Management, Case Vignettes, and Inappropriate vs. Disruptive Baheavior

    Managing Unprofessional Behavior

    Peer monitoring and reporting

    • 64% of physicians agreed that they had a professional commitment to report
    • 69% felt prepared to do so
    • 17% had direct knowledge of impaired physicians, but only 67% of this group had reported  

    (Des Roches 2010)   

    Intimidation and Patient Care

    • 60 year-old female physician-patient in good health
    • Celiac artery bypass; insufficient pain medication for severe pain
    • Surgeon not contacted because of his anger when called at night  

    Intimidating physicians can cause poor patient care!  A 60 year-old female physician in previously good health underwent a celiac artery bypass.  She chose as her surgeon one of the most well-known vascular surgeons at a large medical center hospital.

    Postoperatively, the patient experienced severe pain that was unresponsive to one milligram of morphine per hour, all the pain medication that was ordered for her.  The nurses refused to call her surgeon, citing his anger when called at night and his feeling that “nobody died from a little pain.”   The chief resident was called but would not alter the pain medication without permission from the surgeon.

    The patient credits her gastroenterologist with saving her sanity when he walked in the next morning and ordered a PCA pump for her.

    This is a true example from a TMA PHR Committee consultant.
       

    Inappropriate or Disruptive?  Persistent, repeated inappropriate behavior can be a form of harassment and, thereby, become disruptive and subject to treatment as “disruptive behavior”   

    Examples of inappropriate behavior:

    • Personal sarcasm or cynicism
    • Deliberate lack of cooperation without good cause
    • Deliberate refusal to return phone calls, pages, or other messages concerning patient care or safety
    • Intentionally condescending language
    • Intentionally degrading or demeaning comments regarding patients and their families, nurses, physicians, hospital personnel, and/or the hospital
    • Belittling or berating statements
    • Name-calling
    • Use of profanity or disrespectful language
    • Inappropriate comments written in medical records
    • Blatant failure to respond to patient care needs or staff requests   

    Intimidation and Fatal Error  

    • Poor handwriting on medication order
    • Physician contacted, but is irritated at being awakened and does not answer the nurse's question
    • Nurse misreads the order and administers a fatal dose of the wrong drug  

    A rookie nurse working the night shift gets a medication order she cannot read, and calls physician at home at 2 am for clarification.  Irritated at being awakened for a minor question, the physician yells at nurse and hangs up without answering the question.

    Intimidated, the nurse is afraid to call back and takes the best guess about his handwriting.  Unfortunately, the young nurse misreads the order and administers a fatal dose of the wrong drug.

    The hospital is looking into this incidence as a medication error issue and to analyze their process.  However, another problem is bubbling to the surface: the abusive behavior of some physicians.
      

    This vignette would be a sentinel event, requiring JC disclosure. 

    Disruptive Behavior

    • Physically threatening language directed at anyone in the health care environment
    • Physical contact with another individual that is threatening or intimidating
    • Throwing instruments, charts, or other items  

    Consequences

    • Patient care issues
    • Workplace issues
    • Impact on physicians  

    There are several possible ways disruptive behavior can impair patient care.

    Inappropriate ventilating of emotions deflects the attention of the physician from patient care, resulting in errors in clinical judgment and performance.

    Disruptive behavior of one physician can impair the effectiveness of the entire health care team.  For example, staff may be so anxious or intimidated in the face of a physician’s disruptive behavior that they may lose their usual clinical focus and productivity.  Other times, these colleagues may veer from their usual course of professional activity, going out of their way to avoid the physician who is displaying disruptive behavior.

    Communication breakdown can result in delays or mistakes in making and implementing critical medical decisions.  Often these errors then result in another and escalated round of inappropriate behavior.

    The consequences of disruptive behavior include: (1) decreased morale in the workplace, (2) increased level of workplace stress, (3) inordinate time spent by staff appeasing or avoiding these physicians, (4) increased risk for errors, and (5) increased potential for malpractice litigation and/or Board action.
      

    Addressing Disruptive Behavior

    The initial goal is to help the physician assume accountability for the disruptive behavior and acknowledge that he or she is at least part of the problem.   

    It may become necessary to refer the physician for a formal assessment.  Disruptive behavior may or may not overlap with a psychiatric diagnosis and/or other impairment.


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