Comments on: How hospitals should deal with disruptive physician behavior

By: David Deitsch, RN

David Deitsch, RN — Mon, 28 Sep 2009 20:33:57 +0000

Dr. Simon, as a nurse, I feel like I should be praising your article, but I cannot, and the reason that I cannot is, in part, because of the football player illustration with which you begin your article. In the example you site, the individual punches someone in the face, a potentially dangerous assault (especially when carried out by a young, fit athlete). You then argue for sanctions against such things as verbal abuse, which though always regrettable, is hardly comparable. In fairness, you do acknowledge this in your call for “clearly delineated standards,” “punishment reflective of the severity of the offense,” and “stepwise consequences.” You are obviously a fair-minded individual. My concern is that, in the real world of hospital life, less reasonable heads might not do as admirable a job of parsing out the details in cases where the accusation is as vague as “being disruptive.” The vague nature of the charge will tend to do what might be implied in your choice of allegory: homogenization of all misbehavior to the point that too little distinction will be made between rudeness (a sad but universal human vice) and throwing a scalpel (a potentially dangerous attack of a sort that few physician will ever commit). I also cannot ignore the absence of any mention of an effort to assist to a physician who may be presenting with the initial signs of physical or mental illness, or simply being briefly overwhelmed and in need of collegial support. Now I might not be being fair in that last observation, as you were emphasizing a different point, and may have simply decided not to mention that as a way to keep your article brief, which is understandable. However, this is, I think, an important consideration.

Best wishes, sir.

By: Doc Stone

Doc Stone — Wed, 23 Sep 2009 00:43:45 +0000

When we speak of genuinely disruptive physicians (not those who disrupts the hospital owners attempt to make more money by neglecting quality of care), we are talking about bullies.

Bullies have to be stood up to and held accountable not just by the authorities, but by the victims who need to be supported in that. The teacher can’t be the final solution. I have seen nurse bullies, clerical bullies, and administrative bullies in hospitals as well.

By: Doc99

Doc99 — Mon, 21 Sep 2009 20:31:43 +0000

“Disruptive physician” can be used as code for “troublesome whistleblower.”

By: annieRN

annieRN — Mon, 21 Sep 2009 19:56:08 +0000

If you ask a nurse the definition of a disruptive physician,
it would be verbal or physical abuse directed toward the nursing staff or trainees, usually behind the closed doors of the OR. Some actions I have witnessed would be no less than battery in any other arena. But in a medical setting, it is tolerated, ignored or swept under the rug. If there is a wistleblower, you can bet their days are numbered. And any witnesses asked to verify the incident would be reluctant to do so for fear of losing their job. It’s just part of the culture.

By: Dr. Mary Johnson

Dr. Mary Johnson — Mon, 21 Sep 2009 19:43:44 +0000

Dr. Simon, respectfully, I’ve been preaching “physicians police your own” for six years in this blogosphere.

And I’m eleven years beyond “potential”.

Likewise, the doctors featured in the P-PG “Cost of Courage” (excellent link, ninguem) series are way beyond “potentially” destroyed.

The AMA and JCAHO (and USDHHS for that matter) have known that administrative abuse of the “disruptive physician” diagnosis (I hesitate to call it that) by hospitals has been a problem FOR YEARS. Yet these so-called advocacy and regulaotry bodies have turned their noses up (and their backs on) the problem.

For instance, my own situation, as long-standing as it is, could be resolved and cleaned-up – RIGHT NOW – with a few well-placed phone calls from the Federal agencies with jurisdiction. It hasn’t happened because our government (for all of the “hope & change” being preached by Obama) just doesn’t care.

I note you are an OB – a hospitalist. I could tell you a couple of really ugly tales about two OB-Gyns I used to know.

In the first story, the hospital adored the guy (a fine clinician) – execs winked and nodded at everything he did – no matter how destructive to morale. But it wasn’t about “stature” (part of the story is that his stature – by virtue of his behavior – was on the downswing – his head was just too inflated to realize it). It was about the MONEY he brought into their coffers. Ultimately, he was brought low by the Medical Board (for a heinous ethical lapse that I won’t describe here). Once that happened, it was amazing how quickly he got dumped.

In the second story (involving another OB), the little/rural hospital KNEW that there were BIG behavioral and clinical problems – but had to face/kick down every roadblock known to man in order to stop him – because our legal and medical systems are so screwed up. It took two years and more very bad medical badness to get the Medical Board to move.

