eMJA: Wilhelm & Lapsley, Disruptive doctors

eMJA The Medical Journal of Australia

The Profession

Disruptive doctors
Unprofessional interpersonal behaviour in doctors

Kay A Wilhelm and Helen Lapsley

Disruptive behaviour in the workplace affects patient care and requires active management

MJA 2000; 173: 384-386

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How to handle disruptive behaviour - The growing use of dispute resolution - Prevention - Acknowledgements - References - Authors' details
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"Unprofessional conduct" is a broad term covering behaviours ranging from rudeness to fraud and sexual assault. The idea of a "disruptive doctor" is a North American one, which highlights the doctor whose unprofessional conduct may lead to increased workplace difficulties, decreased morale in other staff and overt or covert decline in patient care.

Disruptive behaviours include repeated episodes of:

sexual harassment
racial or ethnic slurs
intimidation and abusive language
persistent lateness in responding to calls at work.¹

The behaviour of the disruptive doctor does not necessarily lead to patient complaints or referrals to a disciplinary body. However, a survey of patients' complaints to the New South Wales Health Care Complaints Commission suggests that a substantial minority of patients' complaints may be related to disruptive doctors (Box 1).

Several factors are contributing to increasing sensitivity to the disruptive doctor. Patients are better informed and more assertive, complaint mechanisms are more accessible, and junior medical staff are more questioning of the traditional medical hierarchy. At the same time, medicine is practised in an environment of ever-tightening resources and calls for greater accountability. In these circumstances, some disruptive behaviour by doctors may be seen as a distress signal from the medical workplace.

A disruptive doctor may be impaired or incompetent within the terms specified by his/her local medical board (Box 2), but this is not necessarily the case. In about half the complaints about disruptive doctors to US medical boards, the disruptive behaviour indicates episodes of impairment related to substance abuse, bipolar affective disorder, depression, schizophrenia, delusional disorder, delirium or evolving dementia.³ In such cases, disruptiveness may resolve with successful treatment of the impairment.

Temporary causes of disruptive behaviour include sleep deprivation, overwork, poor health or stress related to work or to personal matters. These generally respond to social support and lifestyle changes. More sustained disruptive behaviour may lead to complaints from colleagues about rudeness, lack of empathy or uncooperativeness. Disruptive doctors may fail to meet ethical or clinical standards, or constantly challenge administrative decisions and policy. Disruptive behaviour may be indicated by an increase in critical incidents or problems identified at performance assessments of individuals or teams.

"Disruptive behaviour" is not a diagnostic category, but is a useful concept to draw attention to behaviours that can compromise patient care, both directly and indirectly. These behaviours are often overlooked when there are no mechanisms for dealing with them. Box 3 lists four "disruptive doctor scenarios" in which resort to the regulatory procedures of medical boards would seem inappropriate, but where some response is clearly required (the scenarios are presented with some suggestions for management).

How to handle disruptive behaviour

Informal solutions, such as a "quiet chat", protecting the colleague, diverting patient flow and encouraging the doctor to move elsewhere,⁴ avoid active resolution of the problem, usually to avoid confrontation. These solutions are inadequate if the disruptive behaviour is an established pattern. Traditionally, lack of adequate and relevant documentation has been a consistent problem: incidents that seem minor in isolation may show an unprofessional behaviour pattern if a series of incidents and complaints are documented.

The initial steps recommended for handling disruptive behaviour are:

1. Assess the complaint

2. Assess the behaviour

What is the context and severity of the behaviour?
Is this a single (uncharacteristic) incident or part of a pattern?

3. Determine the response

The growing use of dispute resolution

Mediation is becoming more widely used in both public or private work settings,^5-7 by medical boards and, in NSW, by the Health Care Complaints Commission.^2,8 It is found to be effective in terms of both the financial and emotional costs^7,9 and likely to become a more commonly used alternative. The aim is to find a solution that is acceptable to all parties. The best outcomes are a result of the parties' coming to appreciate each other's point of view.³ Conciliation aims to provide compensation for the wronged party and often involves a medical defence organisation.

