By Dr. Gordon Wallace

Building a culture of respect in any healthcare setting is critically important. A stable, collegial and productive workplace leads to safer medical care and positive outcomes for patients. It also results in better job satisfaction among healthcare providers, and higher rates of employee retention. However, establishing a respectful work environment is not always easy. In particular, disruptive behaviour on the part of physicians can undermine the healthcare setting, put patients at risk, and jeopardize a healthcare institution’s reputation.

Nearly 73 per cent of respondents to the Canadian Association of Internes and Residents 2012 National Resident Survey reported experiencing inappropriate behaviour by others that made them feel diminished during their residency. Half of all respondents experienced this behaviour from physicians or nursing staff. The most commonly cited behaviours were yelling, shaming and condescension. According to a study in the Annals of Internal Medicine, approximately five percent of practicing physicians engage in recurrent disruptive behaviour.

A comprehensive analysis of the Canadian Medical Protective Association’s closed cases of disruptive physician behaviour found that incidents of disruptive behaviour represented five percent of all medical regulatory authority (College) cases, and five percent of all hospital cases that the association dealt with. The majority of these cases ended up with unfavourable outcomes for the physicians involved, including communication and anger management courses, written or verbal admonishments, suspensions and practice limitations.

Fortunately, the healthcare community is collectively working to eliminate disruptive behaviour in hospitals and other healthcare environments – recognizing the negative impacts that this conduct has on patient safety and staff. Key to successfully addressing disruptive behaviour is to first recognize that it is occurring.  A widely used definition of disruptive behaviour is: “Any inappropriate conduct, whether in actions or in words, that interferes with or has the potential to interfere with quality healthcare delivery.” Examples of disruptive behaviour to be on the lookout for include:

1. Inappropriate words
2. Abusive language
3. Yelling and screaming
4. Shaming of other staff
5. Outbursts of anger
6. Throwing of medical instruments
7. Threats of unwarranted physical force

Disruptive behaviour is rarely an isolated incident. At times, disruptive behaviour can be subtle. Instances of subtle disruptive beaviour include refusing to work cooperatively with others; being chronically late for meetings, scheduled appointments and surgeries; and paying more attention to e-mail than to discussions during meetings. Beyond showing a lack of respect for other people’s time and work, this type of behaviour prevents the proper functioning of the workplace and can put patients at risk.

If left unchecked, disruptive behaviour on the part of physicians, and others, often worsens and can have short and long-term consequences. Healthcare providers working in a disruptive environment do not communicate effectively and may perform poorly in their jobs. Over the long-term, disruptive behaviour can lead to ineffective care, harm to patients and poor clinical outcomes. Providers subjected to a disruptive work environment may also become distracted, stressed, and suffer negative impacts on their personal health and relationships.

Legislation and regulations are helping to raise awareness about disruptive behaviour. In every province and territory, legislation is now in place to address violence, harassment and safety in the workplace. In addition, many provinces have legislation that requires hospitals to report to Colleges any and all cases of physician suspensions or privilege restrictions due to misconduct. This is helping to foster a zero tolerance environment in healthcare for beaviour that is considered to be harmful to staff morale and patient safety.

At CMPA, we feel strongly that disruptive physician behaviour requires a collaborative and tiered response from institutions. Healthcare institutions are well positioned to address these matters in-house given their knowledge of the situation, the workplace and the individuals involved. An adversarial process at the College level should be avoided in favour of a step-by-step approach that includes early identification, proactive intervention, workplace assessment and remediation.

Given their position, experience and influence, physician leaders have an important role to play in addressing disruptive behaviour on the part of their colleagues and subordinates. Doctors with formal leadership roles, such as chiefs of staff and department heads, can address disruptive behaviour in healthcare institutions by setting clear expectations, modeling exemplary behaviour, and emphasizing positive values and behaviours. Physician leaders should also set clear expectations for professional conduct among residents and faculty, including consequences for non-compliance.

Complaints about disruptive behaviour should be investigated and addressed promptly through a process that is transparent, fair and consistent. A single unprofessional incident may be subject to an informal intervention such as a “coffee conversation” with a colleague. If the behaviour recurs, or a pattern develops, a documented intervention with the physician’s supervisor would be appropriate. A persistent pattern of disruptive behaviour that is unresponsive to lower level interventions may require escalation to a higher authority, with further documentation and an action plan put in place. Finally, failure to respond to the authority intervention could lead to disciplinary action and sanctions.

Taking steps to address disruptive physician behaviour is not always easy. But it is necessary to build a respectful and collegial workplace that puts patient safety first. The CMPA will continue to work with physician leaders, healthcare institutions and other stakeholders to enhance civility in the workplace.

Physicians and other hospital leaders are encouraged to develop transparent policies and procedures that incorporate a graduated and fair approach to addressing disruptive behaviour. Patience and due process are important for all involved. Finally, do not forget the emotional impact that disruptive behaviour can have on staff, physicians and hospital leaders. Ensure that the necessary supports are in place to enhance resilience.

Dr. Gordon Wallace is Managing Director of Safe Medical Care at the Canadian Medical Protective Association.