The disruptive doctorBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h3553 (Published 20 October 2015) Cite this as: BMJ 2015;351:h3553
- Marika Davies, medicolegal adviser, Medical Protection Society,
- Mark Dinwoodie, director of education, Medical Protection Society
Efforts to improve patient safety often focus on identifying and dealing with systems errors, but individual doctors’ poor behaviour can also put patients at risk. Marika Davies and Mark Dinwoodie consider the impact of the disruptive doctor on patients and colleagues
Many doctors have witnessed an angry outburst by a colleague. A one-off incident may be unsettling, but a repeated pattern of such behaviour can be demoralising and detrimental to the functioning of a healthcare team. The National Clinical Advisory Service (NCAS), which advises healthcare managers and NHS organisations on how to deal locally with concerns about the performance of doctors, says that a considerable proportion (59%) of the concerns it sees contain a behavioural or conduct component. These have “a significant and detrimental impact on team relationships and patient care,” it says.1
The NCAS 2011 annual conference focused on the issue of disruptive behaviour, recognising the growing body of evidence on behavioural concerns in doctors. In 2012, NCAS published a set of best practice guidance to help NHS organisations deal effectively with concerns about a doctor’s behaviour.1
In the United Kingdom there is no standard definition of disruptive behaviour by a doctor, and the NCAS guidance relies on a definition from the College of Physicians and Surgeons of Ontario, Canada. This definition says: “Disruptive behaviour occurs when the use of inappropriate words, actions or inactions by a physician interferes with his or her ability to function well with others to the extent that the behaviour interferes with, or is likely to interfere with, quality health care delivery.”2 Examples of disruptive actions or behaviour may extend to angry outbursts, bullying, or throwing objects (see box). The American Medical Association describes disruptive behaviour as “personal conduct, whether verbal or physical, that negatively affects or that potentially may negatively affect patient care.”3
Impact of disruptive behaviour
Lucian Leape, adjunct professor of health policy at Harvard School of Public Health, and colleagues say that disruptive doctors are found in almost all hospitals, and although only 5% or 6% of doctors fall into this category, their detrimental influence far outweighs their numbers.4 A single disruptive doctor can poison the atmosphere of an entire unit, they say.
The adverse impact of a disruptive doctor is widespread, affecting colleagues, the functioning of the team, and patient care. NCAS warns that doctors who behave badly can cause alarm, distress, and anger in those working around them. The distraction of a disruptive doctor will divert attention from patient care and so put patients at risk. The recipients of disruptive behaviour are at increased risk of making errors: rudeness has been shown to affect an individual’s ability to perform tasks.5
Colleagues will try to avoid a disruptive doctor, and so may not seek help or clarification of instructions when they should, and they will also avoid making suggestions about patient care. A doctor who is disruptive may also become increasingly professionally isolated as colleagues seek to avoid them.
The team as a whole suffers when one of its members is disruptive, as an effective team requires communication, mutual respect, and trust. The detrimental effect on the collaborative working of a team is also a barrier to improving patient safety. Poor morale or a hostile working environment make it harder to retain staff, and disruptive behaviour impacts on the learning environment of students, who may learn to emulate such behaviour. Complaints and claims from patients are also more likely.
Disruptive behaviour is caused by a combination of factors related to the individual and their environment. A doctor’s personality might lead to conflict with others or they may lack the skills to express an alternative opinion in a constructive way.6 Some individuals lack the ability to override their impulsive responses to challenging or provoking situations.
Underlying mental health issues, such as depression, bipolar disorder, or substance addiction, may also cause disruptive behaviour. Fatigue, physical illness, and domestic stresses could also be contributing factors.
The working environment is important as difficult relationships with colleagues, inadequate staffing, and pressures of workload can all contribute to the development of poor behaviour. Leape and colleagues consider one of the major factors leading to disrespectful behaviour to be the stressful environment of modern hospitals, particularly the requirement to see high numbers of patients. They also point out that a doctor who has previously been a victim of disruptive behaviour may emulate that behaviour in stressful situations, thus continuing the cycle.
Tackling disruptive behaviour
The NCAS guidance includes practical steps on how managers can categorise a concern, engage with the doctor involved, and manage and resolve the issue. Behavioural concerns, once identified, should be dealt with early, it says. The guidance recognises the need to identify underlying health issues and personal circumstances, describes how to engage with the doctor concerned, and highlights the importance of offering them support. The organisational response, it says, must be demonstrably fair and consistent with the way all staff are treated.
A guidebook for managing disruptive physician behaviour, published by the College of Physicians and Surgeons of Ontario, says that if an institution is to take conduct concerns seriously it must make it as easy as possible for doctors and other staff to report them.2 Similarly, guidance from the Medical Council of New Zealand says employers should make it clear that disruptive behaviour is unacceptable and develop policies and processes to manage such behaviour. It says that employers should make sure that all staff are aware of behavioural expectations and the reporting process. All complaints should be assessed to determine whether a problem is caused by disruptive behaviour, underlying causes should be considered, and action should be taken to tackle the problem.6
Hickson and colleagues at Vanderbilt University Medical Center, USA, suggest four graduated interventions for managing unprofessional and disruptive behaviour: informal conversations for single incidents; non-punitive “awareness” interventions when a pattern is identified; leadership developed action plans if patterns persist; and imposition of disciplinary processes if these fail.7
Roland Gray, medical director of the Physicians Health Programme in Tennessee, USA, says that, for disruptive doctors to be rehabilitated they must be willing to take some responsibility for their behaviour.8 Self regulation is an important part of being a healthcare professional. Doctors must look at themselves closely, see the disruptive behaviour, and grasp its consequences.
“Unfortunately, disruptive doctors do not seem to learn from their mistakes, because they cannot admit that they have made any,” Gray says. He suggests that disruptive doctors would benefit from educational courses on anger management, conflict resolution, sensitivity training skills, and impulse control training. Peer monitoring or a leave of absence may be needed, and institutional discipline may be necessary in some cases, he says.
Leape and colleagues say that institutions should work to create a culture of respect.9 They recommend a code of conduct that sets out the expectations of the institution and is supported at its highest levels. The core institutional value, they suggest, is that everyone is entitled to be treated with courtesy, honesty, respect, and dignity.
Examples of disruptive behaviour2
Inappropriate, profane, disrespectful, insulting, demeaning, or abusive language
Shaming others for negative outcomes
Demeaning comments or intimidation
Inappropriate arguments with patients, family members, staff, or other care providers
Boundary violations with patients, family members, staff, or other care providers
Gratuitous negative comments about another physician’s care
Passing severe judgment or censuring colleagues or staff in front of patients, visitors, or other staff
Outbursts of anger
Behaviour that others would describe as bullying
Insensitive comments about the patient’s medical condition, appearance, or situation
Jokes or non-clinical comments about race, ethnicity, religion, sexual orientation, age, physical appearance, or socioeconomic or educational status
Inappropriate actions and inactions
Throwing or breaking things
Refusal to comply with known and generally accepted practice standards, such that the refusal inhibits staff or other care providers from delivering quality care
Use or threat of unwarranted physical force with patients, family members, staff, or other care providers
Repeated failure to respond to calls or requests for information or persistent lateness in responding to calls for assistance when on-call or expected to be available
Repeated and unjustified complaints about a colleague
Not working collaboratively or cooperatively with others
Creating rigid or inflexible barriers to requests for assistance or cooperation
Competing interests: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.