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39 The abusive and disruptive physician
A hospital’s busiest surgeon is universally disliked because of his persistent negative demeanor, punctuated by harsh and abusive outbursts that spare no category of healthcare provider, and often upset the efficient functioning of patient care areas. Over the years, this behavior has been tolerated without any effective attempt at correction or control by the medical staff. His list of surgeries has been delayed because the preceding surgeon (who is slow and marginally competent) took 2 hours longer than anticipated. The surgeon berates the OR secretary, technician and circulating nurse. Then as the anesthesiologist is transferring his patient to the recovery department, the surgeon demands that his case get started in short order.
The surgeon has stated in his workup that his patient is having a right inguinal herniorrhaphy – but the patient has related to the admitting nurse that she has left-sided symptoms and was told by the surgeon in his office that she has a left-sided hernia. In the preoperative unit the surgeon marks the right side as the operative site and convinces a somewhat recalcitrant – but otherwise timid – patient to sign an informed consent for a right-sided herniorrhaphy. The preoperative nurse, known herself for harsh verbal attacks against physicians and co-workers, calls the anesthesiologist to warn him of this potential for wrong-site surgery, and rails against the head nurse for assigning her to this surgeon’s patients. In the background the anesthesiologist can hear the surgeon berating her for making the phone call to him.
The behavior described in this scenario is experienced by many physicians during their professional careers. It is termed abusive and disruptive, and adversely impacts the ethical practice of medicine. Abusive behavior signals the treatment of others harshly, cruelly and unremorsefully. Disruptive behavior indicates interference with the integrity and continuity of functions necessary for the provision of quality care. One may encounter nonabusive but disruptive behavior, represented by the slow surgeon in our case. Or, one may encounter abusive but nondisruptive behavior, represented by the preoperative nurse in the case scenario. The focus of this chapter, however, is mean, abusive, and disruptive (MAD) behavior of medical professionals in the workplace.
The importance of respect and civility in assuring good patient care is a foundation of the American Medical Association’s Code of Medical Ethics.1 MAD behavior subverts the ethical obligation of healthcare professionals from consistently placing the interests of the patient foremost, by interfering with the normative processes of collegiality, cooperation, communication, and teamwork. This sabotages the viability of an effective and efficient institutional culture of safety and quality care. Indeed, there is ample evidence of the linkage of MAD behavior to adverse events, medical errors and compromise of patient safety.2
MAD behavior – definition and consequences
MAD behavior encompasses an extreme degree of uncivil and unprofessional demeanor. It violates ethical standards of practice and impedes patient safety and quality improvement. It is a pattern of personality flaws and traits that interferes with a physician’s effective clinical performance and can be directed at any member of the healthcare team, as well as patients and/or their family and friends. Manifestations include, but are not limited to:
(1) Verbal abuse – threats; intimidation; insults; degrading, demeaning, or foul language; or unwarranted yelling, tone or innuendo.
(2) Physical abuse – inappropriate physical contact that is threatening, humiliating or intimidating, or actual physical violence (from finger poking to battery).
(3) Invasion of the space or boundaries of others, physically and/or psychologically.
(4) Visual abuse – threatening or humiliating movements; or inappropriate writings, drawings or photographs, including electronic transmissions.
(5) Harassment or discrimination against any individual on the basis of race, religion, color, ethnicity, national origin, ancestry or culture, socioeconomic status, physical, mental or other medical disability, marital status, gender or sexual orientation.
The MAD physician controls others through intimidation, bullying, belittling, berating, and condescendence. They manifest impulsive and unexpected anger, behave with arrogance, inconsideration and inflexibility, blame others rather than accepting responsibility, and are intolerant of those they deem to be “incompetent.”
MAD behavior’s harmful impact on workplace staff increases the risk for substandard care and adverse patient consequences. It amplifies stress; diminishes productivity; lowers self-esteem and morale; increases absenteeism, turnover, “sick” leave and worker compensation claims; and impedes the hiring of new staff. MAD behavior encourages failures to follow policies and procedures – for example by causing fear, disinclination or disinterest in questioning a MAD physician’s orders no matter how illegible, inappropriate or incorrect they may appear to be. MAD behavior decreases or aborts normative communication regarding patient care and polarizes staff into those who are deemed as “favored” versus “not favored.” The adverse impact on healthcare institutions includes time-consuming, unpleasant, and frustrating medical staff investigations; malpractice claims; and legal suits because of creation of a hostile work environment.
The aberrant personality of the MAD physician
MAD behavior is an Axis II psychiatric classification (which is not a psychiatric diagnosis or illness) characterized by an underlying personality with maladaptive behaviors that deviate markedly from normative expectations. This behavior poses a direct danger to patients as well as an indirect one by disrupting institutional and professional cultures of safety. This personality disorder is one of enduring traits, that is, it is part of the person’s innate character, and not merely a response to environmental factors. Cultural factors, concomitant substance abuse, or a dual psychiatric diagnosis may play a contributing role. But, because they suffer from lack of insight, the MAD physician is impervious to psychotherapy. The only potential treatment is to hold the MAD physician to strict limits of acceptable behavior. Unfortunately, the medical community’s history has been one of impotence, permissiveness, frustration and a collective unwillingness to act decisively to address these antics.
Quelling MAD behavior – a standard for assuring quality of care
The Joint Commission has declared that MAD behavior constitutes a “Sentinel Event Alert” because of the potential to “foster medical errors, contribute to poor patient satisfaction and to preventable adverse outcomes.”3 Indeed, in the new “Leadership Standard” requirements, they state that
“The hospital [must have] a code of conduct that defines acceptable and disruptive and inappropriate behavior … [and that] … leaders [should] create and implement a process for managing disruptive and inappropriate behaviors.”4
Two of the six core competencies for which The Joint Commission and the Accreditation Council for Graduate Medical Education (ACGME) want every physician to be regularly appraised relate to MAD behavior: “interpersonal and communication skills … that enable [physicians] to establish and maintain professional relationships with patients families, and other members of the healthcare team;” and professionalism, especially for “behaviors that reflect a commitment to continuous professional development, ethical practice, and understanding and sensitivity to diversity, and a responsible attitude towards their patients, their profession, and society.”4
Related posts:
Informed consent and the pediatric patient
The use of ethics consultation regarding consent and refusal
Revising the Uniform Anatomical Gift Act – the role of physicians in shaping legislation
Animal subjects research Part I: Do animals have rights?
Disclosure of medical errors in anesthesiology practice
Opioid therapy in addicted patients: background and perspective from the US
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