Despite denials of her request for an elective surgical procedure by multiple orthopaedic surgeons, Patient Y felt a desperate need for the procedure. Just when Patient Y thought that she might be out of options, she found Surgeon X, who was willing to take on the case. Surgeon X was a board-certified orthopaedic surgeon with a complicated and storied reputation. Although he was a talented surgeon, Surgeon X had accumulated complaints regarding his behavior at the bedside of his patients and in interactions with staff.
Postoperatively, Patient Y made a complaint about Surgeon X's professionalism and behavior, and she indicated that she had received less than optimal hospital care as a result of Surgeon X's behavior. The hospital took the patient's allegation seriously and interviewed both parties. However, since the two parties recollected different versions of the event in question and the hospital had no standard policies in place to properly identify and address Surgeon X's potentially unprofessional behavior, the result was a stalemate.
Was Surgeon X guilty of unprofessional disruptive behavior resulting in adverse events for Patient Y? Why did the hospital not have standard policies in place to identify and address disruptive physician behavior? Has orthopaedic surgery been oblivious to defining and addressing the issue of professionalism, particularly disruptive surgeon behavior and its ramifications?
Critiquing physician behavior is not a novel idea. Since the time of Hammurabi's Code over thirty-seven centuries ago, unacceptable, permissible, and required behaviors by physicians have been agreed on and passed on between generations, with penalties in place for poor performance1. Thousands of years later, medicine and physician-patient relationships have evolved as a result of countless charters, mandates, and commissions. Despite this evolution, further changes and improvements in physician behavior continue to be necessary.
In order to change their behavior, physicians must first be aware of what constitutes disruptive physician behavior. According to the American Medical Association (AMA), disruptive physician behavior is defined under the Code of Medical Ethics as “personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care.”2 This definition includes behavior that may not be seen as disruptive until a negative patient outcome occurs.
Since the landmark publication of the Institute of Medicine report To Err Is Human, there has been a substantial effort to decrease the number of negative patient outcomes resulting from disruptive physician behavior3,4. Although improvement in this area has been made throughout the field of medicine, there has been a relative lack of discussion in the orthopaedic surgical field regarding disruptive physician behavior.
Why Surgeons?
The operating room is one of the most complex work environments, and an estimated 234 million surgical procedures are performed annually in the world5,6. The combination of complexity and high volume creates an exceptionally stressful atmosphere within the operating room. It is predicted that physicians will be under even more stress in the future, as they are asked to cope with working with increasing patient volumes and advancing technology, pressure to reduce the length of hospital stays to match increasing patient volumes, continuous reductions in physician reimbursement, and higher costs of medical liability insurance7.
The perceived notion by some in the medical field is that surgeons are expected to display focused and authoritative behavior8. Since surgeons work in an environment where “please” and “thank you” may not be commonplace and where efficiency is maximized, ancillary medical staff may perceive surgeons as unfriendly, demanding, and narrowly focused. However, surgeons’ behavior may be appropriate given this circumstance. Although the specific reason for disruptive or unprofessional behavior in an individual case is difficult to establish and is most likely multifactorial, stress and dissatisfaction with work undoubtedly play an integral role in physician behavior9.
Why Orthopaedic Surgeons?
Surgeons have a valuable opportunity to affect a vast patient base. The importance and reach of orthopaedic surgery in the United States are increasing as millions of Americans rely on orthopaedic surgeons to take an active role in their health care delivery10. The United States is facing a rapid increase in the elderly population, and this group has named the musculoskeletal system as their foremost concern with regard to limitation of physical activity10. By 2030, the annual demand for primary total knee arthroplasty in the United States is expected to reach 3.48 million procedures, and the number of revision knee arthroplasty procedures is projected to increase by over 600%10.
Orthopaedic surgery ranks fourth-highest among medical fields (behind general surgery, neurosurgery, and cardiovascular surgery) with regard to the prevalence of disruptive events, and it ranks fourth-lowest (behind the same three fields) with regard to patients’ ratings of satisfaction with their physician3. To optimize patient care by ensuring proper communication with the patient and among the members of health care delivery team, physicians must minimize disruptive events or distractions11.
As health care costs rise and reimbursements decrease, increasing demands will be placed on orthopaedic surgeons. As a result of this projected imbalance, burnout will also be a serious concern due to long hours and increasing stress associated with the responsibility of caring for a larger number of patients12. In turn, this could lead to a negative attitude toward patients, other members of the health care delivery team, and overall job responsibilities12.
