The healthcare consequences of disruptive physician behaviour
In our last blog post, we reviewed the different ways disruptive behaviours manifest in healthcare. In this post, we will take a closer look at how such behaviours impact on healthcare and patient safety. Lucian Leape and John Fromson, in their paper titled Problem Doctors: Is There a System-Level Solution?, argue that disruptive, intimidating, or abusive behaviour increase the chances of human error, and this is partly because other members of the healthcare team avoid interacting with the disruptive physician, or they may hesitate to ask them for help, or decline to ask them to clarify their instructions. The disruptive physician’s colleagues may also be reluctant ‘to make suggestions about patient care’ to them. More directly, the disruptive physician’s behaviour may divert the physicians from paying attention to their patients thereby impairing their clinical judgment and performance. Equally worrying is the effect of witnessing disruptive behaviour on patients – a sight that ‘undermines their confidence in the physician and the institution, as well as their willingness to partner in their own care’.
Alan Rosenstein and Michelle O’Daniel, in their paper titled Managing Disruptive Physician Behavior: Impact on Staff Relationships and Patient Care, also explored the effect of disruptive physician behaviour on other healthcare members. In their survey of more than 4,500 healthcare practitioners, 75% reported that they had witnessed disruptive physician behaviour, and this was most frequent in general surgery, cardiovascular surgery, neurosurgery, orthopaedic surgery, and obstetrics & gynaecology; it was less evident in medical specialities, of which cardiology, gastroenterology, and neurology featured highest. The authors argued that disruptive behaviour threatens patient safety when team members become unwilling to approach disruptive physicians about clinical matters ‘in fear of provoking an antagonistic or hostile response’.
Victoria Bradley and colleagues looked at the impact of a specific type of disruptive behaviour they labelled destructive communication. Exploring this in a paper titled Sticks and Stones: Investigating Rude, Dismissive and Aggressive Communication Between Doctors, they defined destructive communication as rude, dismissive, and aggressive (RDA) communication. To estimate the frequency of this in healthcare, they surveyed more than 600 healthcare workers in 3 teaching hospitals in England, and found that a third were exposed to destructive communication ‘multiple times per week or more often’. They also found that rude communication was most frequent in radiology, general surgery, and neurosurgery, and, disturbingly, 40% of the doctors reported that RDA communication ‘moderately or severely affected their working day‘. The authors explained that rude communication is often a coping strategy that some doctors use in response to such factors as ‘workload, lack of support, hierarchy, and culture’; they however stressed that ‘the expression of rudeness is likely to be counterproductive‘.
In their own assessment of rude behaviour, Arieh Riskin and colleagues explored its impact on physician performance in their paper titled The Impact of Rudeness on Medical Team Performance: A Randomized Trial. They carried out a training simulation with 24 neonatal intensive care unit teams, and they found that the teams that were deliberately exposed to rude comments performed significantly worse in diagnostic and procedural measures than the teams that were exposed to neutral comments. The authors therefore concluded that rudeness impairs performance, and they noted that this is partially because it interferes with working memory. They further remarked that their findings probably underestimate the trueimpact of rudeness on performance which they believe occurs more frequently, and more intensely, in real practice.
Bullying is another common disruptive behaviour which impacts healthcare. Bradley and colleagues addressed this familiar disruptive behaviour which they distinguished from disruptive communication. They defined bullying as ‘a more persistent and power-based form of abuse most commonly occurring within a department’. They characterised it as one of the ‘negative workplace behaviours‘ that is detrimental to patient safety. Bullying, they explained, impacts on victims by causing ‘increased levels of stress and depression‘ and by evoking ‘a desire to leave medicine‘. Perhaps more significantly, the authors argue that ‘this kind of adverse staff interaction leads to worse patient outcomes and can represent a patient safety threat‘.
Elisabeth Paice and colleagues also looked into the consequences of bullying behaviour on doctors in training in their paper titled Bullying among doctors in training: cross sectional questionnaire survey. Their survey revealed that ‘most negative behaviours were perpetrated by other doctors in a pecking order of seniority, although nurses and midwives were also targets of bullying by junior grade doctors. They pointed to the evidence that ‘workplace bullying is associated with stress, depression, and intention to leave‘, noting that bullying has ‘potential impact on staff health, retention, and patient care‘.
having explored the epidemiology of disruptive behaviour, we will turn our attention in the next blog post, to the question of whether there is an error-prone personality.