Disruptive Physician Behavior the Objective

Disruptive Physician Behavior The objective of this work is to examine disruptive physician behavior with the focus of this study on the relationship dynamics between doctors, nurses, and other groups in the hospital setting. There is a wide range of behaviors among physicians including providing support and being helpful to staff then on the other end of the spectrum dictatorial and abusive behavior occurs which serves to create conflict in the working environment of the hospital.

This work defines disruptive physician behavior and addresses the costs associated with this type of behavior in the hospital setting. The causes of disruptive physician behavior are reviewed as well as are conflict resolution methods. Finally, this work recommends a conflict resolution action plan for utilization in the hospital setting for dealing with the problem of disruptive physician behavior.

Background of the Study The American Medical Association defines disruptive physician behavior as "personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively." (Ford, 2010) Disruptive physician behavior is stated to specifically include "conduct that interferes with one's ability to work with other members of the health care team." (Ford, 2010) the assumption stated is that "disruptive behavior by health care workers impacts quality of care and patient safety." (Ford, 2010) What is not clear is the response that should be given to this type of behavior on the part of physicians.

IV. Literature review The work of O'Daniel (2008) entitled: "Professionalism: Managing Disruptive Physician Behavior" states that disruptive physician behavior may be defined as "...any inappropriate behavior, confrontation, or conflict, ranging from verbal abuse to physical or sexual harassment. Disruptive behavior is not a new concept -- it is not unique to physicians and it is not unique to healthcare.

However, for the health care sector, disruptive behavior is taking on a new meaning." (O'Daniel, 2008) O'Daniel reports that in the past hospitals were hesitant to attempt to cope with the disruptive physician as these physicians were not employees of the hospital but instead admitted their patients to the hospital on a voluntary basis and were a primary source of revenue for the hospital.

In addition this issue is stated to have also been "...masked by a hierarchal system which placed the physician on a pedestal because of training and clinical expertise.

Many organizations tolerated this type of behavior as a way of doing business, shrugging off the problem as a minor occurrence with no ill effects to patients or staff." (O'Daniel, 2008) Two primary issues which are stated to have brought the situations "more into focus" were as follows: (1) First was the 1999 Institute of Medicine Report titled "To Err Is Human." This report detailed the significant number of medical errors, adverse events, and deaths that occurred in patient care and raised serious concerns about patient safety and quality outcomes.

The report called for significant improvements in system design and resources to more effectively monitor patient care in an effort to prevent patient injury. Part of the emphasis was on the need to address human factor issues and behaviors and their influence on bedside care. The second major issue had to do with nurse staffing and supply; and (2) in 2001, Aiken et al.

published a landmark article on the state and status of the nursing profession, concluding that growing frustration and dissatisfaction is causing significant turnover in the nursing profession and that the upcoming supply of nurses will not adequately meet patient needs. A shortage of nurses directly affects hospital capacity and ability to provide comprehensive patient care services. It can also adversely affect patient outcomes of care. One of the key factors affecting nurse satisfaction and retention is their relationship with physicians.

(O'Daniel, 2008) O'Daniel states that hospitals have started to take an approach that is more proactive in conducting assessment and monitoring behavior of staff and have as well developed policies as well as procedures that serve to enforce appropriate behavior. The work of Vikas Singh entitled: "Disruptive Physician" states "Disruptive behavior or activity is anything that disrupts the social fabric of the workplace or organization. It may be fits of anger, verbal abuses and insinuating remarks, interfering with normal work processes, or even violent action or sexual harassment.

It may be long standing or may be of more recent onset. It should be differentiated from constructive criticism and activities done in good faith and with aim of improving patient care." (Singh, 2007) A. Characteristics of Disruptive Physician Behavior Disruptive behavior includes a pattern of behavior characterized by one of more of the following: (1) Employs threatening or abusive language, directed at nurses, hospital personnel, or other physicians (e.g.

belittling, berating, and/or threatening another individual) (2) Makes degrading or demeaning comments regarding patients, families, nurses, physicians, hospital personnel, or the hospital; (3) Uses profanity or other grossly offensive language while in a professional setting; (4) Utilizes threatening or intimidating physical contact; (5) Makes public derogatory comments about the quality of care being provided by other physicians, nursing personnel, or the hospital; (6) Writes inappropriate medical records entries concerning the quality of care being provided by the hospital or any other individual; (7) Imposes idiosyncratic requirements on ancillary staff which have nothing to do with better patient care, but serve only to burden staff with "special" techniques and procedures.

(North Carolina Physicians Health Program cited in: Singh, 2007) B. Causes of the Disruptive Physician Behavior Singh states that common causes of disruptive behavior on the part of physicians include the following causes: (1) Medical problem(s): While medical problems are not usually the cause of disruptive behavior, NCPHP has encountered poorly controlled diabetes, Cushing's disease, and undiagnosed CNS tumors causing personality and behavior changes. If medical problems are a factor, there will often be an acute change in behavior or personality.

