Poll results: doctors' disruptive behavior disturbs physician leaders; Survey reveals ongoing problems with physicians yelling at nurses, refusing to carry out tasks and showing a severe lack of respect for others.

They're out there ... browbeating nurses and pharmacists, dressing down hapless staff, belittling patients to their faces, swearing at the tops of their voices, muttering ominous threats, dripping sarcasm and snide innuendo, slouching in late day after day, raging, sulking, hurling surgical instruments, blowing off appointments, sabotaging meetings, sneering at administrators, insulting their colleagues, refusing to answer pages, addling their judgment with drink or drugs, breaching sexual boundaries, "climbing into bed with an overdose patient in the ICU" ... oh yes, you name it, no matter how outrageous, one of them is pretty sure to have done it ... because....

They're out there: The Problem Docs.

More than 95 percent of physician executives who responded to a recent survey by the American College of Physician Executives reported encountering these disturbing, disruptive and potentially dangerous behaviors on a regular basis.

In fact, one in three of the more than 1,600 survey respondents said they observe "problems with physician behavior" either weekly (14 percent) or monthly (18 percent). And an unfortunate 3.4 percent reported daily breaches of the institutional peace by a problem doc.

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"This is the most difficult aspect of being a physician executive," commented a respondent. "I find it really distasteful to have to counsel a 'renegade' physician."

From overt to subvert

Every one of the transgressions listed above was mentioned specifically as having been witnessed by respondents to the survey.

To be sure, they agreed, in general terms it is simply "disrespect" that is the most common form of physician misbehavior roiling their organizations. Disrespectfulness among doctors, which covers a multitude of sins, was cited as a source of problems by almost 83 percent of respondents, and chronicled in more unpleasant nitty-gritty in their comments.

More than half of those surveyed--51 percent--said "refusal to complete tasks or carry out duties" was another typical ignition point. Forty-one percent cited "yelling" and 37 percent "insults." Only 9 percent agreed that "physical abuse (including throwing items)" is a typical occurrence. But almost 14 percent described "other," less readily classifiable, bad behaviors--like the outrageous ICU incident.

Paradoxically, the graver the offense, the easier it may be to deal with. As the medical director of an 8,000-physician network health plan observed, "egregious behaviors (sexual misconduct, criminal behavior, fraud and other unprofessional behavior) ... are often grounds for suspension or termination."

Substance abuse, which might readily explain a serious lapse in conduct--and at least carries a clear-cut course of corrective action--accounts for no more than 10 percent of the physician behavior problems in their organizations, the respondents overwhelmingly reported.

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Almost half said alcohol or drugs played no part whatsoever in the problems they've encountered. Just 5 percent said addictions are linked to more than a tenth of occurrences.

No, it's the nagging, grating, low-level stuff that a preponderance of physician executives said gives them heartburn.

"Physician disruptive behavior can range from overt to subvert," wrote one. "The subvert behavior is the hardest to deal with because the offenders oftentimes have well devised excuses/explanations that make it very hard to [take] action."

The executives strongly agreed that it is really just a few bad apples who are to blame. Fully 70 percent of survey respondents reported that "physician behavior problems at my organization nearly always involve the same [people] over and over again." Fewer than 30 percent reported that problems "crop up among various physicians from time to time with no clear pattern."

A good summation was provided in this extended comment:

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"Most physicians are emotionally well-developed and find a way to be kind and respectful even in times of great stress. In other words, they behave as doctors should behave, and they do so always and throughout their careers.

"I think significant behavior issues fall into two categories. First is the category of one-time offenders in the setting of unusual stress. These people are generally ashamed of their behavior after they settle down, and they rarely repeat.

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"Second is the far more trouble-some category of people who repeatedly violate many boundaries, including workplace rules and ordinary social norms. They are, over the course of time, globally disruptive. Some repeaters suffer alcoholism, depression, dysthymia, etc. However, many, if not most, [have] diagnosable personality disorders.

