The Disruptive Orthopaedic Surgeon and the Consequences of Disruptive Behavior

The Disruptive Orthopaedic Surgeon and the Consequences of Disruptive  Behavior

                                                DR KS Dhillon

What is disruptive behavior?

The American Medical Association’s, Code of Medical Ethics defines disruptive physician behavior as ‘‘personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care’’ [1]. Behaviors that can be considered as disruptive include the use of inappropriate language, yelling, gossip, facial expressions, and other mannerisms, as well as physical violations. Disruptive physicians can also affect learning [2] and other work such as research [3].

In the USA, since the publication of the Institute of Medicine report ‘To Err Is Human’, there has been a substantial concerted effort to reduce the number of negative patient outcomes resulting from disruptive physician behavior [4,5]. Apparently, although substantial improvements have occurred in this area in the field of medicine, the same cannot be said for the orthopaedic surgical field regarding disruptive physician behavior [6].

Disruptive Behavior and Orthopaedic Surgery

The working environment in the operating theatre (OT) is very complex. The number of surgical procedures in the OT increases year after year. This combination of complex environment and a high volume of cases creates a very stressful working atmosphere. The surgeons will be under even more stress in the future, when they will have to cope with increasing patient load and advancing technology, reductions in physician reimbursement, and higher costs of medical liability insurance [7].

Private hospitals in some countries have been steadily increasing the number of doctors that they are recruiting to improve their business revenue. The numbers of patients coming to the hospitals is not increasing proportionally resulting in lower incomes for the doctors. This leads to increased stress and a tendency for the doctors to perform more surgeries where the indications may be somewhat doubtful. This can also affect patient outcomes and increase in litigation which in turn leads to higher medical insurance premiums.

Authoritative focused behavior is common among surgeons in the OT and words like please and thank you are not common. The focus is usually on efficiency. This makes some ancillary medical staff perceive surgeons as demanding and unfriendly although surgeons’ behavior may be appropriate in the given circumstance [6].

In most individuals, the specific reason for unprofessional or disruptive behavior is difficult to establish. It is most likely multifactorial, with stress and dissatisfaction with work playing an integral role in the physician’s behavior [8].

Orthopaedic surgeons play a very active role in health care delivery in most countries. With the aging population, musculoskeletal disorders are becoming more common. The numbers of orthopaedic operations are proportional increasing.

A survey by Rosenstein and O’Daniel [9] showed that orthopaedic surgery ranks fourth-highest behind general surgery, neurosurgery, and cardiovascular surgery, with regard to the prevalence of disruptive events. Orthopaedic surgery also ranks fourth-lowest (behind the same above three fields) with regard to patients’ ratings of satisfaction with their doctors [6]. Optimal patient care can only be provided by having proper communication with the patients and other members of the health care delivery team. Doctors must ensure that disruptive events and distractions are minimized at all costs [10].

Rising health care costs and reduction in reimbursements places increasing demands on orthopaedic surgeons. They will have to see more patients and their increase in hours of work will lead to increases in stress  [11]. This increase in stress can lead to a negative attitude toward patients as well as other members of the medical delivery team and also towards the overall job responsibilities [11].

Understanding Disruptive Behavior

What constitutes disruptive behavior remains unclear. The leadership of the Grand Rapids (Michigan, USA) 7 hospital health care system’s perioperative services department led an initiative to evaluate and reduce the incidence of intimidation in the department. They surveyed 110 physicians to ascertain their beliefs about behaviors that constitute intimidation. They found that a majority of physicians in the perioperative services agree that behaviors that were identified as intimidating by national organizations actually constitute intimidation in only 4 of 9 instances. Even for the most egregious behaviors, there was a lack of complete agreement that the behavior constitutes intimidation. These findings suggest why traditional means of addressing intimidating behavior may not be effective [12].

