AMA House of Delegates

AMA meeting: Disruptive behavior standard draws fire

■ The AMA will ask for a one-year hold on the Joint Commission rule. Delegates seek to shift the focus to behavior that harms patients.

By Kevin B. O’Reilly — Posted Dec. 1, 2008

Orlando, Fla. -- A Joint Commission standard on disruptive behavior could lead to "arbitrary and capricious enforcement" against physicians, the AMA House of Delegates warned.

Delegates at the Interim Meeting directed the AMA to seek a one-year moratorium on the new standard, slated to take effect Jan. 1, 2009, to allow organized medical staffs time to change their bylaws to comply with the rule. The house also adopted policy advocating that medical staffs develop their own conduct codes and investigation and appeals procedures.

In July, the commission issued a sentinel event alert on disruptive behavior that said "intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. ... Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions."

The commission's alert cited research showing such behavior impedes communication among the health care team and can harm patients. A spokesman said the commission was contacted by the AMA and is reviewing the Association's requests.

Defining problems

The broad definition of disruptive behavior drew delegates' ire.

"The definition is very important," said Stephen L. Schwartz, MD, a delegate for the Pennsylvania Medical Society. "Intimidating colleagues is wrong; everyone would agree with that. But let me point out that intimidation is in the eye of the beholder. If I ask someone a question and they feel intimidated, did I intimidate them?"

Arthur E. Palamara, MD, a delegate for the Florida Medical Assn., agreed. "We need some absolute standard of what constitutes disruptive behavior."

He and other delegates expressed concern that some health care organizations are using disruptive behavior policies to retaliate against physicians who are outspoken about quality of care. When "we say something about it, we are now titled disruptive physicians," Dr. Palamara said.

Jay A. Gregory, MD, a general surgeon and chair of the AMA Organized Medical Staff Section Governing Council, said the commission's definition is workable. But the new standard allows health care entities too much latitude with their own definitions. It is imperative, he added, that medical staffs exert control over any complaints against physicians.

Other delegates also said the rule can be used against physicians who have competing economic interests.

"This is just another tool these health care entities might find to use against staff physicians," said John O. Cletcher Jr., MD, a delegate for the American Academy of Orthopaedic Surgeons.

ADDITIONAL INFORMATION

Meeting notes: Medical ethics

Issue: The AMA's Code of Medical Ethics has not been comprehensively reviewed in more than 30 years.
Action: The AMA Council on Ethical and Judicial Affairs will undertake a three-year project to reorganize the code to make it easier to use and to consolidate opinions and identify gaps in policy.

Issue: Drug- and device-maker funding of graduate and continuing medical education can pose conflicts of interest for physicians and unconsciously bias the content of educational activities.
Action: CEJA and the AMA Council on Medical Education are working together to issue recommendations at the 2009 Annual Meeting on how best to manage these conflicts. An open call for comments will be posted to the AMA Web site.

Issue: Some hospitals, required to provide uncompensated long-term care for immigrant patients have had the patients deported to home countries, where appropriate care is often lacking.
Proposed action: The AMA should adopt policy opposing the deportation of patients. [ Referred for study ]

Issue: The AMA has no ethical policy explicitly outlining physicians' duty to provide the right care to the right patient at the right time through continuous quality improvement.
Proposed action: A CEJA report spelled out physicians' ethical obligation to provide high quality care. Some delegates objected that the proposed policy placed untenable demands on doctors in underserved areas. [ Referred for study ]

Issue: Health care organizations are increasingly using "secret-shopper" patients to report on physician and hospital performance in areas ranging from customer service and patient-centeredness to hand hygiene and decor.
Proposed action: A CEJA report stated that secret-shopper patients could be used as one way to assess and improve quality. But, the council said, these pseudo patients should not deprive real patients from getting care and should be used only with the approval of physicians. Delegates overwhelmingly objected that secret-shopper patient programs are inherently deceptive and misallocate scarce health care resources.[ Not adopted ]