There is growing interest in addressing the issue of disruptive behaviour in healthcare due in part to legislative and regulatory changes, and mounting recognition of the negative impact of this behaviour on providers and on patient safety. Recognizing that disruptive actions by doctors and others have never been acceptable, the healthcare community is collectively working to eliminate this conduct.
During the 2013 CMPA Annual Meeting in Calgary, the Association released a discussion paper entitled, The role of physician leaders in addressing physician disruptive behaviour in healthcare institutions [PDF].
The CMPA's interest in helping address physician disruptive behaviour stems from its mandate to protect the professional integrity of doctors and to promote safer medical practice. Highlights from the CMPA's discussion paper, which are included here, can help physician leaders and practising physicians address the issue in a constructive and proactive manner.
Establishing a common understanding
Disruptive behaviour generally refers to inappropriate conduct, whether in actions or in words, that interferes with or has the potential to interfere with quality healthcare delivery.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 physician 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 which may initially seem inappropriate are actually disruptive. Much depends on the nature of the behaviour and the context in which it arises. The College of Physicians and Surgeons of Ontario provides examples of conduct which is 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 doctor, 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.3
Although all health professionals and administrators can display disruptive behaviour, such conduct by doctors may be particularly noticeable because of their role in the delivery of healthcare. Studies show approximately 5% of practising physicians engage in recurrent disruptive behaviour.4 An analysis of CMPA closed cases found that cases pertaining to disruptive behaviour represented 5% of all medical regulatory authority (College) cases and 5% of all hospital cases. The majority of these had unfavourable outcomes for the physician.
Legislation and regulations are helping to raise awareness about disruptive behaviour. In all provinces and territories, legislation now exists regarding obligations to address violence, harassment, and safety in the workplace. In addition, many provinces have legislation requiring hospitals to report to Colleges cases of physician suspensions or privilege restrictions due to misconduct. 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
Physician 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 doctors should be addressed by the healthcare institution where the conduct occurs. 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 medical regulatory authorities 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.
Constructive approaches to be considered
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
Empowering 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 physician disruptive behaviour may begin early in a doctor'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.
Physician leaders should receive and lead training on acquiring the skills required to address disruptive behaviour effectively.
Actions and tools for physician leaders
Within healthcare institutions, physician leaders and other doctors and healthcare providers should be educated about disruptive behaviour and its impact. Specific training on teamwork, communication skills, and conflict resolution may be beneficial. Beyond training opportunities, medical 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" with a colleague in the case of a single unprofessional incident, followed by documented intervention for recurring behaviour. 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.5
The CMPA believes physician leaders can play a meaningful role in addressing physician disruptive behaviour. The CMP's discussion paper includes recommendations that can help guide physician leaders in this effort.
- College of Physicians and Surgeons of Ontario, "Guidebook for Managing Disruptive Physician Behaviour," 2008, p.4
- Ibid, 5
- Joint Commission Perspectives on Patient Safety, Managing Disruptive Behaviour, January 2009. Retrieved June 2013 from: www.jcrinc.com
- Leape, L. L., Fromson, J. A., "Problem doctors: Is there a system-level solution?" Annals of Internal Medicine (2006) Vol. 144, no.2 p.108
- Hickson, G. B., Pichert, J. W., Webb, L. E., Gabbe, S. G., "A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviors," Academic Medicine (2007) Vol. 82, no.11 p.1042