"We have a horrible track record in our own profession of even recognizing physicians with personality disorders, much less dealing effectively with them. In fact, amazingly, we make excuses for them like, 'He's such a good doctor; his patients love him!' or 'He just has a surgical personality.' My personal favorite excuse for abuse is, 'He holds others to his own high standards!' When I see that one on a reference, the application goes into the garbage can."

Concluded the writer: "Every physician executive should have a refresher course on the psychopathology of personality disorders and on dealing with disruptive physicians."

Blunt criticism

Hospitals and physician practices are hierarchical settings; those at the top of the hierarchy--and indeed those who are alphas in the sub-hierarchies--have often felt a need to parade their status.

Haughtiness, intimidation and self-indulgent outbursts, especially but not exclusively among doctors, have always featured prominently in the history of medicine.

As one respondent observed, "Physicians too often feel they are above rules, regulations, behavioral standards and other day-to-day social etiquette, as they feel they are a privileged class."

And so, not surprisingly, those below them on the totem pole--nurses, physician assistants and other supporting members of the health care cast, at least from the physician's perspective--are most likely to bear the brunt of a problem doc's wrath, according to the survey.

Well over half of respondents said problematic interpersonal conflicts that involve a physician most often have a coworker with less professional clout on the receiving end.

Only 14 percent of respondents said the arguments and fights break out among doctors.

Indeed, clashes with those who assist them, either clinically or administratively, account for the majority of physician behavior problems. Frustration and a sense of vulnerability "due to changes within the organization" are the primary rub according to 26 percent. Almost the same percentage identified refusal to "embrace teamwork" as the principal issue.

Only 4 percent of respondents attributed significant problems to "turf battles among physicians." (Eight percent listed "other" causes as foremost and those ran the gamut from "miscommunication" of the clinical diagnosis to the straightforward description of the problem such as: "He's a jerk.")

In fact, the physician executives who took part in the survey were surprisingly blunt in their assessments of their peers.

"Lots of arrogant, immature snots [are] practicing medicine," wrote one.

"Some people never reach adulthood," suggested another, "Unfortunately, many of them are physicians who, when under stress, behave as adolescents."

"Sometimes in dealing with my docs," mourned a weary respondent, "I am reminded of what Caligula said: 'Would that the citizens of Rome had one neck, that I might hang them all!'"

Not that survey respondents were totally lacking in sympathy for the small minority of their professional colleagues who succumb to pressures or provocations by venting inner demons.

"In my experience," wrote one, "most are reasonable people, deficient in interpersonal and emotional intelligence competencies and under tremendous stress."

Enough to test a saint

Several respondents suggested that physician comportment in general is much better these days. Others disagreed.

"The problem seems to be worsening," wrote one, synthesizing the bleaker view, "as many docs are asked to do more with fewer resources and they tend to lash out at anyone within striking distance. As finances get tighter there seems to be a larger disconnect between docs and administration as well."

"This has been a chronic problem that is acutely getting much worse," agreed another. "The stress of our jobs (I am a surgeon) is increasing due to the decrease in reimbursement for professional activities, increasing regulatory requirements and severe financial constraints placed upon the hospitals in which we must practice."

Agreed a third: "Economic pressures (malpractice premiums, etc.) that threaten their very ability to stay in practice have made the docs more irritable and short-tempered than I have ever seen before."

Again and again, survey respondents outlined backdrops to physician misbehavior that test even the saintliest among them:

* "This is a difficult time for physicians with flat or declining income, rising expectations, rising office overhead, and diminished autonomy. Professionalism has sagged. Physicians are depressed about their loss of control and enormously frustrated by the complexity of the health care system. They bristle at the need for regulatory oversight and have a great deal of difficulty with any non-physicians mandating any kind of activity or behavior, clinical or otherwise. Their frustration boils over all too easily."

* "In our organization, most problems with physician behavior seem to stem from stress and frustration, either with dealing with difficult patients (pain management patients demanding drugs, patients with mental illnesses), or dealing with the frustrations of working in a bureaucratic organization with limited resources."