Mediation is not always successful and it may be necessary for the employer or a medical board to impose a unilateral code of expected behaviour, with provision for feedback, education and review. It is also "not a substitute for reporting or disciplinary action in the case of suspected impairment or unethical behaviours".¹⁰

Prevention

Some doctors display an exaggerated sense of responsibility, coupled with a tendency to avoid rather than resolve conflict.^5,11 This personality style is not ideal for dealing with disruptive behaviours. Disruptive behaviours may be ameliorated if all doctors learn that good medical practice requires communication and interpersonal skills as well as the demonstration of knowledge and ability.^12,13 Medical schools are introducing professional development as a formal subject within the curriculum. Colleges, medical boards, health services and doctors' organisations need to increase their commitment to ongoing education in interpersonal skills such as giving and receiving feedback, stress and anger management, change management, conflict resolution and team building, all of which are now considered important in large commercial organisations.^14,15 These may have other positive spin-offs for doctors' family lives, as they will also assist in dealing with marital conflict and in negotiating with adolescents.

Acknowledgements

We thank Dr Peter Arnold, Dr Kerrie Breen, Dr Michael Diamond, Ms Geri Ettinger, Dr Jillann Farmer, Ms Penny Johnston, Dr Beth Kotze, Ms Jacqui Milne, Dr Alison Reid, Ms Anne Scahill and Dr Peter Taylor for their helpful comments.

References

Pfifferling J-H. The disruptive physician: a quality of professional life factor. Physician Exec 1999: 56-61.
Daniel A, Raymond JB, Horarik S. Patients' complaints about medical practice. Med J Aust 1999; 170: 598-602.
Summer G, Fleming A, Thomas R. Board prescriptions for disruptive physicians, Federation of State Medical Boards, 87th Annual Meeting, St Louis, Miss, USA, 1999.
Rosenthal M. Promise and reality: professional self-regulation and "problem" colleagues. In: Lens P, van der Wal G, editors. Problem doctors: a conspiracy of silence. Amsterdam: JOS Press, 1997.
Miller M, Wax D. Instilling a mediation-based conflict-resolution culture. Physician Exec 1999; 25(4): 45-51.
Siders C. Conflict management checklist: A diagnostic tool for assessing conflict in organisations. Physician Exec 1999; 25(4): 32-37.
Macken J. Mediation in the field of industrial relations. Aust Dispute Resol J 1997; 8: 158-161.
Gurley A. Conciliation of health care complaints. Aust Dispute Resol J 1997; 8: 168-171.
Martin W. The levers of influence. Physician Exec 1999; 25(4): 8-14.
Andrew L. Conflict management, prevention and resolution in medical settings. Physician Exec 1999; 25(4): 38-42.
Gabbard G. The role of compulsiveness in the normal physician. JAMA 1985; 254: 2926-2929.
Tempelaar A. The problem doctor as iatrogenic factor: risks, errors, malfunctioning and outcomes. In: Lens P, van der Wal G, editors. Problem doctors: a conspiracy of silence. Amsterdam: JOS Press, 1997.
Clark N, Gong M. Management of chronic disease by practitioners and patients: are we teaching the wrong things? BMJ 2000; 320: 272-275.
Klug M. ADR: trends and directions in commercial disputes. Aust Dispute Resol J 1997; 8: 172-176.
Hood A. Commercial contracts, lawyers and alternative dispute resolution: A proactive habit. Aust Dispute Resol J 1998; 9: 129-138.

Authors' details

This article is based on material presented at the Medical Boards Conference in November 1999 examining the relevance of the term "disruptive behaviour" in an Australian context.

School of Psychiatry, University of New South Wales, Sydney, NSW.
Kay A Wilhelm, MD, FRANZCP, Associate Professor.

School of Health Services Management, University of New South Wales, Sydney, NSW.
Helen Lapsley, BA, MEc, Senior Lecturer.

