In my first month of private practice, I called an ENT attending at our hospital for advice about treating a complex orbital cellulitis case. He berated me for bothering him and said I should know how to manage the case without his help. He then hung up without answering my question. He was rude, aggressive, and—well—nasty. His was toxic, disruptive behavior. Sadly, such conduct is common, and its effects are profound.
Who is the disruptive physician? According to the AMA, disruptive MDs use condescension, abusive language, and insults; berate employees or colleagues in front of patients or peers; raise their voices; throw instruments; give others the “cold shoulder” treatment; and display disrespect.1 And while a person can exhibit one episode of toxic behavior, the disruptive physician has a pattern of acting out.
It’s estimated that 3% to 5% of physicians engage in these behaviors in the workplace. Even one episode of toxic behavior can adversely affect organizational morale. More important, such conduct undermines patient safety. The Agency for Healthcare Research and Quality asserts that disruptive behavior subverts an organization’s ability to develop a culture of safety,2 and the Joint Commission states that “intimidating and disruptive behaviors” can foster medical errors and preventable adverse outcomes.3
In a much-quoted editorial on dealing with disruptive physicians, Lucian Leape, MD, recommended a systems-based approach that includes adopting standards, requiring compliance, monitoring performance, and responding to deficiencies.4 Dr. Leape proposed that institutions develop explicit standards of behavior—such as a code of conduct—and that physicians acknowledge in writing that they are accountable for upholding those standards. The department chair or board president is responsible for a prompt and effective response to reported behavioral deviations.
Should ophthalmology groups have written policies? Yes—and, fortunately, guidelines already exist. The Joint Commission requires hospitals to adopt a code of conduct defining behaviors that undermine a culture of safety and a process for dealing with them. Therefore, local hospitals and academic centers likely have language already in place and can provide a template for your organization. And some residency programs, prompted by the ACGME Core Competency requirement of “professionalism,” are developing documents that define professionalism and a process to address inconsistencies.
As Russ Van Gelder, MD, ophthalmology chair at the University of Washington in Seattle, put it, “Professionalism is crucial to our culture as physicians.” His department adopted the “Washington Way,” a series of documents that define professionalism based on 7 core principles: nonmaleficence; beneficence; honesty; responsibility; respect and tolerance; clear communication and transparency; and competence. The documents include specific expectations for faculty interactions with residents and for research excellence and a well-defined adjudication process.
It’s important to have proactive, formal procedures for addressing problem behaviors instead of ad hoc, reactive responses. A well-defined process increases the chance of a dispassionate and fair solution. Sometimes the physician is not aware of her/his behavior, which can be affected by culture, gender assumptions, and family norms. Furthermore, behaviors might be a response to stress; in this instance, appropriate support is helpful. The goal is to flag problematic conduct and to implement change.
Ophthalmologists are leaders. It’s important to organizational morale and patient safety that every one of us fosters professionalism and respect.
1 www.ama-assn.org/delivering-care/ama-code-medical-ethics. Accessed Sept. 15, 2017.
2 www.psnet.ahrq.gov/primers/primer/15/disruptive-and-unprofessional-behavior. Accessed Sept. 15, 2017.
3 www.jointcommission.org/assets/1/18/SEA_40.PDF. Accessed Sept. 15, 2017.
4 Leape LL, Fromson SA. Ann Intern Med. 2006;144(2):107-115.