* "There is also the issue of employees (often nurses) having very little 'resiliency' and immediately complaining to administration about relatively minor physician behavior problems that human beings should be able to work out among themselves."

* "All my docs are voluntary physicians in a community hospital. I have noticed over the past few years a decreasing willingness to support the hospital or even feel part of it, and reluctance to be a part of a team seems to be growing. I suspect a lot of this is due to the hits that physicians are taking in society in general, from Medicare, MCOs and the trial bar, and the hospital is the easiest and closest place for them to act out. Since the hospital has some empty beds, it is difficult to be extremely aggressive with some physicians whose behavior is episodically problematic. Also, with the nursing shortage and many per diem and agency nurses, physicians don't have the same bonds with nursing, team building is difficult and often seen as 'not worth it' and nurses themselves are only acting as 'task doers' rather than professionals involved as part of a team. So the professional environment breaks down on all sides."

Breaking the code

If in some mythical Golden Age physicians were accountable to no one but Asclepius, the Greek god of medicine and healing, it's obvious those days are long since past.

More than 70 percent of the organizations represented by respondents to the survey--primarily hospitals, large group practices, health care systems and academic medical centers--adopted a written code of behavior that physicians must adhere to. Eighty percent said they established a formal disciplinary process to be followed when doctors are accused of violating behavioral norms.

Nearly 90 percent of the physician executives who answered the ACPE survey reported that they are responsible for investigating complaints about physician behavior in their organizations. Two-thirds are charged with enforcing behavior policies and almost three-quarters personally coach doctors who get into trouble. Almost unanimously they expressed gratitude for black-and-white rules and disciplinary procedures to govern physician misconduct--or lamented their lack.

"A three-stage disruptive MD policy, used by the chief of staff when patient care is not at risk, enables our credentials committee to take action. It is worth its weight in gold!" exclaimed one.

"We tie maintaining privileges to performance and behavior," reported a second. "Disruptive physicians who will not learn to be civil and professional 'voluntarily relinquish their privileges.' Performance and behavioral expectations are clearly defined and physicians sign at initial credentialing and at each reappointment that they have read and will comply with these expectations."

Summarized a third: "One of our biggest institutional problems was that our previous policy had too many 'options' and side channels which would allow the chair to stop the process, stall indefinitely, or repeatedly give final warnings over and over and over.... Once they were removed, the process became more rigid, but freed the chair from being accused of showing favoritism. Options lead to inconsistency, and set dangerous precedents. A rigid policy actually protects the chair by removing his discretion and avoiding complaints of not being equally strict."

Several respondents credited ACPE continuing education courses for opening their eyes to the need for such policies. "Your course, 'Managing Physician Performance,' helped me understand the importance of developing and enforcing standards for physician behavior," wrote one. "Since we have done that more consistently, we have less nursing staff turnover and higher employee satisfaction."

Nevertheless, there are still a number of organizations where doctors have adamantly and successfully blocked implementation of a formal behavior policy, the survey found. Two physician executives reported that they had actually been ousted from their jobs for trying to overcome that obstinacy.

"Medical staff protect physicians," observed one of them "Three attempts to initiate [a] disruptive physician policy were met with stonewalling ... [and my] attempt to ... involve [the] board of directors [in] developing an ethics committee were dismissed--as was I (without cause)."

Said another: "The organization I was with until 1/2004 did not have a physician nor employee harassment policy. The word 'on the street' was: if we had a policy, we'd have to enforce it. I believe I was fired because I tried to hold [a] small group of physicians--who represented substantial revenue to the hospital--accountable for their behavior."

Some walk, others crawl

Survey respondents were remarkably divided in their perceptions of the evenhandedness of enforcement of physician codes of conduct.

Forty-six percent said the rules are invoked uniformly, no matter the status of the offending doctor; the same percentage said application is selective. Some 7 percent said the codes of conduct are not enforced at all.

