AAOS Now

Published 10/1/2020
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Prakash Jayakumar, MD, PhD; Karl Koenig, MD, MS, FAAOS; David Ring, MD, PhD, FAAOS

Are You a ‘Disruptive Physician’?

Approach bad behavior as an opportunity, not a life sentence

In its code of medical ethics, the American Medical Association defines the behavior of disruptive physicians as “personal conduct, whether verbal or physical, that negatively affects or that potentially may affect patient care.” We’ve all been there—colleagues “losing it” and yelling at staff in the OR or saying something that clearly steps over the line in the heat of the moment. Understanding the underlying causes of such behaviors remains the most important path to improvement. A culture of awareness, safety, openness, and communication is key to creating positive changes in personal conduct.

Episodes of poor personal conduct are easily recognized in the form of aggressive physical behaviors and personality traits such as abusive language, threatening gestures, public criticism of colleagues, insults, shaming others, arrogance, intimidation, bullying, invasion of space, sense of entitlement, physically aggressive actions, rigid control, and yelling.

When poor conduct takes the form of passive-aggressive behaviors, it may be harder to pinpoint. Examples include intentional miscommunication and condescending language/tone; malicious gossiping; offensive sarcasm; being unavailable for professional activities (avoiding pagers and delaying phone calls); hostile avoidance (giving the “cold shoulder”); implied threats; intimidation tactics; impatience; and slurs and jokes that are racist, sexist, of a sexual nature, or uncomfortable on grounds of religion, culture, or personal appearance.

The fallout of such conduct can impact patients. As it turns out, the behavior elicits dissatisfaction, disengagement, a breakdown in the physician-patient relationship, and misconceptions about health care, which in turn can compromise patient safety. Teams find this instigates a loss of morale, limits collaboration, and ramps up hostility in the work environment. Ultimately, the individual may experience a loss of concentration and possible burnout, leading to a downward spiral that may affect his or her personal and professional life.

Often, underlying disruptive behaviors are opportunities for positive change and a set of principles that can help foster a culture of safety, growth, and support that optimizes personal conduct.

Opportunities for optimizing personal conduct can be directed at the individual: nurturing a sense of responsibility, building trust, and fostering a collaborative team spirit. It is critical to understand individuals in the context of their personal and professional lives. A lack of closeness in relationships and empathy for others may be the root cause of lapses in personal conduct.

Poor personal conduct also may arise when underlying health concerns or personal stressors surface. Such health concerns include depression, substance misuse, sources of personal stress (e.g., finances, illness, relationship stress), or stress generated by today’s complex healthcare environments.

Opportunities to optimize personal conduct can also be directed at the system level. Methods to help reduce the constant pressure on physicians may help. Developing a safety culture that is responsive to the health and emotional well-being of individuals and a system that anticipates their needs before episodes of poor personal conduct should be capable of unmasking opportunities for improvement and maintaining readiness for change.

Principles for personal conduct

We recommend a set of principles fit for optimal personal conduct in today’s complex and chaotic healthcare environment. First, address lapses in personal conduct “in the moment” through peer-to-peer collegial support at work that also encourages work-life integration. Personal mental and social health issues may tip someone into such lapses. Some people who exhibit disruptive behaviors have insight. They know that there is a better way and express a willingness to improve. Others persist in the belief that their actions were acceptable, even justified, given the circumstances. Often, people experience both sentiments. Individuals in either camp would value a safe environment and feedback from colleagues (perhaps when the dust has settled). That feedback should include what the peer observed and questions about how things are going in the individual’s personal life.

Every institution should have strategies and resources in place for supporting their team members. Ultimately, people in a safe culture welcome feedback and have a growth mindset. When repeated lapses occur within a supportive structure, it signals deeper problems that might benefit from specific treatment, remediation, or consequences—for example, a personality disorder. People with substantial elements of narcissism or sociopathy may not be a good fit for the team, in part because those traits are relatively resistant to treatment.