Meanwhile, there’s what happened to me (visit Dr. J’s Housecalls) – for the act of intervening and reporting badness.

There does not seem to be a happy medium in any of this.

The problem we have right now is that previous sweeping “reforms”, in the form of HCQIA and HIPAA . . . where no one was paying attention to the details – or giving serious thought to the “unforseen consequnces” such inattention might bring to bear . . . have made it impossible for physician discipline to be applied evenly and fairly.

You’re right that someone is going to do it for us. But my gut is telling me they will do it with no more foresight or thought than those who came before.

By: Mark N. Simon, MD

Mark N. Simon, MD — Mon, 21 Sep 2009 18:21:43 +0000

Thanks to all that have taken the time to read and comment on this piece. I would certainly agree that there is the potential for the misuse of the label “disruptive” physician. I am by no means trying to say that keeping someone in the hospital for an extra day is an example of disruptive behavior.
What I was trying to illustrate is that there are physicians, and we all know these people, who display truly disruptive behavior in the hospital or in the office. These people verbally abuse (or worse) nurses, staff, or other physicians. Sometimes medical staff leadership (not hospital administration) is unwilling to address this behavior because of the stature of the physician involved. My piece tried to illustrate how in a different arena (in this case college football), a leader acted with more courage than is sometimes encountered in our profession.
I hope that our profession can do a better job of policing truly abusive and distruptive physician behavior. If we don’t, someone will do it for us.

By: ninguem

ninguem — Mon, 21 Sep 2009 16:21:17 +0000

http://www.post-gazette.com/pg/03299/234499-84.stm

“The Cost of Courage” a series by Steve Twedt of the Pittsburgh Post-Gazette. Abuse of the label “disruptive physician” and the peer-review laws, has been going on for some time.

Read the series if you have not seen it before.

By: DocbLawg

DocbLawg — Mon, 21 Sep 2009 16:13:54 +0000

I agree with the other comments and I disagree with the analogy between the college football player and physician privileges. What is a “disruptive physician”? The definition of those terms is a potential mine field for the practitioner. If a physician acts beyond the hospital’s expectations, then he/she is labled “disruptive”. If a physician doesn’t dictate his notes within a specified period of time, he/she is a “disruptive” physician. If a physician raises his/her voice to staff during a tense moment, he/she is a “disruptive” physician. It is quite easy to fall into the category of “disruptive” physician, especially if the hospital administration already has you on its hit list. So, a “disruptive” physician is a definition at the whim of the hospital administration. It doesn’t matter how good you are, when the administration is against you, you better act with caution. Another caveat, once you get on the administration hit list and your privileges are called into question, do not resign or take a leave of absence, demand your hearing on the matter before the ethics committee, and get attorney representation because it may be the only way your side of the story will get heard in a timely manner.

~DocbLawg

By: alex

alex — Mon, 21 Sep 2009 00:16:53 +0000

“Disruptive” increasingly means “anything the hospital doesn’t like” and ESPECIALLY “anything bad for the hospital’s $$$”. Naturally, well meaning but stupid legislators and bureaucrats have given hospital boards the ability to turn these disputes between provider and hospital into something that can affect the doctor’s permanent record and thus are useful as a cudgel. Nice national database record you got here, shame if not wanting to take extra ED call were to make something happen to it… This is why I look forward to the day that I drop admitting privileges.

So long, suckers. Last one out turn off the lights.

By: David

David — Sun, 20 Sep 2009 23:20:12 +0000

Mark,

Could you please be more specific about ‘disruptive’ physician behavior? I am as concerned about poor behavior on the part of physicians as anyone – but my concern is that certain ethical behavior has been classified as ‘disruptive behavior’ by hospital administrators in an effort to control them. For example, physicians who want patients to stay longer in the hospital because they don’t think it is in the patient’s best interests to leave to sooner, or physicians who believe that hospital practices, in a certain manner, are dangerous and call the administration’s attention to this fact. I could see how such physicians might be viewed as a ‘thorn in the side’ of the hospital, but that is a far cry from being unethical. At least with respect to these types of issues, hospitals should simply be more honest and state that length of stay issues are an important part of the way Medicare pays them, and therefore, they will be enforcing certain rules with respect to that variable. Or that certain safety issues, while addressable in the long run, are not important enough in the current fiscal environment to address. This avoids the use of misleading labels for ethical physicians yet makes the hospital’s position clear.