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At the same time, 61 percent disagreed that "physicians in my organization who generate high amounts of revenue are treated more leniently when it comes to behavior problems than those who bring in less revenue." Nevertheless, favoritism was a recurrent theme in the comments:

* "Nothing ever happens to the most abusive physicians, because they bring in too much money."

* "The worse offenders are the ones in power and [with] friends on our Board of Directors."

* "The surgeons are permitted to act out more because they generate more money and there is the perception that 'this is just how surgeons behave.'"

* "There is ... a two-tier system, the high earners and the rest of us.... The analogy I like to use is Animal Farm: "Some walk upright, the rest of us crawl!!!"

Summarized one executive: "Bad behavior on the part of physicians is the single biggest impediment to improvement of our work environment, improved quality of care and better fiscal integrity. My organization consistently avoids placing any constraints on bad-behaving physicians who are either academically accomplished, big revenue generators or who bring lots of patient volume to the hospital. The tradeoff is a culture that allows physicians to be rude, disrespectful, unhelpful and just plain nasty with no meaningful repercussions. I think this is the most destructive sort of political decision making...."

Indeed, fully half the survey participants acknowledged that problem docs are only reported in their organizations when they're "completely out of line and a serious violation occurs." Twenty-nine percent believe breaches in their organizations are under-reported because employees fear reprisals. Only one in five said staff "readily" reports incidents.

And in fact, almost two-thirds were convinced that physicians in their organizations are "treated more leniently than other employees because of their professional stature."

Only a little more than a quarter saw the reaction to a behavior problem as being "exactly the same" no matter what the offender's job description. And 9 percent suggested that physicians at their organizations are "treated more harshly and held to a higher standard of behavior than other employees."

That minority viewpoint was expressed in the comment: "Because it is easy and RNs (and other paramedical personnel) are encouraged to report perceived behavior problems, many physicians now feel victimized. They feel even more pressured to explain their actions because of the perception that it is not 'politically correct' to side with the physician."

Tailoring the punishment

All but a handful of the survey-takers reported that within the last two years they'd given a problem doc a good talking to. (The precise terminology used was "met with a physician to discuss their behavior problem[s];" 94.5 percent said they'd had to do that.)

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Two-thirds issued a written warning. Just over half ordered a doctor to seek counseling. About a third each had either terminated a physician or, at the other extreme and in all candor, "tried to ignore a problem and didn't take any action."

More than 100 other punitive recourses were listed--suspension of privileges, probation, report to the state licensing board, enforced leave of absence, practice restrictions, even legal action.

In a few cases problem docs were fined or threatened with a fine, or had their salaries reduced. But overall, only 17 percent of respondents said their organizations had any direct links between physician compensation and appropriate behavior.

How effective were the interventions in this grab bag?

About a quarter each of respondents judged that their organizations' attempts to correct physician misbehavior were successful either 26-50 percent of the time or 51-75 percent of the time. A particularly skillful 14 percent claimed a 75-100 percent success rate. At the opposite end of the spectrum, six percent of respondents doubted their organizations had curbed a problem doc's worst tendencies more than 5 percent of the time--at best.

But as a great many of the physician executives who commented on the survey emphasized, improper conduct can range from a momentary burst of pique to habitual and flagrant malfeasance. And the settings in which disruptions occur vary enormously.

"Three to five [incidents per year] is a different metric for small offices than for large [organizations]," pointed out one respondent.

Explained another: "[Hospital] physicians often are treated differently (including more leniently) not because of their professional status but because they are private volunteers (medical staff members) and NOT employees. Medical staff bylaws are not the same as employee HR policies.... The medical staff is more akin to a PTA (volunteers) working with employees (teachers and principal) for the good of students (patients). Disciplining PTA parents for poor performance is different--different rules/fewer options/etc.--than disciplining the teachers."

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Interestingly, only one respondent to the survey admitted to having once been a problem doc himself.

"Being a physician executive has not made me immune," he wrote. "... I was fortunate to have had my own issues addressed with great professionalism and with sensitivity by two of my colleagues ... and I appreciated the clarity with which they established parameters of performance balanced by their wish to see me through my difficulties.