(2) Sleep deprivation/fatigue: This is usually due either to the consequences of the behavior (e.g. threatened loss of privileges, etc.), or related to overwork and other self-care issues. In other words, sleep problems are more of a symptom than a cause. (3) Adjustment disorder: Marital, financial, family, legal and other stresses are often found in conjunction with disruptive behavior.

Personal stress tends to exaggerate pre-existing personality traits, and it's typically not the healthy traits that blossom! Physicians referred to NCPHP for disruptive behavior will often minimize underlying stress, or say they have "already dealt with it." Unfortunately, life has a way of presenting us with new and recurrent stresses, and the development of healthy coping skills is necessary.

(4) Personality disorder (or traits): The American Psychiatric Association's Diagnostic and Statistical Manual -- Fourth Edition (DSM-IV) defines a personality disorder as "an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" manifested in the person's cognition, emotional response, interpersonal relations and/or impulse control. Personality traits are those noticeable characteristics that do not rise to the level of a personality disorder. Obviously, we all have some pathological personality traits, and the line between "healthy" and "unhealthy" is often fuzzy.

(North Carolina Physicians Health Program cited in: Singh, 2007) C. Costs Associated with the Disruptive Physician The costs associated with having a disruptive physician on the hospital floor are stated to include those as follows: (1) Medical malpractice; (2) Lawsuits by employees; (3) Cost related to employee turnover; (4) Patient satisfaction and market share; and (5) Soft costs like employee morale, team work, patient care, quality and safety.

(Singh, 2007) Interventions are stated to include specific interventions listed as follows: (1) Collegial intervention: usually for less serious issues in which the management staff discusses the issues with the physician and demands correction of the questionable conduct. Manager should communicate in unequivocal terms what are the issues and how it is affecting the staff and patient care, what is the expected behavior and consequences of not correcting the questionable conduct and also support of the management to help them in bringing about these changes.

It serves as warning sign for the physician, gives an opportunity to documents the facts and actions taken, affords an opportunity to establish rapport and work together, prevents from lawsuit damages and paves the way for starting the formal investigation process in case of physicians failure to change; (2) Formal investigation: is an extreme step and is used for serious issues.

Any kind of action taken in this process goes to the permanent record of the physician and if any corrective action is taken it would be entered into the National Physician Data Bank, which might make it virtually impossible for physician to relocate and start working again. It can lead to either behavior modification or taking away of physician privileges; and (3) Clinical Intervention: when there is some pathological condition or substance abuse and mental disorders for which you send the physician for necessary intervention to physician health program (PHP).

(Singh, 2007) D. Requirements for Referral Requirements for referral are stated to include the following requirements: (1) a pattern of behavior has been established and documented; (2) There is a treatable condition; (3) the physician/PA is willing to take some responsibility for his behavior and acknowledge that he is at least part of the problem; (4) the referral is presented and intended as being for help rather than Punishment; and (5) the referring agency is willing and able to impose consequences if the behavior does not change. (Singh, 2007) E.

Conflict Resolution Conflict resolution is inclusive of several specific steps which are stated to include: (1) Fact finding: Identify all individuals who are affected by the behavior and get complete history about the patterns of physician's behavior, preferably in writing (assuring the complainant about confidentiality). Identify probable risk to all affected individuals including patients and the organization itself. Make sure and document this step. (2) Meetings: meeting comes when manager has got the most complete knowledge about the issue and its consequences. It is advised to plan for the meeting beforehand.

Set the agenda for the meeting, communicate about the issues and how it is affecting staff and the workflow, and what is expected or desired. listen, listen, listen to the physician (sometimes just listening itself resolves the issue or gives you an idea about what to do). Stay focused on the issue, don't send mixed messages and don't bluff. Tell them about the consequences of non-compliance and make sure to follow up on it. Again, make sure this is documented.

(3) Resolution: the result of the meeting is either resolution or call for action. Both the parties may understand each others perspectives and deficiencies during the meeting and make a commitment to make necessary changes. Document this step just as in the first and second step. (4) Follow up: is important to ensure adherence. Formulate a process or system to ensure adherence to the agreed resolutions and behavior monitoring of the physician. It is also the most important step to start the next one -- Formal Investigation. This should also be documented.

F. Methods of Conflict Resolution Methods of conflict resolution are stated to include the following steps: (1) Coaching: One of the most effective ways. In this method you establish a rapport with them and get their attention. Then you need to communicate to them about the issues and expectation in the way they understand and make an effort to make them feel like both the parties are concerned about each other and they are partners in change.

It should seem like a collaborative process in which management is acting out of care and concern but at the same time make sure that you tell the hard truth. If possible give them a plan for change or necessary steps of change and help them through the process; (2) Mediating: is one of the other most often used techniques. The mediator is the third party, frequently medical director of the organization.

In this scenario both parties agree voluntarily to come to a mutually acceptable solution or agreement and are dedicated to follow up or deliver.