Reprints will not be available from the authors.
Correspondence: Associate Professor K A Wilhelm, Consultation Liaison Psychiatry, St Vincent's Hospital, Sydney, 2010.
kwilhelmATstvincents.com.au

©MJA 2000
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Kay A Wilhelm and Alison M Reid. Critical decision points in the management of impaired doctors: the New South Wales Medical Board program Med J Aust 2004; 181 (7): 372-375. [Confronting Dilemmas – Impaired Do] <http://www.mja.com.au/public/issues/181_07_041004/wil10342_fm.html>

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2: Competence and impairment

The medical boards in Australia do not have a uniform definition of "incompetence" and "impairment". Here, we use the definitions in the New South Wales Medical Practice Act 1992, which defines competence (rather than incompetence) and impairment.

Competence to practise medicine
A person is "competent" to practise medicine only if the person:

has sufficient physical capacity, mental capacity and skill to practise medicine;
has sufficient communication skills for the practice of medicine, including an adequate command of the English language.

Impairment
A person is considered to suffer from an impairment if the person suffers from any physical or mental impairment, disability, condition or disorder which detrimentally affects or is likely to detrimentally affect the person's physical or mental capacity to practise medicine. Habitual drunkenness or addiction to a deleterious drug is considered to be a physical or mental disorder.

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3. Common examples of disruptive unprofessional behaviour

The aggressive senior

A senior doctor, head of a high profile department, is known to bring in research dollars, to be very hard working and adept at specialised medical procedures. S/he is well known for shouting at nurses, throwing instruments back at them, and belittling and humiliating junior medical staff. S/he is often absent from department, but becomes irate when not consulted, even about trivial matters. Complaints are made to hospital administration from staff members; increased numbers of "critical incidents" and staff resignations are noted.

Solution: If the parties consent, an independent mediator gathers background information, then conducts a mediation. A mutually acceptable solution may include such outcomes as acknowledgement of differing views concerning an incident; an apology from one or more parties; recommendations for counselling; education on conflict resolution for the doctor and other members of the team; inclusion of ongoing performance goals and a capacity to monitor performance to provide feedback and follow-up assessments; undertakings from hospital administrators to ensure changes to work practices to alleviate chronic stressors for the whole team. Where there is no clear impairment, there may still be a need for referral for counselling or debriefing for the doctor concerned. (These principles hold for the other scenarios.)

A sexist male

A young registrar with a "great future" comes from a culture where women are not highly valued. There have been numerous complaints from nurses, junior medical staff and patients about his "arrogant" attitude. When the subject is broached with him, he suggests that these comments are simply motivated by racism. Complaints are likely to come to the medical board from patients or to the hospital administration from staff.

Solution: Educational counselling and/or mediation would be appropriate depending on the context. In either case, access to a doctor from the same ethnic background to "interpret" for the doctor and debrief him later would be helpful. Outcomes may include apologies (to patients or staff); mentoring by a senior colleague who understands the cultural issues involved; referral for communication training; setting clear performance indicators to monitor change, with a date set for review and feedback.

A difficult student

A final-year medical student has caused disruptions throughout the course by monopolising time in tutorials, behaving inappropriately with patients and being unwilling to heed advice. Many patients refuse to be interviewed by her/him and have complained to staff. S/he has not failed any exams, but several tutors and nurses have raised concerns about the student's "attitude" and ability to work as an intern.

Solution: An approach is made to the university student affairs coordinator, who meets with the student to ask whether s/he is happy with medicine as a career and to determine future performance indicators. The student is offered assistance through student counselling services and has progress supervised on a term-by-term basis. The student is advised to notify his/her director of clinical training at the start of internship for further assistance.

An unreliable GP

A general practitioner is consistently late or absent for rostered sessions. S/he gives no explanation, leaving the partners to fill in and make excuses. When confronted, s/he becomes abusive in front of office staff and patients. The partners complain to the practice manager (and patients may complain to the medical board).

Solution: The partners meet together (or with an independent mediator) and agree on appropriate professional behaviour and performance indicators for everyone. They agree on regular reviews of the performance indicators, with an understanding that continuing partnership is dependent on meeting the agreed standards. If involved, a medical board may require a health assessment, consider educational or disciplinary counselling or use a mediation process. Some boards will soon have the ability to require a workplace performance assessment.

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