Understanding Disruptive Behavior
Patients identify confidence, empathy, respect, thoroughness, and candor as ideal physician behaviors. These behaviors, along with professionalism, are associated with higher patient satisfaction, trust, compliance, and recommendations to others, as well as with fewer patient complaints and patient litigation2. Physicians are more likely to know what is ideally expected of them than what constitutes disruptive or unprofessional behavior13.
Although the AMA has established a definition for disruptive physician behavior, surgeons have been incapable of agreeing on exactly what constitutes disruptive behavior in practice. When 110 surgeons at one hospital system were surveyed regarding nine behaviors that had been previously identified as disruptive by various national organizations, only four of the behaviors were classified as disruptive by most of the surgeons14. Thus, even if education regarding disruptive behavior is available, all surgeons must believe in a comparable definition of disruptive behavior to avoid it.
Patient Safety
Although the prevalence of disruptive behavior has decreased as a newer generation of surgeons has entered the work force, such behavior still persists. Episodes of disruptive surgeon behavior adversely affect team dynamics and patient outcomes because they diminish communication, collaboration, and information exchange with the patient and staff.
Rosenstein and O'Daniel conducted a survey of staff at 102 hospitals in the United States. Seventy-seven percent admitted to witnessing disruptive physician behavior3. Of those who witnessed such behavior, 67% indicated that at least one of the episodes of disruptive physician behavior was associated with an adverse event, 71% indicated that the episode was associated with a medical error, and 27% indicated that it was associated with patient mortality3.
There is a major discrepancy between the rate at which incidents of disruptive behavior are acknowledged by physicians and the rate at which they are acknowledged by other medical staff. In a study by Jones and McCullough, 74% of the nurses and doctors but only 43% of the surgeons who responded to a survey reported having witnessed disruptive behavior15. The percentage of physicians and surgeons who have been reported for disruptive behavior in the United States is approximately 3% to 5%16, although disruptive behavior among physicians is likely more prevalent. Unfortunately, these relatively few doctors have a large impact on their organization and on patient care.
Loss of Market Share
In addition to patient safety, patient satisfaction is becoming increasingly important for practicing physicians in the United States. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), a set of twenty-seven standardized questions created and validated by the Centers for Medicare and Medicaid Services, is an instrument that is now being used by the U.S. government to gather information about inpatient care experiences17. The HCAHPS facilitates public reporting of such information and thereby creates new incentives for hospitals to improve quality of care. Moreover, use of the results of this assessment to determine Medicare reimbursement is scheduled to begin in 201317. Thus, disruptive physician behavior has the potential to affect the financial bottom line of both the practicing physician and his or her health care institution.
Disruptive physician behavior can affect the likelihood that the patient will return for further care and/or refer friends or family. According to studies conducted by the Technical Assistance Research Programs, if a physician satisfies one patient, that positive experience will reach four more people. However, if a patient feels alienated, that negative experience will reach ten or more people17.
Morale
Disruptive surgeon behavior in an operating room adversely affects team dynamics and promotes negative patient outcomes. For example, staff may neglect to share important data, staff recruitment and collaboration may decline, and medical costs may increase because of the disruptive physician18.
The increased stress, frustration, and diminished relationships produced by a disruptive physician are likely to lead to impaired communication among all members of the surgical team. The leading cause of avoidable surgical errors is poor communication among the surgical staff, and especially by the surgeon19. According to The Joint Commission, 60% of all avoidable adverse medical events can be traced back to communication errors20.
Staff Turnover
Disruptive behavior also leads to a higher employee turnover rate2. The individual employees who are affected by disruptive behavior report increased psychological distress and greater dissatisfaction with their personal life and work, and are therefore more likely to quit their job21,22.
Malpractice and Punitive Damages
A growing body of literature attests to the link between disruptive physician behavior and the risk of malpractice litigation23-26. The public recognizes that safe and high-quality patient care requires effective teamwork, open communication, and a collaborative work environment. Conversely, they understand that a hostile workplace imperils patient safety. When patients witness or are subjected to intimidating and disruptive behavior, their confıdence and trust in the entire health care system diminishes. The event that transforms a patient into a plaintiff is usually a lapse in professionalism.
In most cases, sustaining an iatrogenic injury will not prompt a patient to seek legal recourse, provided that the patient-physician relationship is preserved. Patients typically do not file malpractice claims unless the physician-patient relationship is harmed, usually by poor communication or loss of trust23. The risk of a malpractice claim is particularly high when the physician responds to an adverse outcome with a lack of empathy24. Patients who file malpractice claims often feel that their concerns were not taken seriously, that their perspective was not valued, that they lacked appropriate access to care, or that information was not communicated effectively to them25. However, perhaps the most important cause involves a health care provider who was perceived to be insensitive and lacking in compassion or integrity. When patients feel valued and feel that their opinion matters to their whole care team, they are far less likely to seek legal remedies23,26,27.