"In all of my dealings with colleagues since that intervention," he continued, "I have tried very hard to adopt a similar posture. I can honestly say that I have become a more effective leader since I have identified the source of my own prior personal poor behavior, and I feel that I owe my professional career to the patience of these two supervisory colleagues. I have learned from them not to tolerate inappropriate actions from any physician, but rather to attempt vigorously to get those physicians to understand themselves better and to take the necessary steps to carry themselves more professionally."

Yes, they're out there, those problem docs. But they're not all lost causes. As one respondent put it, the troubles with disruptive behavior were much worse in the past. "Behaviors that would have been covered up or tolerated 15 years ago would not last five minutes now!... Things are improving!"

Generally speaking, problems with physician behavior occur within my
organization:

                            Response    Response
                            Percent     Total

Once or twice a year          17%         276
3 to 5 times a year           24.1%       392
More than 5 times a year       9%         309
Monthly                       18.1%       294
Weekly                        14.1%       230
Daily                          3.4%        56
Never                          4.3%        70
Total Respondents                        1627
(skipped this question)                     8

[c]ACPE 2004 Physician Behavior Survey

Typically, problems with physician behavior at my organization involve:

                                               Response  Response
                                               Percent   Total

Refusal to complete tasks or carry out duties    51.7%     803
Physical abuse (including throwing items)         9%       140
Insults                                          36.6%     568
Disrespect                                       82.6%    1284
Yelling                                          41%       637
Other                                            13.5%     210
Total Respondents                                         1554
(skipped this question)                                     81

[c]ACPE 2004 Physician Behavior Survey

Physician behavior problems at my organization:

                                                  Response  Response
                                                  Percent   Total

Crop up among various physicians from time to       29.7%     457
time with no clear pattern
Nearly always involve the same physician(s) over    70.3%    1080
and over again
Total Respondents                                            1537
(skipped this question)                                        96

[c]ACPE 2004 Physician Behavior Survey

When a problem with physician behavior arises, it MOST OFTEN involves
conflict between a physician and:

                                               Response  Response
                                               Percent   Total

Another physician                                14.7%     229
A nurse or nurses, physician assistants, etc.    56.5%     878
Members of the administration                    14.5%     226
A patient or patients                            14.2%     221
Total Respondents                                         1554
(skipped this question)                                     81

[c]ACPE 2004 Physician Behavior Survey

The MAJORITY of physician behavior problems in my organization stem
from:

                                                   Response  Response
                                                   Percent   Total

Conflicts between physicians and staff members       36.1%     562
(including nurses)
Turf battles among physicians                         4.3%      67
Physicians who refuse to embrace teamwork            25.4%     395
Physicians who are feeling frustrated and            26%       405
vulnerable due to changes within the organization
Other                                                 8.1%     126
Total Respondents                                             1555
skipped this question)                                          79

[c]ACPE 2004 Physician Behavior Survey

We have a WRITTEN code of behavior at my organization.

                           Response    Response
                           Percent     Total

Yes                         71.7%        1115
No                          28.3%         440
Total Respondents                        1555
(skipped this question)                    80

[c]ACPE 2004 Physician Behavior Survey

As a physician executive at my organization, I am responsible for:
(Check all that apply)

                                                     Response  Response
                                                     Percent   Total

Developing physician behavior codes and policies       49.9%     689
Enforcing physician behavior codes and policies        69.1%     955
Training physicians about behavior codes and
policies                                               50.5%     698
Coaching physicians who exhibit improper behavior      73.7%    1019
Investigating complaints about physician behavior      87.7%    1212
Carrying out disciplinary action against               60.2%     832
physicians with behavior problems
Teminating physicians with behavior problems           40.6%     561
Total Respondents                                               1382
(skipped this question)                                          253

[c]ACPE 2004 Physician Behavior Survey

If you answered "Yes" to having a behavior code, do you think it is
enforced:

                         Response    Response
                         Percent     Total

Uniformly                 46.3%        505
Selectively               46.4%        506
Not at all                 7.2%         79
Total Respondents                     1090
(skipped this question)                539

