Hospitals are finally starting to take the problem of disruptive physician behavior seriously. Several years ago, the Joint Commission released Sentinel Event Alert 40 ("Behaviors that undermine a culture of safety"), which established a link between disruptive behaviors and medical errors, poor patient/family experience, worse outcomes, increased staff turnover, and higher costs of care! Most physicians agree that disruptive behaviors negatively impacts patient care (one survey found that 90% of the physicians agreed with the statement that disruptive behavior leads to worse care). And while most studies suggest that only about 3-5% of physicians are responsible for these disruptive behaviors, even just a few disruptive physicians can have a profound impact on the overall culture of an organization.
The cost of disruptive physicians is not trivial. The combined costs of disruptive physician behavior (due to the impact on staff turnover, patient outcomes, and cost of care) for a 400 bed hospital exceed $1 million per year. Given the negative impact of disruptive behavior on the quality of care (poor outcomes and poor patient/family experiences) and costs, both medical staff leaders and physician executives must address these behaviors when they occur and create the kind of organizational culture where these kinds of behaviors are not acceptable.
While there are a number of different definitions for disruptive physician behaviors (apparently, disruptive physician now has its own Wikipedia page), the American Medical Association defines it in their Code of Medical Ethics as "personal conduct, whether verbal or physical, that negatively affects or that potentially may affect patient care." Examples include (but are certainly not limited to just these) angry outbursts, throwing objects, chronically showing up late to clinic or the operating room, ignoring pages and/or telephone calls, refusal to follow hospital policies, and demeaning staff. However, as discussed further below, not every disruptive physician is the stereotypical hot-tempered individual that is prone to frequent, angry outbursts and frequently portrayed in the media (think Hugh Laurie's character, Dr. Gregory House from the television series, House or Alec Baldwin's character, Dr. Jed Hill in the 1993 movie, Malice).
One group of investigators defined four common archetypes of the disruptive physician that I have found particularly useful, particularly. Again, some of these descriptions may not fit your typical description, but they can be disruptive nonetheless. Here are the archetypes with a brief explanation:
1. The Know-It-All: Most, if not all, physicians are highly intelligent. However, there are some physicians that feel the need to prove their intelligence to the point where they intimidate those around them. They become unapproachable and can never see alternative viewpoints or opinions. They know best, so it's always "their way or the highway!"
2. The Insecure: I would say that the aforementioned "Know-It-All" is more common than the "Insecure" physician, at least in my experience. These physicians are constantly doubting or questioning their own ability and frequently seek affirmation from others around them. Their insecurity often results in being overly thorough and "ruling everything out" before establishing a diagnosis. When it comes to clinical decision making, these physicians are often paralyzed.
3. The Flake: These are the physicians who are always asking for someone to cover a clinical call or shift due to conflicting plans. Unfortunately, they are almost never able to pay someone back in return. While generally pleasant to be around, these physicians are frustrating as colleagues. They almost never finish their clinical documentation on time, and frequently fail to respond to telephone calls or e-mails due to "patient care responsibilities."
4. The Combatant: These are the classic, stereotypical disruptive physicians. They have short tempers and frequently display temper tantrums. They frequently issue ultimatums (especially to administrators - "Fix this problem or I will send my patients somewhere else") and rule by intimidation and fear.
During my career, I have worked with disruptive physicians representing all four archetypes. When we think of disruptive physicians, we tend to think of either the "Know-It-All" or more commonly, the "Combatant." However, the "Insecure" and the "Flake" can be just as disruptive. The article offers a general framework for dealing with all four archetypes, as well as specific recommendations for dealing with each individual archetype. At least for now, I will leave that for a post in the future.
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