Generally, patients identify thoroughness, empathy, respect, candor, and confidence as ideal physician behaviors. Such behaviors, along with professionalism, have been found to be associated with higher patient satisfaction, trust, compliance, and recommendations of the doctor to others, as well as with fewer patient complaints and patient litigation [6]. Often physicians are more likely to know what is expected of them by patients than what constitutes disruptive or unprofessional behavior [13].

Prevalence of Disruptive Physician Behaviors

A survey by the American College of  Physician Executives [14] of 1627 physician executives, showed that 95.7% of the physicians encountered disruptive physician behavior on a regular basis, and 70.3% of the physicians reported disruptive behaviors nearly always involved the same physician(s). Some of the common disruptive behaviors encountered included disrespect, yelling, insults, physical abuse, refusal to complete tasks and carry out duties and throwing items. A majority (56.5%) of the physicians reported that disruptive physician behaviors very often involved conflict with a nurse or other paramedical staff. The survey also found that disruptive behaviors also involved other physicians (14.7%), administrators (14.5%), as well as patients (14.2%). Eighty percent of the respondents said disruptive physician behavior is often under-reported because of the victim’s fear of reprisal or is only reported when a serious violation occurs.

A survey [15] at 50 Veteran's Administration hospitals in the US was done which found that 86% of nurses surveyed had witnessed disruptive physician behavior. There have been other surveys [16,17] that have found that more than 90% of nurses experienced verbal abuse within the previous year. Physician abuse of pharmacists [18] and students have also been reported to be common [13].
Disruptive physician behavior is often not reported. Most patient complaints to disciplinary boards are usually due to disruptive physician behaviors. Most often the complaints are due to rudeness, poor communication, and unethical or improper behavior [20].

Consequences of Disruptive Physician Behavior

Safety of patients

When there are episodes of disruptive behavior by the surgeon, there is diminished communication, collaboration, and information exchange between the patient and the paramedical staff which adversely affects team dynamics and patient outcomes.

A survey was conducted by VHA West Coast in the US to assess the significance of disruptive behaviors and their impact on patient care. A survey of staff at 102 hospitals was carried out. The staff included physicians, nurses and administrative executives. Seventy-seven percent of the respondents admitted to witnessing disruptive physician behavior [4].

Sixty-seven percent of those who witnessed such behavior indicated that at least one of the episodes of disruptive physician behavior was associated with an adverse event. Seventy-one percent indicated that the episode was associated with a medical error, and 27% indicated that it was associated with patient mortality [4].

The rate at which incidents of disruptive behavior are acknowledged by physicians and by other paramedical staff varies widely.

Jones and McCullough [21] carried out a survey in which they found that 74% of the nurses and doctors but only 43% of the surgeons who responded to the survey reported having witnessed disruptive behavior. Though the incidence of disruptive behavior is prevalent, the percentage of physicians and surgeons who have been reported for disruptive behavior in the US is low at about 3% to 5% [22].

In the survey by Rosenstein and O'Daniel [15], most nurses believed that physician disruptive behavior produced frustration, stress, impaired concentration, reduced collaboration and communication, and led to negative patient outcomes.

Disruptive surgeon behavior in the OT can adversely affect the team dynamics and promote negative patient outcomes. Communication among all members of the surgical team becomes impaired due to frustration, stress, and diminished relationship produced by the disruptive surgeon. One of the leading causes of avoidable surgical errors is poor communication between the surgeon and the surgical staff [23].

According to the Joint Commission guide to improving staff communication, 60% of avoidable adverse medical events are due to communication errors [24].

Malpractice and Punitive Damages

Without any doubt, there is a link between disruptive physician behavior and the risk of malpractice litigation [25,26,27,28]. The public is aware that effective teamwork, good communication, and a collaborative work environment is required for safe and high-quality patient care. They are also aware that a hostile workplace can put the patients safety at risk. Patients lose confidence and trust in the healthcare system when they witness or are subjected to intimidating and disruptive behavior [6].
This lapse in professionalism often transforms a patient into a litigant.

Most iatrogenic injuries do not lead to litigation provided that the patient-physician relationship is good. Poor communication and loss of trust can harm the physician-patient relationship and lead to litigation and malpractice claims [25].

