Staff less tolerant of rude doctors

Code pink means trouble.

A doctor is yelling at a nurse about something, and a call goes through the hospital for other nurses to rally to their colleague's side. Code Pink.

"Any nurse who is not immediately occupied will go up and stand behind the nurse being yelled at. The doctor suddenly stops talking; they see all these silent nurses looking at them and they get the idea that this behavior is embarrassing to everybody," said Timothy Keogh, PhD, associate professor in the Dept. of Health Systems Management at Tulane University Health Sciences Center, New Orleans.

That's what it's like being around a disruptive physician. It's a behavior all too familiar at hospitals, group practices and clinics nationwide, says a new survey of physician executives.

The national survey of more than 1,600 physician executives found that one in three of them sees disruptive behavior by doctors at their facilities on a daily, weekly or monthly basis. Seven in 10 executives said physician behavior problems almost always involved the same doctors over and over again. Disrespect topped the list of offensive behavior.

"Problems usually involve just a few physicians and their interaction with nurses, discharge planners, other team members," one survey respondent said.

But researchers said the survey shows disruptive behavior is an issue that health care leaders must address.

"There could be increasing prevalence of this because of managed care and pressures of liability. As medicine becomes more and more of a business corporate model, it places more pressure on physicians," said William Martin, MPH, PsyD, associate professor in the Dept. of Management, College of Commerce, at Chicago's DePaul University. "The prevalence of disruptive behavior is too high."

Drs. Keogh and Martin co-authored the survey for the American College of Physician Executives, a 10,000-member association in Tampa, Fla. The survey findings are included in a series of articles in the September/October Physician Executive.

One in three surveyed executives said most physician behavior problems stem from conflict. Another 25% said problems were linked to doctors who refused to embrace teamwork.

One respondent grumbled: "Some people never reach adulthood. Unfortunately, many of them are physicians who, when under stress, behave as adolescents."

More than half of respondents said nurses or physician assistants are most often the targets. About 15% of the time, the conflict pits one physician against another.

"It has a big impact on how an organization runs. One physician can taint the culture of the unit," Dr. Keogh said. "They're not clinically bad. They're behaviorally bad. They yell at people. They may throw something."

Many executives said their organization has a written code of behavior and a formal discipline process. But when physicians are punished, they are treated more leniently than other staff members. Nearly 40% of surveyed executives said physicians who generate high amounts of revenue are treated more leniently than doctors who bring in less revenue.

Other researchers and counselors support the survey findings. Bad behavior takes the form of insulting patients and colleagues, ignoring pages, screaming at nurses, swearing at staff and uttering sarcastic remarks.

About 12% to 15% of doctors are chronically disruptive, said Wayne Sotile, PhD, a Winston-Salem, N.C., psychologist and editor of the Resilient Physician Newsletter. "It's an issue with a mushrooming awareness."

Hospitals used to be less active in addressing the problem because they didn't have adequate programs or intervention, said Larry J. Harmon, PhD, a psychologist and co-director of the Miami-based Physicians Development Program, which provides evaluation and monitoring of disruptive doctors.

"It's fairly common for a physician to throw a pen or a file or bang a wall. Hospitals have tolerated disruptive behavior from physicians that would not have been tolerated in any other workplace," said Dr. Harmon, who spoke about disruptive physicians at this year's annual meeting of the Federation of State Medical Boards.

Institutions respond

But Dr. Harmon and other counselors say attitudes toward disruptive physicians are changing.

Executives and patients are less tolerant of such behavior than they were 20 years ago, Dr. Martin said. "If the nurse would complain, nothing would happen. Now they feel more comfortable complaining, and institutions are responding."

The physician executive survey notes the leniency of many facilities toward physicians because of their stature and money-making power. But counselors say increased concerns about litigation are shifting that attitude and prompting more hospitals and other groups to develop disruptive behavior policies.

Experts say physician behavior can be changed. Dr. Harmon said his program of intervention and workplace behavior monitoring decreases disruptive behavior by 55%.

Drs. Keogh and Martin said keys to reducing behavior problems are coaching doctors on appropriate behavior, mediating disputes between doctors and staff, referring troublesome doctors to counseling and taking strong disciplinary action.

"If you're trying to help with this problem, you want to make it as practical and frontline as possible," Dr. Keogh said. "The behavior is what we want to change, not the human being."