A carefully conceived disclosure policy may lower the total number of lawsuits, legal fees, and compensation expenses28,29. Disclosure is a central aspect of reforms involving patient safety, and many hospitals and insurers have adopted disclosure policies30,31. One of the early observations regarding the impact of disclosure comes from the Veterans Affairs (VA) hospital in Lexington, Kentucky. This facility adopted a policy of disclosure of medical errors, combined with early offers of compensation for the affected patients, following two malpractice cases that cost over $1.5 million28. Roughly twenty years later, the average settlement was $15,000 per claim, compared with over $98,000 at other VA institutions28.
Such a disclosure policy has also been shown to decrease the duration of legal cases and the resulting legal expenses. In 2001, the University of Michigan Health System initiated a comprehensive claims management program that involved full disclosure and compensation for medical errors30. Between August 2001 and August 2005, annual litigation costs decreased from $3 million to $1 million, the average time for resolution of a claim decreased from 20.7 months to 9.5 months, and the annual number of claims decreased from 262 to 11428,30. The University of Michigan Health System also began to reinvest these savings in improving its patient-safety reporting systems, thereby resulting in an additional improvement in patient safety30. These examples support the notion that patients often want an apology after an adverse event and that providing an apology, along with fair compensation, may decrease the possibility of punitive damage awards31,32.
The Joint Commission recently established a new leadership standard for all accredited programs that addresses disruptive and inappropriate behaviors33. Since January 1, 2009, hospitals and other accredited organizations have been required to have a code of conduct and to create a process for managing disruptive behaviors33. Although The Joint Commission has no universal guidelines that state specifically how health care organizations should deal with disruptive physician behavior, they do recommend that senior management work with the governing bodies within the organization to develop a process that will be easy to implement when a problem arises34.
Along with these new requirements, The Joint Commission has put forth strategies for dealing with disruptive behaviors3. These strategies include establishing methods to review credentials, regulating clinical privileges, and ensuring the participation of medical staff in the improvement process35.
Rosenstein and O'Daniel discussed nine recommendations designed to help identify and address disruptive physician behavior3. By adhering to these recommendations, which are listed below, physicians and staffing entities can improve disruptive behavior and overall staff and patient satisfaction.
1) Recognition and Awareness
The first step is recognition and awareness of each individual incident. It is important to identify not only the types of incidents that are the most commonly reported but also the types that are most commonly unreported. According to Rosenstein and O'Daniel, this could best be accomplished with use of self-assessment surveys in which respondents report on observed behaviors and incidents that may adversely affect job performance and patient care3. Confidentiality should be ensured to prevent fear of retaliation.
2) Commitment to Adherence
A commitment by all staff members, and particularly by those who are in leadership positions, is necessary. All members of the organization would have a responsibility to maintain a well-defined professional standard of behavior.
3) Development of a Clear Universal Policy
By developing a clear standard of acceptable behaviors embodied in the form of well-defined policies and procedures, organizations will reemphasize appropriate behavior. Incidents must be dealt with uniformly throughout all levels of the organization. All employees who choose to work in the organization would be required to sign a code-of-conduct agreement included with their contract. According to Rosenstein and O'Daniel, no exceptions would be made on the basis of an employee's position or revenue production3.
4) Structured Incident Reporting
An organization needs a uniform approach for incident reporting to avoid inconsistencies in its response. Furthermore, making it safe and acceptable for employees to report incidents and addressing the incident in a timely fashion through an appropriate follow-up are both critical steps toward proper reporting of incidents.
5) Establishment of an Oversight Committee
Establishment of a committee to address reported incidents lends credibility to the structure and process of the entire system. Once policies have been firmly established and a safe and anonymous reporting method is functional, it is important to have a consistent approach to investigate and deal with reported incidents. This committee would likely consist of a wide array of health care professionals, including physicians, physician executives or hospital administrators, nurses, and human resource personnel, who strive to adhere to a standardized process.
6) Preventive Measures
Understanding why a disruptive event occurred makes preventive measures possible. In the case of isolated incidents involving physicians who had never been known to exhibit this behavior in the past, the answer may simply involve increased stress on one particular day. However, other situations might reflect a plethora of complex factors that may involve the physician's core set of values or innate biases and the effects of his or her cultural background, personality, and training. By understanding the initiating factors, the committee can make an effort to prevent future incidents.
