Misbehaving physicians and professional ethics.

The average medical man is an educated gentleman, a delightful
companion, a man of parts, and many such are our best friends. But
doctors, when associated in corporate matters, are oftentimes too
self-seeking. With an eye out for their profession, they are inclined to
be aggressive, and naturally, under such conditions are not a gracious,
peaceful, easily cooperative body of men.
--George H.M. Rowe, MD, Association of Hospital Superintendents, 1902

Agnes Miller, RN, an excellent staff nurse on 3-North, has a problem.

Dr. William Smith's patient in room 322 has suddenly developed a serious post-operative complication that requires immediate transfer to the intensive care unit. Miller does not have the authority to order the transfer, Smith cannot be reached, and the surgeon covering for him is in surgery and cannot call back for three hours.

Miller calls VPMA Dr. John Ames, who has no clinical practice, but is available to help nurses with physician issues. "Get the patient to ICU, now," Ames orders.

Smith returns, picks up his phone messages and learns that his patient has been transferred to the ICU without his prior consent. He immediately goes to the ICU and angrily writes two orders:

"Transfer this patient to the care of Dr. Ames!"

"Cardiology consult STAT."

Smith then takes Miller aside and tells her that if this ever happens again he will see that she is fired.

The vice president of nursing tells Ames about the angry record entry and the insult to Miller. Ames is surprised because Smith is an excellent surgeon. In addition, although Smith frequently disagrees with management, he is an articulate and often helpful dissenting voice, not a troublemaker.

Ames orders the offensive entry purged from the record, gets the whole story from Miller and decides on a strategy for confronting Smith.

First, he contacts the chief of surgery, explains, and says, "May I borrow your authority? I would like to handle this." The chief of surgery is more than happy to stay out of the matter altogether.

Ames then allows an overnight cooling off period. The next day he calls the operating room and leaves a message for Smith, asking him to come by between cases.

When the two meet, Smith immediately says, "John, I guess this is about that childish, idiotic thing I did on 3 North yesterday. I have already apologized to the nurses."

Ames reads the situation quickly and decides that no further action is necessary.

"Dr. Smith, here is what I want to tell you in no uncertain terms. I don't mind you transferring patients to me, but don't you ever order a cardiology consult on one of my patients again. Do you have time for lunch?"

Impatience and frustration

Does this incident sound familiar? Situations like it are commonplace and it is time for physician executives to pay attention to these bursts of anger and arrogance from physicians who are physically and mentally intact, and whose emotions are ordinarily under control.

Outrageous incidents like alcohol or drug abuse or a physical altercation are much easier to handle than these more subtle, infrequent behavior problems that crop up among physicians.

By temperament, by training, by inference (doctors order nurses), and because of their unique God-like importance to sick and injured people, physicians are famous for assuming that impatience, frustration and disrespect are acceptable characteristics.

They are not.

Physicians find several features of today's health care system frustrating. Forty percent of practicing physicians in one survey feel that they are "plagued by bureaucracy, loss of autonomy, diminished prestige and deep personal dissatisfaction." And 40 percent say they would not enter the medical profession if they were deciding on a career today. (1)

Physician frustrations with managed care include heavy paperwork, restrictions on referring patients to colleagues and being urged to design diagnostic workups according to cost instead of patient need.

Physicians are also frustrated with multi-layered management bureaucracy in their organizations. In the ACPE Physician Behavior Survey, respondents report that nearly 52 percent of problems with physician behavior involve refusal to complete tasks or carry out duties. Presumably, this means in part, that physicians do not meet expectations of executives and managers who assign organizational duties. What are we expecting of practicing physicians and how are we expressing our expectations?

In the ACPE poll, nearly 83 percent of respondents reported that physician behavior problems involved disrespect, and 56 percent of problems involved conflict with a nurse or physician's assistant.