Effective communication strategies should be a priority for the organization, with regular measurement, feedback, and coaching. Everyone can improve their communication abilities. Behavior standards should be applied equally to all employees. An American College of Physician Executives survey demonstrated that a significant number of respondents felt that physicians in their organization who generated high amounts of revenue were treated more leniently when it came to behavioral problems than those who brought in less revenue. Furthermore, institutional culture plays a role in shaping how lapses in personal conduct are addressed. Common cultural elements that precipitate additional disruption behavior include:

  • inaction regarding “the recurrent offender”
  • “today’s abused junior, tomorrow’s disrupter”
  • “innate disruptive personality accelerated by ‘bad/tough love’ medical training”
  • “identification with the aggressor”
  • “role modeling by uncivil authority figures”
  • general bullying, hazing, ragging, ritual belittling, and humiliation during rounds and meetings by peers
  • egotistical mentors and attendings
  • having paid dues or a sense of entitlement to reenact abuse

Provide a clear and easy mechanism for submitting ideas for improvement, act on them, and communicate the results of such actions both to the individual who made the suggestion and the entire organization. When people have a useful and receptive channel to address and express the part of their daily work that could be improved, they will be less likely to have a lapse in professional behavior.

Hold people accountable. Accountability largely manifests in supporting the culture and the systems in place, with remediation and consequences becoming less common. Holding all team members accountable is also an important part of a safety culture, as people want to see all their team members engaged in growth and improvement.

Finally, institutions should tread carefully around language, taxonomy, and pinning labels: Categorizing an individual as “disruptive” is counterproductive because it impugns the person rather than the behavior. Stereotyping is rife among orthopaedic surgical professionals throughout surgical training and the rigors of practicing surgery.

Lapses in personal conduct should be seen as opportunities both for the individual and the entire enterprise. In this milieu, there is room for civil and positive constructive criticism, with a culture that encourages and makes a safe space for challenging the status quo.

Prakash Jayakumar, MD, PhD, is an assistant professor of surgery and perioperative care and director of value-based health care and outcome measurement in the Dell Medical School at the University of Texas at Austin. He is also a visiting professor of orthopaedics at Duke University.

Karl M. Koenig, MD, MS, FAAOS, is the medical director of the Musculoskeletal Institute and associate professor in the Department of Surgery and Perioperative Care at the University of Texas at Austin. He is the director of the Joseph M. Abell Arthroplasty and Value-based Health Care Delivery Fellowship and leads the initiative to improve access to musculoskeletal care for the residents of Austin and beyond.

David Ring, MD, PhD, FAAOS, is past chair of the AAOS Patient Safety Committee.

References

  1. American Medical Association: Physicians with Disruptive Behavior. Available at: https://www.ama-assn.org/delivering-care/ethics/physicians-disruptive-behavior. Accessed July 31, 2020.
  2. Heslin MJ, Singletary BA, Benos KC, et al: Is disruptive behavior inherent to the surgeon or the environment? Analysis of 314 events at a single academic medical center. Ann Surg 2019;270:463-72.
  3. Johnson HM, Irish W, Strassle PD, et al: Associations between career satisfaction, personal life factors, and work-life integration practices among US surgeons by gender. JAMA Surg 2020 [Epub ahead of print]
  4. Reynolds NT: Disruptive physician behavior: use and misuse of the label. J Med Regul 2012;98:8-19.
  5. Krizek TJ: Ethics and philosophy lecture: Surgery… is it an impairing profession? J Am Coll Surg 2002;194:352-66.

Key Principles

  • Address lapses in personal conduct swiftly through collegial support.
  • Prioritize effective communication through measurement, feedback, and coaching.
  • Apply behavioral standards equally within a positive learning and work culture.
  • Establish clear, easy mechanisms for submitting ideas and enabling action.
  • Hold all team members accountable within a culture of safety and improvement.
  • Set the right language and tone, and avoid labels and stereotyping.