[c]ACPE 2004 Physician Behavior Survey

I believe physician behavior problems in my organization are most
likely:

                                                   Response    Response
                                                   Percent     Total

Under-reported because employees fear reprisals      29.5%       458
if they report a physician
Only reported when a physician is completely         50.3%       781
out of line and a serious violation occurs
Readily reported by the staff                        20.2%       313
Total Respondents                                               1552
(skipped this question)                                           83

[c]ACPE 2004 Physician Behavior Survey

Physicians in my organization generally are:

                                                  Response  Response
                                                  Percent   Total

Treated exactly the same as other employees when    27.6%     426
a behavior problem is reported
Treated more leniently than other employees         63.2%     977
because of their professional stature
Treated more harshly and held to a higher            9.2%     143
standard of behavior than other employees
Total Respondents                                            1546
(skipped this question)                                        88

[c]ACPE 2004 Physician Behavior Survey

In the last two years, my organization has taken the following
actions to address physician behavior problems:

                                                      Response  Response
                                                      Percent   Total

Tried to ignore a problem and didn't take any action   31.3%       486
Met with a physician to discuss their behavior         94.5%      1465
problem(s)
Issued a written warning to a physician                67.7%      1050
Ordered a physician to seek behavior counseling        53.4%       829
Terminated a physician                                 36.4%       565
Other (please specify)                                  6.5%       101
Total Respondents                                                 1551
(skipped this question)                                             84

[c]ACPE 2004 Physician Behavior Survey

Attempts to intervene and correct physician behavior at my organization
are successful:

                         Response  Response
                         Percent   Total

0%-5% of the time          6.1%      92
6%-10% of the time        11.3%     172
11%-25% of the time       18%       274
26%-50% of the time       25.3%     385
51%-75% of the time       25.5%     388
75%-100% of the time      13.8%     209
Total Respondents                  1520
(skipped this question)             115

[c]ACPE 2004 Physician Behavior Survey

RELATED ARTICLE: Voices of dissent

Just two of the 1,627 members of the American College of Physician Executives who responded to the online survey on physician behavior problems took bitter exception to its very premise.

One said: "Physicians are not perfect, never have been, never will be. ACPE is becoming part of the problem, NOT part of the solution. ACPE has become a pawn and its rhetoric has become a tool to be wielded and abused against high-quality physicians (and ultimately patients) by corporate practitioners and even criminals who have invaded health care."

The other offered a more extended critique: "I do not think that this is a valid survey because it focuses only on the behavior of the physician.... The hospital setting is literally a Pandora's Box of personalities who will at one time or another affect the physician's patient.... If their behavior is obtuse, critical, professionally immature and this behavior is encouraged or not checked by the administration, then the care of the patient will be compromised. The physician will not be able to practice to his ability and his behavior toward the staff may be affected....

"Perhaps," the writer continued, "there should be trained and professionally licensed behavioral psychologists strategically set on the turf who can identify problems in a positive way to ensure that the personnel are mutually supportive in the interest of the patient. Perhaps they should be on the floor when the patient rings for an hour for a bedpan, or when the dietary aide removes the untouched tray from the sick patient before he has had any assistance in eating it. The hospital is full of cruelties that should be corrected and monitored. Administrators cannot correct them from their wood-paneled offices. [They] have to be there! Do you not think that these omissions affect the spirit, if not the behavior, of the physician caring for that patient? When the physician is terminated, who will feed the patient in that hospital?

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"Let's all be Human if not Divine, and let's have communion," she urged. "Let's solve our problems the old fashioned way. Let's all talk and be civil. This focus on physician behavior is wrong, unrealistic and biased.... I believe there is no such thing as a disruptive physician; rather there is disruption within the hospital. This campaign against the physician must be halted...."

--David O. Weber

David Ollier Weber is a freelance health writer and frequent contributor to this journal. He can be reached by e-mail in Mendocino, Calif., at [e-mail]