When doctors respond to adverse outcomes with lack of empathy the risk of a malpractice claim becomes very high [26]. Not taking the patient’s concerns seriously, not valuing their perspective, not providing appropriate access to care, and not effectively communicating with the patients leads to litigation and malpractice claims [27].

The most common reason why patients file malpractice claims is when the doctor is perceived by the patient to be insensitive and lacking in integrity or compassion. On the other hand, when patients feel valued and they feel that their opinion matters to the medical care team, they are less likely to seek legal remedy [25,28,29].

An increasing number of lawsuits, legal fees, and compensation expenses have led several states in the US to introduce mandatory disclosure of serious events laws [26].

A serious event has been defined in the law as "an event, occurrence or situation involving the clinical care of a patient in a medical facility that results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health care services to the patient," [30]. Reforms in the US have led many hospitals and insurers to adopt disclosure policies [31,32].

Successful outcome of disclosure of medical error policy was first noticed in the Veterans Affairs (VA) hospital in Lexington, Kentucky. They introduced the policy following two malpractice cases which cost them over $1.5 million. About twenty years after the introduction of the policy the average settlement was $15,000 per claim as compared to over $98,000 at other VA institutions [33]. Such a policy also reduces the duration of legal cases and reduces the legal expenses.

A comprehensive claims management program which involved full disclosure and compensation for medical errors was introduced by the University of Michigan Health System in 2001 [34]. Between 2001 and 2005, their annual litigation costs decreased from $3 million to $1 million. The average time for resolution of a claim also decreased from 20.7 months to 9.5 months and their annual number of claims also fell from 262 to 114 [33,34]. They then began to reinvest the savings in patient-safety reporting systems which resulted in an additional improvement in patient safety [34].
Providing an apology and fair compensation following an adverse event appears to reduce the possibility of punitive damage awards [35,36].

How to Manage Disruptive Behavior

The US Joint Commission has established leadership standards for all accredited programs which addresses inappropriate and disruptive behaviors [37]. From January 1, 2009, The Joint Commission in the US set up a new leadership standard for all accreditation programs, to address disruptive and inappropriate behaviors in two of its elements of performance [37]:

• EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.
• EP 5: Leaders create and implement a process for managing disruptive and inappropriate behaviors.

The Joint Commission has no universal guidelines which can specifically help health care organizations to deal with disruptive physician behavior.  They do, however, recommend that senior management should work with the governing bodies in the organization to develop a process that would be easy to implement when any problem crops up [38]. The Joint Commission has put forward several strategies for dealing with disruptive behaviors which include [39]:

•  Establishing methods to review credentials
•  Regulating clinical privileges
•  Ensuring the participation of medical staff in the improvement process

Rosenstein and O’Daniel have come up with ten recommendations to help identify and address disruptive physician behavior [9]. These include:

