JULY 2005 • Volume 29 • No. 7

Ignoring 'Dr. X'

by: LAWRENCE M. SHUER

Disruptive behavior in the hospital or clinic isn't hard to recognize: Normal conversations and activities are suddenly distracted by a loud voice - often punctuated by obscenities. Then you see an angry physician standing in the face of a junior physician or nurse whose expression may suggest hurt, confusion or anger.

This scene is often followed by the voice of "reason":

"Oh, that's just Dr. X. He always acts like that. Just ignore him."

But we can't ignore this behavior, and not only because it's rude and hurtful. Disruptive behavior is far more than a social problem - it negatively impacts patient care and the overall effectiveness of a hospital or clinic. We have come to realize that disruptive behavior can be as toxic as sexual or racial harassment.

Disruptive behavior is now getting a thoughtful, systematic response. For example, in April, several of our SHC Medical Board members, nurses and I attended a national seminar here at Stanford entitled "The Disruptive Individual in Hospital and Medical Staff Relations." (This excellent gathering, by the way, was organized by one of our Medical Staff members, Jim Missett, M.D., PhD., co-director of Stanford's Center for Psychiatry and the Law.)

The Well Being Committee of the Medical Staff has agreed to take on this issue and help physicians, including residents, who are referred to the committee for exhibiting disruptive behavior under the guidelines set forth in the Disruptive Behavior of Physicians and Physicians-in-Training Policy.

This SHC policy comprehensively defines disruptive behavior as "conduct that interferes with the provision of quality patient care; conduct that constitutes sexual harassment; making or threatening reprisals for reporting disruptive behavior; shouting or using vulgar or profane or abusive language; abusive behavior towards patients or staff; physical assault; intimidating behavior; and refusal to cooperate with other staff members."

Increasingly, hospitals are developing policies similar to ours to confront disruptive individuals and hopefully help them recognize and correct toxic behaviors.

With lawsuits now arising out of such conduct, institutions will take greater care to prevent an environment where disruptive behaviors can lead to costly litigation. For example, recently the AMA reported that an Indiana jury ordered a heart surgeon to pay a $325,000 claim to a hospital employee for "workplace bullying." In this case the cardiac surgeon was accused of yelling at a perfusionist and then walking towards him in a threatening manner. The article points out that experts who have studied the subject see this as a "growing, yet murky area of law." Clearly physicians, if they ever were, are no longer given a free pass for abusive behavior.

We must also continually monitor how disruptive behavior influences teamwork. If Dr. X repeatedly yells and screams when nurses try to interact with him, most reasonable nurses will choose to avoid interactions not only with Dr. X, but potentially, by extension, with other authority figures as well. Dr. X may not even realize that the damage he or she is causing is systemic.

Even though disruptive behaviors may sound more benign than sexual harassment or physical assault, the results of both can ultimately be equally devastating, and therefore, both toxic behaviors must be identified and corrected with the same vigor.

We can no longer rationalize. The common excuse that Dr. X is "stressed" or is simply a perfectionist demanding the best care for his patients is not going to fly. Such excuses just "enable" or perpetuate a vicious circle of disruptive behavior. We are not doing Dr. X any favors by failing to confront and explain that such behaviors reduce effectiveness and jeopardize patient care.

Our SHC policy encourages persons who are directly involved to informally resolve incidents of disruptive behavior. But if this collegial first step is unsuccessful, everyone is encouraged to report alleged disruptive behavior to me as the Chief of Staff - either orally or through written vehicles, including the Patient Safety Network.

After I'm notified, I will conduct an investigation. First, if warranted, I will meet with the practitioner to review the allegations. I will make sure the person involved is aware of our policy and will ensure that he or she understands how and why disruptive behavior can negatively impact patient care and the viability of our institution. Our policy then requires that I outline the events in a report, which is kept on file and shared with the practitioner.

If the practitioner becomes a "repeat offender," I will refer the matter to the Well Being of Physicians and Physicians-In-Training Committee, whose members will meet with the practitioner to seek ways to structure working relationships to end disruptive behavior and resolve problems. The committee will also set up a mechanism to monitor the practitioner to help prevent recidivism.

Changing behaviors is not easy. Our policy is not going to eradicate all profanity or disruptive behaviors. Nevertheless, it is a step in the right direction and gives us a mechanism to deal with these issues that for so long have been tolerated or ignored.

If you have any questions regarding our policy on dealing with disruptive behavior, or if you wish to report a situation, please contact me at lshuer@stanford.edu or through the Chief of Staff Office at (650) 723-5371. We can no longer ignore Dr. X.