The nature and scale of physician bad behaviour

We have now concluded our review of the cognitive foundations of human error, and we will start our exploration of the behavioural foundations of human error. In this section, we will look at the psychological and personality factors that drive human error with an emphasis on disruptive physician behaviour. Other themes we will explore are healthcare etiquette, emotions, and burnout. In this post however, we will focus on what constitutes bad physician behaviour, and how widespread it is in healthcare.

Angry. Phil Whitehouse on Flickr.

We will start with the illustrative story of orthopaedic surgeon Hank Goodman which Atul Gawande narrated in his excellent book Complications: A Surgeon’s Notes on an Imperfect Science. Atul Gawande used Goodman’s story to illustrate the ‘behavioural sentinel events‘ which often manifest in error-prone physicians, and which eventually culminate in patient safety incidents. These behaviours which Goodman had demonstrated included:

  • Persistent poor anger control
  • Abusive behaviour
  • Bizarre or erratic behaviour
  • Transgression of professional boundaries
  • A disproportionate number of complaints or litigation
Angry boy. Dushan Hanuska on Flickr

Whilst prominent ‘bad apples‘ like Goodman are few, they however have a disproportionate impact on patient safety. To emphasise this, Robert Wachter, in his book Understanding Patient Safety, cited data to show that only 5% of US doctors accounted for more than 50% of litigation payouts between 1990 and 2002. Such doctors, symbolised in the most extreme by the mass murder physicians Michael Swango and Harold Shipman, are indeed the exception in healthcare, but they are the visible tip of a huge iceberg of dangerous physician behaviours which equally compromise patient safety. Lucian Leape and John Fromson, in their paper titled Problem Doctors: Is There a System-Level Solution?, estimated that 3-5% of physicians manifest disruptive behaviour as defined by abusive behaviour which ‘interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care‘. 

Counterproductive health behaviour. CREST Research on Flickr.

In tracing the roots of disruptive physician behaviour, Lucian Leape and colleagues, in their paper titled The Nature and Causes of Disrespectful Behaviour by Physicians, identified three major factors:

  • Ingrained personality traits such as insecurity and aggressiveness
  • Stressful health care environments
  • Hierarchical hospital cultures which tolerate and reinforce disrespectful behaviour

They also discussed the ways by which disruptive behaviours threaten patient safety. For example, they demonstrated how such acts as the ‘everyday humiliations of nurses and physicians in training’ and the’ passive resistance to collaboration and change‘ can have destructive healthcare consequences, partly because they impair teamwork and undermine morale. They further illustrated how the bad behaviour of just one individual can have wide-reaching repercussions, asserting that ‘a single disruptive physician can poison the atmosphere of an entire unit‘. 

Charging bull – New York City. Sam Valadi on Flickr.

In a major breakthrough in acknowledging the scale of disruptive physician behaviour, The Joint Commission set out a Sentinel Event Alert in 2008 on Behaviours that Undermine a Culture of Safety. The alert explained how intimidating and disruptive behaviours can create ‘an unhealthy or even hostile work environment‘. The alert also listed a wide range of behaviours that the Commission deemed to be disruptive, and these included:

  • Verbal outbursts
  • Physical threats
  • Refusal to perform assigned tasks
  • Uncooperative attitudes
  • Reluctance or refusal to answer questions, return phone calls or pages
  • Condescending language or voice intonation
  • Impatience with questions

The alert also identified some personality traits that increase the likelihood of exhibiting disruptive behaviour, and these are:

  • Self-centredness
  • Immaturity
  • Defensiveness
  • Poor interpersonal, coping, or conflict management skills
Anger. Saurabh Vyas on Flickr.

To demonstrate a fuller range of disruptive physician behaviours, Grena Porto and Richard Lauve, in their paper titled Disruptive Clinician Behavior: A Persistent Threat to Patient Safety, added the following examples:

  • The use of profane or disrespectful language
  • Name-calling
  • Sexual comments or innuendo
  • Inappropriate sexual and non-sexual touching
  • Racial or ethnic jokes
  • Throwing instruments, charts, or other objects
  • Criticising other caregivers in front of patients or other staff
  • Comments that undermine patients’ trust in other caregivers or the hospital
  • Comments that undermine the self-confidence of other caregivers
  • Failure to adequately address safety concerns raised by another caregiver
  • Intimidating behaviour that suppresses the input of other team members
  • Deliberate failure to adhere to organisational policies
  • Retaliation against members of the healthcare team who report or investigate violations
Anger. Patrick Nygren on Flickr.

To provide a structure to understanding disruptive physician behaviour, several groups have tried to classify the behaviours. Leape and colleagues for example classified them into six

  • Disrespectful behaviour
  • Passive disrespect
  • Systemic disrespect
  • Humiliating and demeaning treatment of nurses, residents, and students
  • Passive-aggressive behaviour
  • Dismissive treatment of patients

The classification by Michael Housman and colleagues, in their paper titled Measuring Disruptive Behavior: The Disruptive Behavior Questionnaire, is into five broad groups and these are illustrated by key examples:

  • Divisive behaviours
    • Intentionally excluding others from the group
    • Talking about people behind their backs
    • Treating new people harshly
  • Intimidating behaviours
    • Setting others up to fail
    • Bullying
    • Publicly humiliating others
  • Disrespectful behaviours
    • Yelling
    • Turning away before a conversation is over
    • Hanging up the phone before a conversation is over
  • Inhibiting behaviours
    • Using a personal phone in ways that interfere with work
    • Failing to respond to phone calls, pages, and/or requests
  • Offensive behaviours
    • Touching people in overtly sexual ways
    • Making comments with sexual, racial, religious or ethnic slurs
    • Showing physical aggression such as grabbing, throwing, hitting, and pushing
CC BY 2.0, Link

We have now seen the breadth and scope of disruptive healthcare behaviours. In the next blog post, we will explore, in more detail, the impact of these behaviours on patient safety.

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