critical input, such as a medication error or a breakdown in adherence to safety protocols.

To ensure good patient care, respect among all healthcare professionals is at the very foundation of the ethics advocated by the American Medical Association (AMA) and the AAOS. Intimidating, condescending, off-putting, or discouraging behavior by the physician inhibits positive team work. If OR staff, floor nurses, or physical or occupational therapists are working suboptimally because of disruptive behavior by the physician or another team member, overall care quality is compromised and patient safety is threatened.

From captain to team member
Both the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties (as part of its Maintenance of Certification® process) include ‘system-based practice’ as a required core competency. To be effective, system-based practice requires that physicians make a paradigm shift from ‘captains of the ship’ to ‘key team members.’ This change is especially challenging because patients—as well as the healthcare system and the medical liability system—still hold the physician as primarily accountable.

Regulatory bodies such as the Massachusetts Board of Registration in Medicine have created specific disruptive behavior policies. The policy includes “foul language; rude, loud or offensive comments; and intimidation of staff, patients and family members” as examples of disruptive behavior detrimental to patient care.

The AMA recognizes that “Personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care constitutes disruptive behavior. (This includes but is not limited to conduct that interferes with one’s ability to work with other members of the health care team.)” The policy also states, however, “criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior.”

The risk of sanction
Despite that caveat, physicians have claimed that they were targeted as disruptive when they advocated for safety and quality. Disruptive behavior is also an emerging risk factor for physician professional peer review and being reported to the National Practitioner Data Bank.

In January 2009, a new standard issued by the Joint Commission [formerly JCAHO] went into effect. It requires hospitals to have “a code of conduct that defines acceptable, disruptive, and inappropriate staff behaviors” and for its “leaders [to] create and implement a process for managing disruptive and inappropriate staff behaviors.” The rationale for the standard states: “Leaders must address disruptive behavior of individuals working at all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.”

A Joint Commission sentinel alert includes “uncooperative attitudes” and “condescending language or voice intonation and impatience with questions” as disruptive behaviors. The sweeping definition and concerns of potential misuse are problematic.

Is sanction becoming a sledgehammer?
At a recent AMA meeting, concerns in the House of Delegates about potential “arbitrary and capricious enforcement” against physicians based on the new Joint Commission standard prompted a vote to ask the AMA to revise its current policy and to work with the Joint Commission to delay implementation of the new standard. The AMA was also asked to work with other institutions to “develop a definition of disruptive behavior by a physician to include the actions that would rise to the level of true abusive behavior” and to develop appeal mechanisms.

The AMA, in response to the delegates’ request, has formulated a model code of conduct that helps to define disruptive behavior and its management.

In today’s increasingly complex patient care paradigm, it is critical that each member of the healthcare team perform optimally in a harmonious fashion to ensure patient safety. Each should be vigilant and able to communicate freely—especially regarding safety concerns—with the team.

Disruptive behavior may result in individuals’ complying with an order for potentially erroneous treatment out of fear, ignoring a required step in the protocol for patient safety, or avoiding giving a valuable suggestion, raising an alert, or reporting an adverse factor that may ‘hold up’ the ‘smooth’ progress. Disruptive behavior also leads to poor morale, poor job satisfaction, increased staff turnover, and overall reductions in quality of care.

What can we do?
We, as orthopaedic surgeons, must avoid such behavior ourselves and be leaders in fostering a culture of mutual professional respect at all levels, effective team work, and open, fearless, and respectful communication. We need to encourage free discussion of concerns regarding patient safety. We should obtain training in conflict resolution and help others do likewise. Those of us in leadership should include interpersonal communication and behavior in agendas and discussions as routine items, just as we do with clinical care issues.

We must constantly improve our professional knowledge and skills—including our interpersonal communication skills. Our attitudes and behaviors as key members of the care team should foster mutually respectful and open communication and encourage contributions by team members for the best care.

The definition of disruptive behavior and its management are best left to the individual institutions, but disruptive behavior must be carefully defined to avoid misuse. When necessary, orthopaedic surgeons should participate in fair and effective peer review and help colleagues enhance their interpersonal skills.

These measures will reduce the traditional risk of medical liability by enhancing patient safety. They will also minimize career risk through well-defined criteria and fair processes for sanctioning disruptive behavior.

To paraphrase William Shakespeare, “The quality of d’sruption is strain’d; ‘tis hell’s fury or quiet poison from the few upon the team of care. It is thrice cursed: It curseth ones who give and ones who take, and most, the one we serve, our patient.”

S. Jay Jayasankar, MD, is a member of the AAOS Medical Liability Committee. He can be reached at jaymd@massmed.org

Editor’s Note: Articles labeled Orthopaedic Risk Manager are presented by the Medical Liability Committee under the direction of contributing editor Douglas W. Lundy, MD.

Articles are provided for general information and are not legal advice; for legal advice, consult a qualified professional.

E-mail your comments to feedback-orm@aaos.org or contact this issue’s contributors directly.

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AAOS Now
May 2009 Issue
http://www.aaos.org/news/aaosnow/may09/managing5.asp