For safety's sake disruptive behavior must be tamed

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

MOST PHYSICIAN BEHAVIOR PROBLEMS come down to "'bad hair days' and generate sincere apologies," wrote one of the 1,627 physician executives who took part in the ACPE online survey.

But 1,565 nurses, 354 pharmacists and 176 other hospital workers surveyed last November by the Institute for Safe Medication Practices (ISMP) in Huntingdon Valley, Pa., were not so sanguine.

During that year, according to nine out of 10 of them, they experienced subtle or overt intimidation from a doctor.

In the former category they listed "condescending language or voice intonation" (88 percent); "impatience with questions" (87 percent); and "reluctance or refusal to answer questions or phone calls" (79 percent).

So okay, maybe nurses and other role-players on the health care team need to develop thicker skins. That's what several respondents to the ACPE survey hinted.

Wrote one: "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."

But wait. Almost half the nurses and pharmacists polled by the ISMP said they'd experienced rather more vigorous intimidation: "strong verbal abuse" (48 percent); "threatening body language" (43 percent), even "physical abuse" (4 percent).

Now, doctors weren't the only intimidators, emphasizes ISMP vice president Judy Smetzer, RN, BSN. But they were the major offenders--twice as likely as non-physicians to dismiss a query about a medication (two thirds of the ISMP survey respondents said they'd been squelched by the retort, "Just give what I prescribed" at least once during the year) and quick with threats to report someone to a manager for having the temerity to vocalize even a moment's doubt about a doctor's acumen.

Here's what's really frightening about that picture, Smetzer says. It's not that hair gets ruffled on the health care team, or that noses get out of joint--it's that half the respondents to the ISMP survey said they had felt pressured into dispensing or giving a drug when they harbored serious doubts about its safety. Two out of five admitted they held their tongues rather than risk setting off a known intimidator--and 7 percent reported they'd been involved in a medication error during the past year as a direct result.

"We're part of the national medical error reporting program," observes Smetzer, "and we know that when a fatality occurs, almost always somebody knew it was wrong. Someone felt it in their gut."

Many physician executives who participated in the ACPE survey observed that problem docs cost their organizations significant amounts of money by driving away scarce personnel.

"Younger nurses especially do not tolerate this kind of behavior, and readily exit the system when faced with it." warned one. (Recruiting and training a single medical/surgical RN replacement costs $46,000 at a minimum, the VHA estimates, and studies indicate 20 percent of nursing turnover in hospitals is attributable to clashes with doctors.

But killing patients is the most serious potential problem of ineptitude in interpersonal relations, and many ACPE survey respondents made a point of that.

"We view [physician behavior] as a safety issue," as one put it. "An employee who is intimidated may be reluctant to question an order or action when by doing so an error might be avoided."

In the wake of its survey, the ISMP has sketched out a tentative map for changing the "culture of intimidation" in health care. Suggested steps include:

* Establishing a diverse steering committee drawn from all levels of the organization--top to bottom--to explore and define intimidation. The ISMP proposes a simple one: "not being treated with respect, or any behavior, no matter how small, that causes another to doubt their self-worth."

* Creating a code of conduct to be signed by all staff when hired and again each year.

* Surveying staff attitudes about intimidation and how they handle it, as a consciousness-raiser.

* Opening a dialogue using objective moderators.

* Establishing a standard, assertive communications process. Some suggested features include using a first name to capture attention when important information has to be conveyed; or adopting a code phrase like "red light" to signal that behavior is going too far.

* Establishing a conflict resolution process. One facet might be a "two-challenge rule"--used in other industries where safety is a paramount concern--under which any question that is not answered must be posed again, and if still not answered must automatically be referred to a third party for resolution.

* Encouraging confidential reporting.

* Enforcing zero tolerance, but confronting offenders with "data, authority and compassion" rather than punishment.

* Providing ongoing education and training.

* Rewarding outstanding examples of collaborative teamwork.

* And, of course, as always: Leading by example.