Originally published March 2014
When faced with abusive behaviour, physicians should:
- Remain calm, professional, and non-confrontational.
- Take steps to protect patients, staff, themselves, and their families if there is an imminent and serious threat to safety.
- Take the lead by treating others with respect and compassion.
- Try to identify the root causes of the abusive behaviour.
- Focus on the issues rather than on personalities to reach a mutually acceptable resolution.
- Seek help from trusted colleagues or contact the CMPA for advice and assistance.
- Refer to policies governing the management of abusive behaviour in the workplace, when applicable.
- Document abusive encounters clearly and factually.
A day rarely passes without the CMPA responding to a request for help from a physician who reports being bullied, intimidated, or harassed. The inappropriate behaviours to which physicians are exposed may be relatively minor (rudeness, yelling, verbal threats, personal insults), major (physical aggression, destructive behaviour), or severe (assault, stalking).
Being the subject of bullying and other abusive behaviour not only affects the well-being of the targeted individual, in a healthcare setting it may impact patient safety and increase the risk of an adverse event. Physicians who are subjected to ongoing abuse may suffer mental health issues and sleep disturbances, and may decide to change workplaces. Knowing how to respond appropriately may help defuse such situations and prevent potential medico-legal difficulties for the physician.
Patients and their families
Physicians and their staff have the right to work in a safe environment. Many healthcare settings post notices of policies indicating zero tolerance of abusive behaviour.
Nevertheless, when a patient's or the family's expectations are not met, they may resort to abusive behaviour or threaten to launch a complaint or go to the news media. Patients and their families may become frustrated and stressed by uncertainty, long wait times, or when a physician denies requests that the physician deems are unreasonable. The latter may occur when, for example, the family requests information about the patient and the doctor denies the request citing lack of patient consent to release such information. Or the patient may be uncertain or may not understand why the doctor is providing a certain treatment or why a request for a narcotics prescription is refused.
Difficult as it may be, physicians should continue to follow the standard of care and not be intimidated into providing investigations or treatments they feel are not in the patient's best interest.
A male comes into the office for a pre-operative history and physical assessment. The patient is told his provincial health card has expired. He is told he can either apply for a new card, or pay for the visit and seek reimbursement once his new card arrives. The patient becomes verbally abusive toward the receptionist and begins throwing things. The office manager is able to get the patient to leave. The doctor discharges the patient from the practice, pointing out the posted zero-tolerance-to-violence sign.
The response to abusive behaviour should be calm, professional, non-confrontational, and preferably in private, away from other patients. Physicians should consider and address the security needs of their staff and themselves. Steps to consider when dealing with abusive behaviour from patients and families include the following:
- When safety is not a concern, verbalize the specific behaviour and clearly tell the individual that it is unacceptable. If the behaviour is minor and not recurring, outline the consequences of continuing or repeating such behaviour.
- If the abusive behaviours are recurring but minor, there may be insufficient trust in the relationship to provide continued quality care which may lead to ending the doctor-patient relationship.
- If the abusive behaviours are major or severe, consider ending the doctor-patient relationship, in keeping with the applicable medical regulatory authority (College) guidelines.
- In hospital or large clinic settings, consider using other available resources such as social work, patient advocacy, and pastoral care.
- If there is a serious and imminent threat to safety, notify the police or a security guard if in a hospital. A report to police should include only the name of the threatening individual and the nature of the incident. Divulging any patient medical information should be avoided, if possible.
- Document the abusive behaviours clearly and factually.
Colleagues and other healthcare workers
Conflict with physician colleagues and other healthcare workers may result in abusive behaviour if the conflict is not well managed. While some of these conflicts arise from disagreements over patient care, many stem from power struggles, working conditions, substantive issues (compensation, office space, support), and personality differences. Physicians need to understand the environment in which they are practising, and ensure their own behaviour does not contribute to the issue.
A member contacts the CMPA because he feels he is being bullied by his department chief: his clinic time is being cut. The CMPA medical officer is able to discern that the reduction in clinic time is due to the member having a large number of incomplete medical records and having been warned there would be consequences if they were not completed by a specified date. The hospital has stated it would reinstate the clinic time when the records were completed. The medical officer suggests to the member that this is not bullying. The member is advised to complete the records in a reasonable time as the hospital is obligated to have complete records to ensure safer patient care.
In the workplace, behaviour that is perceived as abusive should be addressed in a calm, respectful, and non-confrontational manner. Steps to consider when dealing with workplace issues include the following:
- Identify the issues. Is it a new problem or recurring issue?
- Seek counsel from a respected peer who may assist the parties to find common ground.
- Refrain from speaking broadly about the grievance. Rather, physicians may want to discuss the issue with the appropriate individuals in the chain of command in a stepwise fashion (for example, service head, department chief, director of professional affairs).
- Document the discussions and share the documentation with attendees.
Lawyers, police officers, insurance company representatives, and others may request information about a patient. Even if there is no authorization for releasing such information, the requesting individuals may insist it is their right to obtain the information and may threaten the physician or staff with consequences if the physician does not comply.
A distraught member calls the CMPA while in the midst of an encounter with a police officer who arrived at the clinic and is demanding information about a patient she had seen the day before. He is threatening her with obstruction of justice if she does not answer his questions. The CMPA medical officer advises the physician that she calmly tell the officer that she would be happy to assist, but that she requires consent from the patient or legal documentation such as a search warrant or court order. She is able to successfully defuse the situation.
Member physicians are encouraged to contact the CMPA for additional advice and assistance on dealing with disruptive behaviour.