Disruptive behavior is hard to spot and can undermine a culture of safety. What do you do if it happens to you?
It is a typical afternoon at your practice, and you are reading an image from your latest patient. You’ve nearly finished when suddenly your colleague, Dr. X, stands and roughly turns off his monitor.
He mutters inappropriate remarks on the way out, slamming the door. Later, you overhear him chewing out one of the technologists — while she is with a patient.
Actions like Dr. X’s aren’t pretty, and they aren’t helpful. Not only has Dr. X interrupted your reading time, he has disrupted the technologist and at least one patient.
What’s in a Name?
Dr. X’s aggressive behavior is certainly rude and disconcerting, but it also undermines the safety culture by disrupting team members while engaged in their work. Other types of unprofessional behavior or performance may be even more common, according to James W. Pichert, PhD, co-director of the Center for Patient and Professional Advocacy at Vanderbilt University.
While most individuals associate some of the more recognizable actions — yelling, throwing things, or harassment — with disruptive behaviors, more passive acts can also qualify. Failing to follow policies, being passive-aggressive, spreading rumors, and failing to communicate with other members of the health care team can also undermine a culture of safety.
Disruptive behavior is more common — and can be a larger problem — than you might at first believe. In a 2011 survey on disruptive physician behavior, 70 percent of the 840 physicians surveyed stated that they encountered disruptive behavior at least once a month. Ten percent noticed it on a daily basis. More than 25 percent admitted to engaging in disruptive behavior themselves at least once during their career.
With such prevalence comes cost — usually in the form of staff turnover and medical errors, says Pichert. If an individual creates a negative environment, staff are bound to leave, and rehiring can be an expensive and time-consuming process. Those who don’t leave may be stressed or upset, increasing the likelihood of a mistake. Ultimately, Pichert adds, the practice may face not only an increased risk for the patient but also potential lawsuits due to adverse outcomes associated with slips and lapses that occur when professionals are distracted or disrupted by unprofessional behavior.
Besides staff turnover, disruptive behaviors fail to create a culture of safety and quality care. Approximately 7 percent of medical errors are due to disruptive physician behavior, according to a recent article by James V. Rawson, MD, FACR, Norman Thompson, MD, MBA, FACR, Gilbert Sostre, MD, and Lori Deitte, MD, FACR.3 Because these errors are so preventable, Rawson and his colleagues estimate that a disruptive physician’s annual cost to a typical 400-bed hospital is $480,000. When you combine that with staff turnover, medication errors, and procedural errors caused by disruptive behaviors, by addressing them, Rawson estimates that same hospital could save over a million dollars annually.
In addition to its effect on the workplace, disruptive behavior for radiologists could mean a delay in diagnosis or failures of communication among physicians, resulting in poor decision making.
Finding a Solution
The literature identifies various ways management should address disruptive physicians (and others) and their behavior. Suggestions include establishing a code of conduct, setting up reporting procedures, and educating staff about such behavior, the code of conduct, and related procedures that ensure quality care. Rawson says that leaders should also establish a clear resolution when disruptive behavior occurs, whether it is simply a face-to-face discussion with the physician in question or a mandatory training session.
But what if you are the one in a position to report concerns about another professional’s behavior? Some may fear retaliation from the reported physician or worry that nothing will come of the report, allowing issues to go unresolved. You shouldn’t let those fears stop you if you see an incident, says Rawson. “When you make a complaint in a hospital or health system for patient safety or compliance, retaliation is prohibited. If someone does retaliate against you, they are probably putting their job or even their career in jeopardy.”
Pichert adds, “Ultimately, a culture of safety is made of people’s willingness to trust an organization and speak up without overwhelming fear. That means the leadership must also make it absolutely clear that everyone knows they have a willing ear and want people to speak up.” (To read more about error reporting, please visit the January Bulletin).
Getting to the Point
Whether you are reporting an incident, speaking to a colleague about some behavior that appears to be unprofessional, or addressing the issue in your role as a leader, the language is the same. “Be objective,” says Rawson. “Present it in a straightforward manner. Tell them the events as they happened or as they were explained to you in a patient complaint.”
If this is not an issue that happens frequently, you may feel that it is better to speak directly to your disruptive colleague. For example, in the opening scenario, you might consider having what the Center for Patient and Professional Advocacy calls an informal, respectful, collegial “cup of coffee” conversation. This approach is simply a short and tothe- point conversation. It is not about correcting the individual. The goal is to let the physician or staff member know that the behavior was observed and did not appear to be consistent with the organization’s values (code of conduct) or with its commitment to high quality teamwork with patients and colleagues.
When preparing for the meeting, plan how you will address the issue. There is a good chance that you may feel awkward or embarrassed, and preparation can help alleviate that. It is also important to stay calm and focused — you will be most effective if you are brief and concise. Also, try to choose a neutral, private location where you will both feel comfortable.3
It is also important to balance empathy and objectivity. “Use passive language,” says Pichert. Returning to the opening scenario, for example, you might begin, “Dr. X, may I have a couple minutes of your time? I observed something I don’t understand. First, I sensed you were unhappy when you smacked your monitor and slammed the door to our reading room, and I couldn’t help overhearing when it seemed you were yelling at a technologist in the presence of a patient. Help me understand.”
After listening to Dr. X’s side of the story, you might respond, “I can appreciate why you might have felt that way, but I also know your commitment to professionalism and to our organization’s values. I’m just not sure our technologist, the patient, or others in our reading room will understand your commitment. You are important to us, and that’s why I felt the need to share the observation. Well, we’re both busy, so thank you for this minute of your time.” If the positions were reversed, asks Pichert, wouldn’t you want a colleague to share the observation in an informal, non-punitive, non-authoritarian fashion and give you an opportunity to reflect and consider alternatives?
There are many potential reactions to a conversation about disruptive behavior. Most physicians take the message with dignity and understanding. However, be prepared for finger-pointing, denial, defensiveness, or even tears. “These conversations are very individual,” says Rawson. Often, the individual does not connect a poor outcome to a problem with their behavior. “They don’t see a connection with their behaviors and adverse outcomes for patients or the work environment,” he says.
If your colleague does not respond positively, there are several actions you can take. In these situations, Rawson recommends that practice leaders help physicians gain insight into the fact that there is a problem. He shows them literature, such as a 2008 Joint Commission report on the topic, or articles that demonstrate staff turnover or errors due to disruptive behavior. You may also want to show them the policies that your hospital or practice has created that outline these behaviors as unacceptable. What Rawson ends up saying most is this: “You are a valuable member of the team, and we’d like you to be here long-term. But you have a behavior that is not consistent with you being here long-term.”
No matter how you think the physician may react or what misgivings you have about the situation, you should always address disruptive behaviors. By responding to a situation that undermines quality care, you are working toward creating a better environment for everyone — your patients, your colleagues, and the disruptive individual as well.
By Meghan Edwards