Disruptive behavior in the healthcare setting negatively impacts all providers and compromises patient safety. Physicians can address the issue in a constructive and proactive manner.
Establishing a common understanding
Disruptive behaviour generally refers to inappropriate conduct that interferes with or has the potential to interfere with quality healthcare delivery, whether in words, actions, or inactions.1 Examples include inappropriate words, abusive language, shaming, outbursts of anger, throwing medical instruments, and use or threat of unwarranted physical force. There is usually a pattern to disruptive behaviour, rather than a single isolated incident. Disruptive behaviour can also be quite subtle, such as refusing to work cooperatively with others or being chronically late for meetings, scheduled appointments, or surgeries.
Not all instances of behaviour that may initially seem inappropriate are actually disruptive. Much depends on the nature of the behaviour and the context in which it arises. Some medical regulatory authorities (Colleges) provide resources addressing disruptive behaviour among physicians.234 The College of Physicians and Surgeons of Ontario provides examples of conduct not deemed disruptive, including "healthy criticism offered in good faith with the intention of improving patient care or facilities, making a complaint to an outside agency, testifying against a colleague, or good faith patient advocacy."2
Disruptive behaviour has both immediate and long-term consequences. There is an immediate effect on the individual at the receiving end of the behaviour, such as a nurse or another physician, and this can affect performance in providing care. In the long term, disruptive behaviour can lead to ineffective care, harm to patients, and poorer clinical outcomes.
In all provinces and territories, legislation exists regarding obligations to address violence, harassment, and safety in the workplace. In addition, many provinces and territories have legislation requiring hospitals to report cases of physician suspensions, or privilege restrictions due to misconduct, to regulatory authorities (Colleges). Moreover, some Colleges have developed guidance on disruptive behaviour. Physician health programs are also striving to assist by offering resources specifically aimed at addressing disruptive behaviour.
Tiered response to disruptive behaviour
Disruptive behaviour requires a collaborative and tiered response within institutions, and also when College involvement is appropriate.
The CMPA shares the perspective advanced by most stakeholders that disruptive behaviour by physicians should be addressed by the healthcare institution where the conduct occurs. Most healthcare institutions are well positioned to address these matters in-house, given their knowledge of the situation, the workplace, and the individuals involved.
Medical regulatory authority response
Generally, the Colleges have indicated healthcare organizations should investigate and follow a staged response to a complaint about disruptive physician behaviour. Colleges commonly want to be notified about physicians whose employment is terminated or where privileges are restructured or suspended, or when physicians resign from the medical staff during the course of an investigation.
From the CMPA's perspective, an adversarial process at either the institutional or College level should be avoided in favour of a step-by-step approach which includes:
- Early identification
- Proactive intervention
- Workplace assessment
The role of physician leaders
Physician leaders can foster a culture of respect and address disruptive behaviour in healthcare institutions by setting clear expectations, modeling first-rate behaviour, and emphasizing the positive values and behaviour important to the organization. Since disruptive behaviour may begin early in a physician's career, opportunities exist to address this behaviour before it takes hold. Physician leaders should set expectations for professional behaviour among residents and faculty, including clear and tiered consequences for non-compliance.
Specific training on teamwork, communication skills, and strategies in managing unprofessional behaviours may be beneficial. Beyond training opportunities, leaders should play a role in monitoring physician behaviour. This may include conducting reviews or regular staff surveys, team member evaluations, and direct observation.
Physician leaders must take appropriate and fair steps to help resolve disruptive behaviour. A tiered approach to promoting professionalism can help to manage disruptive behaviour. This would generally begin with a "coffee conversation" in the case of a single unprofessional incident, followed by documented intervention for recurring behaviour. The process should be transparent and should include sharing the information gathered with the physician identified as demonstrating disruptive behaviour. This physician should also receive the opportunity to provide their own perspective.
A persistent pattern of disruptive behaviour unresponsive to lower level intervention may require escalation to a higher authority figure, with further documentation and an action plan. Finally, failure to respond to the authority intervention would lead to disciplinary action.
Physician behaviour in the professional environment. Toronto: College of Physicians and Surgeons of Ontario; c2016 May [cited 2022 Nov 2]. Available from: https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Physician-Behaviour-in-the-Professional-Environmen
Guidebook for Managing Disruptive Physician Behaviour. Toronto: College of Physicians and Surgeons of Ontario; c2008 Apr [cited 2022 Nov 2]. Available from: https://www.cpso.on.ca/admin/CPSO/media/Documents/physician/polices-and-guidance/policies/guidebook-managing-disruptive-physician-behaviour.pdf
Disruptive Behaviour by Physicians. Bedford NS: College of Physicians and Surgeons of Nova Scotia; c2018 Oct 12 [cited 2022 Nov 2]. Available from: https://cpsns.ns.ca/resource/disruptive-behaviour-by-physicians/
Managing Disruptive Behavour in the Healthcare Workplace. Edmonton: College of Physicians and Surgeons of Alberta; c2010 Fall [cited 2022 Nov 2]. Available from: https://www.ualberta.ca/anesthesiology-pain-medicine/media-library/eliassons-wellness-docs/managing-disruptive-behaviour-2010-copy.pdf