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

Physician Executive, Sept-Oct, 2004 by David O. Weber

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."