Conflict with nurses is sometimes an expression of disrespect. Nursing advocates justifiably ask for the three R's: respect, recognition, and reward. (2) In one sense that means economic respect and is a plea for adequate pay for nurses. Other times nurses resent the fact that physicians feel superior to nurses. Since most nurses are women and most physicians are men, gender issues also come into play in doctor/nurse working relationships.

Some physician disrespect for nurses is actually a manifestation of resentment and insecurity. Doctors must increasingly share the health care stage with nurses and some doctors don't like that at all.

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Ethics of it all

Physicians who display impatience, frustration or disrespect are abandoning their professional ethics. Most professional organizations have written codes of ethics, all of which require some version of competence, dependability, respect, courtesy and diligent effort.

For physicians, part of the professional ethic is putting patients' needs ahead of other considerations. A physician abandoning the professional medical ethic by behaving unprofessionally is ironic, because the same physician might be loudly critical of managed care for abandoning that part of the professional medical ethic that requires putting patients ahead of profit.

In a 1937 code of behavior for interns and residents in training, doctors were encouraged to develop desirable personal habits and attitudes including the following:

* Make promises sparingly and keep them faithfully.

* Praise good work done regardless of who did it. If criticism is warranted, criticize helpfully, never spitefully.

* Preserve an open mind on all debatable questions. Discuss, but don't argue. It is a mark of a superior mind to disagree and yet be friendly.

* Pay no attention to ill-natured remarks about you. Simply live so nobody will believe them. Disordered nerves and poor digestion are common causes of backbiting. (3)

In the ACPE survey, nearly 72 percent of respondents reported having a written code of behavior in their organization. Unfortunately, written codes of personal behavior resemble prominently posted, altruistically worded codes of business ethics. That is, they are nice window dressing but actually have little impact.

Reporting instances of physician misbehavior is an important issue. There is a fine line between demonstrating support for employees, patients and the medical staff on one hand, and on the other hand carefully distinguishing trustworthy reports from tattling, spying and carrying out personal vendettas.

In the ACPE poll, 29 percent of respondents indicated that behavioral problems were under-reported because of fear the physician would retaliate. Sixty-three percent of respondents reported that physicians were treated more leniently than employees because of their professional stature.

In these two matters, the ethical ball is in management's court. If we continue to treat physicians like spoiled children then some of them will continue to act like spoiled children. Expectations of professional behavior should be made clear, although not used as organizational threats.

They should apply to anyone involved with patient care from telephone operators to prima donna practitioners. If you have not yet tried it, you will be amazed to find that such insistence on professionalism wins respect, not ridicule, from those physicians whose opinions really matter to you. (4)

The manner of handling instances of misbehavior must fit the nature of the offense. The true story that opens this column exposes the mistaken belief that management must always take a hard line. Indeed, as a consultant I have encountered situations where a reasonable physician was turned into a behavior problem because he was badly managed by organizational authorities.

In the ACPE poll, talking to the offender was part of the strategy 94 percent of the time. Handling disruptive incidents without causing escalated disruption requires imaginative application of analytical observation skills and productive interaction techniques.

References

1. Zuger A, MD. Dissatisfaction with medical practice. NEJM 350:1, January 1, 2004.

2. Buresh B and Gordon S. From Silence to Voice: What Nurses Know and Must Communicate to the Public. Cornell University Press. Ithica, New York, 2000.

3. Ponton TR. The Medical Staff in the Hospital. Originally published in 1937. Second Edition, revised by Malcolm MacEachern. Physicians' Record Company. Chicago, 1955.

4. Thompson RE, MD. Keys to Winning Physician Support, 2nd Edition. ACPE. Tampa, Fla., 2001.

By Richard E. Thompson, MD

Richard E. Thompson, MD, is adjunct instructor of ethics at Drury University, Springfield, Mo. and president of Thompson, Mohr and Associates. Previously, he was an adjunct instructor of ethics at the Ethics Institute, St. Petersburg College, St. Petersburg, Fla. He can be reached by phone at [phone] or by e-mail at [e-mail]

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