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Sunday, August 1, 2010

How the Title of “Disruptive Physician” Can Ruin Your Career and How to Avoid It

In response to standards put forth by The Joint Commission, the American Medical Association, through its Council on Ethical and Judicial Affairs, continues to voice its ongoing support for use of the designation “Disruptive Physician” as a mechanism for potential discipline of physicians. In doing so, the AMA has created two distinct forms of “physician behaviors” upon which such actions can be based.


1. Inappropriate Conduct

Inappropriate behavior is conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. This behavior can have a detrimental effect on relationships between healthcare practitioners. Inappropriate behavior includes such things as belittling or berating statements, use of profanity or disrespectful language, inappropriate comments written in the medical record, deliberate failure of cooperation without good cause, and refusal to return phone calls, pages, or other messages concerning patient care or safety. Persistent, repeated inappropriate behavior can become a form of harassment and thereby rise to the level of disruptive behavior.


2. Disruptive Behavior

Disruptive behavior is defined as any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or nonverbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised. Disruptive physician behavior includes, but is not limited to:

• Physically threatening language directed at anyone in the hospital including physicians, nurses, other medical staff members, or any hospital employee, administrator or member of the Board of Directors;

• Physical contact with another individual that is threatening or intimidating; • Throwing instruments, charts or other things;

• Threats of violence or retribution;

• Sexual harassment; and,

• Other forms of harassment including, but not limited to, persistent inappropriate behavior and repeated threats of litigation.1


As this mechanism grows in use, and misuse, physicians, historically revered, honored and beloved by society are no longer being afforded deference by their patients, peers or other clinicians who work with them. Twenty years ago, a physician, known to be abrasive, argumentative, flirtatious with staff or patients, or even demanding in the operating room, would rarely become the subject of scrutiny. Today however, such a physician, whether new to practice or amply experienced, whether a specialist or a general practitioner, and whether internationally renowned or local, can easily be labeled a “disruptive physician”. In the new investigatory, regulatory and competitive climate of healthcare environment, it is critical for physicians to avoid even the inference of being “disruptive”. However, in order to do so, every physician must acquire an understanding of the new healthcare risk landscape and how to maintain a risk prevention “state of mind” with both patients and staff.


Who, or what, defines a physician as “disruptive”?


“Disruptive”, as a newly developing legal term of art, is not only being defined by the AMA but also governs the conduct of physicians through a variety of documents that set expectations for physician conduct including, but not limited to, medical staff bylaws, employee manuals/handbooks, state and/or federal regulations, employment contracts, etc. These documents also typically contain related clauses that set forth the ability to tie disruptive conduct to physician discipline or termination. Disruptive conduct includes hostility, tardiness, belligerence, incompatibility with patients or staff, religious insensitivity, cultural insensitivity, racial insensitivity, uncooperative behavior, sexual impropriety or even the use of profanity. Disruptive conduct can also be described in terms of the work environment that it causes such as a “disharmonious environment”.


By way of recent case examples, the disruptive physician is:


■ the surgeon who raises his or her voice at residents, nurses and/or medical assistants in the operating room—even during a code,

■ the family physician perceived as being dismissive to a patient’s family member,

■ the specialist who criticizes or changes the primary care provider’s hospital orders,

■ the resident who refuses to follow the incorrect orders of a chief resident or fellow,

■ the attending who does not answer his or her pages, or

■ the physician who is not viewed as insensitive to a patient or colleague’s religious observances in providing and scheduling treatment or assigning on‐call schedules.


Why are physicians being targeted as disruptive?


The recent actions by organizations such as The Joint Commission and the American Medical Association rely upon studies which claim a correlation between intimidating physicians, and increased medical error rates (and poor patient satisfaction). From a financial standpoint, it has also been opined that disruptive physicians lead to the transitory nature of patients, thereby interfering with continuity of care and increasing costs. From an operational standpoint, it is believed that such “physician behaviors” can also cause well‐qualified medical practice and/or hospital personnel to resign or seek transfers. Disgruntled patients, colleagues and staff lead to an increased likelihood of medical malpractice lawsuits, whistle blower actions and complaints to various state and/or federal agencies. Any, or all, of these events are viewed as dramatically interfering with the delivery of care, tarnishing the reputation of the facility/practice/physician, and diminishing the health care “experience” for patients and their families.


What are the ramifications of being labeled as disruptive?


If a physician is labeled as disruptive, it can be a career ending event. State and federal agencies can discipline a physician for engaging in disruptive behavior if it is found to impact the quality of patient care or if it suggests moral, ethical or professional shortcomings. Disgruntled patients can complain to health plans/managed care companies, leading to investigations that can result in the termination of the physician’s contract and dramatic loses in income. Action can be taken against a physician’s hospital privileges for intimidating, uncooperative or insensitive behavior. Moreover, each of these events is reportable to the National Practitioner Data Bank and thereby triggers “cross‐investigations” and/or actions as the physician seeks credentialing or re‐credentialing.


What are the risk factors for being labeled as disruptive?


Warning signs do exist for a pending accusation of disruptive or inappropriate conduct. Does he physician have a high turnover rate of staff or clinicians? Is the physician regularly the recipient complaints from patients or staff? What is the physician’s personal reputation in the medical and patient community? What are the results from a simple internet search under the physician’s name? Have there been any patient surveys conducted by the practice, the facility or a health plan? What are the results? Awareness of a physician’s reputation among his or her colleagues and/or patients is the first step to ascertain if your “physician behavior” is creating a risk as being labeled as intimidating or insensitive and thereby “disruptive”.


What should a physician do if labeled as disruptive?

If a physician receives even the inference, verbally or in written form, from a colleague, patient, human resource representative, administrative agency investigator or hospital medical staff board member – it cannot be taken lightly and it must be addressed squarely and relentlessly. When dealing with the question of disruptive behavior, there are no informal inquiries, no casual conferences and certainly no innocuous investigations. Faced with such measures, no physician should offer an admission of wrongful or inappropriate conduct. Demand should be made that any accusation be confirmed from the source in writing and responses to same should be similarly issued in writing. No physician should attend any meeting pertaining to a complaint of disruptive conduct without knowing who will attend the meeting and the allegations or topics to be discussed. If a favorable resolution to the complaint is reached, the physician must demand that the dismissal be reduced to writing and inserted in any applicable medical staff, employment and or credentialing file – and that a copy also be provided to the physician. Otherwise, how a physician’s “conduct” is later perceived by others may well dictate the course of that physician’s future and the physician’s future ability to practice.



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