• Recognition and Awareness.                                                                                                      The first step is to assess the frequency and significance of disruptive behaviors. This can be accomplished by distributing survey forms in which the respondents are requested to report on behaviors and events that affect job performance and/or patient care. These surveys are carried out confidentially to ensure privacy and potential fears about retaliation.
• Cultural commitment/leadership/champions                                                                             The organization needs to have a top-down, bottom-up approach where all staff and employees are responsible for their behaviors and they are expected to strictly adhere to a well-defined professional standard of behavior. The board, administration and clinical leaders have to be committed and they have to endorse the required standard of behavior at all levels of the organization. Support from the physicians, nurses, and other staff will help to move the initiative along.
• Policies and procedures                                                                                                              The organization needs to introduce a clear definition of acceptable behavioral standards and criteria to reinforce appropriate behaviors. There also has to be a zero-tolerance policy for those who are not in compliance. The policies need to be standardized and consistently applied throughout the organization. Disruptive behavior policies need to be developed which outline the process for dealing with disruptive persons. In many organizations, the staff have to sign a code of conduct agreement or a code of behavior agreement.   Appropriate action has to be taken when dealing with disruptive individuals regardless of their position in the organization. The development and implementation of an effective disruptive behavior program will be inhibited if there is a reluctance to confront and address behavioral problems; there is inadequate executive training, management skills and experience; and also if there is a lack of a formalized program or systematic approach to addressing the behavioral problem. 
• Incident reporting                                                                                                                          A uniform approach to incident reporting is essential to avoid pitfalls and inconsistencies in the reporting process. The reporting process has to be safe and acceptable for employees. Once the incident has been reported the incident has to be addressed in a timely fashion.                    There has to be confidentiality in the entire process. Feedback should be given to those who do the reporting. Many organizations have designated task force or committees, to which all incidents are directed. These committees take responsibility for directing the issue to the correct authority.
• Structure and process                                                                                                              There is a need for consistent, uniform methodology for addressing the issues once the policies are in place and the reporting mechanism has been well established. A team of trained, capable individuals with a multidisciplinary representation ( administrators, human resource personnel, physicians, and nurses) is needed. This team will follow a standardized process for the incident assessment, make an appropriate, unbiased decision and come up with recommendations.
• Initiating factors                                                                                                                            In order to prevent the occurrence of disruptive episodes, the background as to why these events occur has to be understood. Some of the reasons include stressful situations, individual perceptions, deep-seated values. Outbursts can also result due to factors such as culture and ethnicity, age, gender, personality, training, as well as life experiences. Interaction of these factors affect staff values, perceptions, interactions, and relationships. Hence, having a better understanding of these factors will help in education and training programs which are designed to improve communication efficiency. 
• Education and training                                                                                                      Education and training is very important in addressing the issue of disruptive behavior. For starters, the focus should be on raising awareness of disruptive behavior and its effect on patient care. The education and training should involve stress management, anger management, conflict management, sensitivity training, diversity training, and assertiveness training. Sometimes behavioral or psychological counseling may be required. Often there will be resistance to implementing an education and training program for offending physicians because these programs are time-consuming and most surgeons do not have spare time in their busy schedules. In such situations, disruptive behavior can be discussed under umbrella topics such as patient safety, team dynamics, and staff satisfaction. 
• Communication tools                                                                                                Miscommunication has been linked to 60% of preventable adverse events. Hence improving the communication skills of the 3% to 5% of physicians with reported disruptive behavior would go a long way in decreasing disruptive behavior and improving patient outcomes [23,40]. Teaching basic communication skills through training courses and role play is an excellent way to improve team dynamics and decrease misunderstandings. Leaders in an organization should foster an environment where respect, situational awareness, open communication, accountability, feedback, and education, as well as shared decision making, is of paramount importance [23,39].
• Discussion forums                                                                                                                Having discussion forums is one good way to improve communication. People should be brought together. Staff interaction can be promoted during patient rounds and at joint conferences. More formally it can be done by placing nurses, physicians, and other staff on task forces or committees where relationships of nurses, doctors, and other staff are discussed. 
• Intervention strategies                                                                                                            Direct steps must be taken, whenever a disruptive event occurs, to minimize its impact. A “code-white” policy exists in some organizations where selected individuals respond to a call for assistance and help to mediate during a disruptive event [41]. In other organizations, immediate debriefing is carried out to discuss the  reasons for the disruptive event and to come up with constructive suggestions on how to handle the situation better in the future. Staff have to be encouraged to speak up when they come across situations that can adversely affect patient care.

Conclusion

Disruptive behavior is a very sensitive subject and it must be handled with a lot of care especially when it involves prominent physicians and senior employee staff. The issue cannot be swept under the carpet since it involves patient care. There has to be educational and training programs to improve communication and collaboration among the doctors and the staff.

There should be zero tolerance for disruptive behavior. All disruptive events must be identified and investigated to improve patient care and prevent negative patient outcomes. Disruptive behavior affects patient safety and is also known to increase the risk of malpractice litigation.
Reforms are needed in all healthcare organizations to overcome the scourge of disruptive behavior.

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