7) Education and Training Programs
An education and training program for offending physicians represents another preventive measure against future incidents. Although there will be resistance to implementing an education and training program, because it will take valuable time away from seeing patients and conducting surgery, many of the contributing factors noted in the previous point can be addressed in such programs. By using patient safety, team dynamics, and staff satisfaction as umbrella topics, disruptive behavior can be discussed more freely. However, more serious situations may warrant individualized behavioral or psychological counseling.
8) Improving Communication
Since miscommunication has been linked to 60% of preventable adverse events, improving the communication skills of the 3% to 5% of physicians with reported disruptive behavior is an important strategy for decreasing the rate of less than optimal patient outcomes17,19. Teaching basic communication is an excellent way to improve team dynamics and decrease misunderstandings. Hospital and medical group leaders can and should foster an environment of respect, situational awareness, open communication, feedback and education, accountability, and shared decision making19,35.
9) Intervention Strategies
A final important recommendation by Rosenstein and O'Daniel is the creation of intervention strategies that help to minimize the impact of disruptive behavior3. This involves creating a special task force that responds immediately and takes necessary actions during or after a disruptive event to minimize its impact. The organization may also wish to implement a debriefing process for the task force members; during the debriefing, possible improvements can be discussed or constructive criticism can be offered to help the responders to deal with future conflicts.
Thinking Outside the Box
Another method that has garnered some success is used during the education of physicians at the Vanderbilt School of Medicine. This program emphasizes an alternative approach intended to identify, assess, and address unprofessional behavior36. The Vanderbilt School of Medicine uses role-playing actors to demonstrate unprofessional behavior and then stimulates discussion of the possible implications of such behavior in the current teaching cases36. This approach, used in conjunction with the traditional, formal case-based teaching about unprofessional behavior at various stages of medical school and residency, has been shown to be effective37. The Vanderbilt School of Medicine has taken a proactive stance on the subject of unprofessional behavior and should be used as a model for other institutions.
Residency: A Time for Improvement
As researchers continue to investigate patterns that lead to disruptive behavior, residency is becoming a new target in addressing these issues. A recent retrospective study evaluated the number of incidents involving surgery residents that were reported between 1995 and 2005; these incidents included poor professional conduct, violation of a protocol, and verbal and other mistreatment of staff. Sixty-six complaints were made against twenty-nine of the 110 residents who were included in the study38. The most common complaints involved professional conduct (83%), protocol violation (33%), and verbal mistreatment (23%)38. Sixteen of the residents who received complaints were repeat offenders and showed a strong pattern of repetition (53% positive predictive value)38. The study showed that disruptive physician behavior manifests early and that it is likely to repeat itself38. In a survey by Daugherty et al., the authors found that 93% of residents reported mistreatment during training. Furthermore, the reported sources of mistreatment were physicians (reported by 80.8%), senior residents (77.3%), and nurses (61.5%)39.
Other studies have shown that disruptive behavior patterns can be traced back even further to medical school. As many as 10% of students who demonstrate disruptive or unprofessional behavior in medical school will make medical errors and have malpractice suits filed against them as a direct consequence of similar behavior at some later point in their career40. The academic health care setting should provide not only technical training but also professional training for students and residents41. Thus, medical schools and resident training programs, through the recommendations and guidance of the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education, should improve their system for identifying and correcting disruptive behaviors before medical students and residents graduate to become practicing physicians.
Physicians charged with teaching medical students and residents can also prevent disruptive behavior by employing respect, empathy, and compassion, thus serving as role models for what is expected of a physician2. Furthermore, the viewpoints of medical students and residents regarding the way in which they were treated may prove extremely valuable.
The historic tolerance of disruptive surgeon behavior has led to a refusal to appropriately address unprofessional behavior and has thereby failed both health care organizations and patients. Many of the abovementioned recommendations made by The Joint Commission are sound, and they address many of the problems that are currently present. However, more research is needed to better define how and when disruptive physician behavior results in adverse events, to quantify the potential resources lost due to such behavior, and to provide universal guidelines on how to address reports of such behavior.
We recommend that surgical professional societies, such as the American College of Surgeons and/or the American Academy of Orthopaedic Surgeons, develop a comprehensive position statement on disruptive physician behavior and its management. By defining disruptive physician behavior, facilitating a reporting protocol, and ensuring fair evaluation and management of disruptive behavior, this position statement could then serve as the standard for implementation of policies on such behavior at medical centers and could further safeguard patient safety.
In today's rapidly evolving health care system, the quality of patient care has continued to come under scrutiny. Orthopaedic surgeons can improve the care that they deliver by properly addressing the issue of disruptive and unprofessional behavior, by clearly defining what constitutes such behavior, and by understanding its consequences.