Physician leaders play an essential role in addressing the disruptive behaviour of physicians in their institutions and, as such, should be aware of the impact of such behaviour and know how to handle these difficult situations effectively.

 

Although only a very small number of physicians exhibit recurrent disruptive behaviour, such behaviour can have a serious impact on patients and families, other physicians and health care providers, and the workplace environment. The Canadian Medical Protective Association (CMPA) shares the perspective that disruptive behaviour by physicians should be addressed by the health care institution where the conduct occurs. Health care institutions are well positioned to attend to these matters, given their knowledge of any given situation, their workplace, and the individuals involved. Top

 

Leaders can foster a culture of respect and address disruptive behaviour by establishing clear expectations, modeling first-rate professional behaviour, and emphasizing positive values and behaviours throughout the organization. Promoting civility is also important.1 Establishing a workplace culture and providing regular feedback (both formal and informal) to professional staff can help physicians gain insight and understand the impact of their behaviour on others.

 

Physician leaders should communicate their organization’s expectations for professional behaviour and establish and communicate a clear, tiered approach and response to incidents of unprofessional behaviour. Physician leaders should also be involved in monitoring physician behaviour, which may include direct observation and team member evaluations. Top

 

Approaches to address disruptive behaviour

 

When occurrences of disruptive behaviour become known, physician leaders must take appropriate steps aimed at managing the issue, assisting the physician to improve his or her behaviour, decreasing the risk of medical-legal consequences, and improving the workplace. A tiered approach that educates and improves behaviour and, where appropriate, keeps the physician in practice through remedial actions is preferred.

 

Isolated, non-egregious behavioural incidents are best handled with an informal “coffee cup conversation” between the physician in question and a colleague or, in some circumstances, his or her direct supervisor. Such simple feedback will often lead to insight and positive behavioural change. Top

 

Recurrent disruptive behaviour generally requires intervention by the direct physician supervisor and should include communicating the impact of unprofessional behaviour, documenting the intervention in the personnel file, and setting expectations for change.

 

A pattern of persistent disruptive behaviour requires escalation to a higher level of authority and a documented action plan with clear deliverables, timelines, and consequences if behaviour does not improve. Physicians unable to change and improve their behaviour in spite of a staged or tiered remedial approach could then face significant disciplinary intervention.2 Top

 

At the institution level, workplace assessments may uncover contributing factors or triggers, such as human, financial, or informational resource issues, excessive workload, lack of engagement in decision-making, and competing interests. Efforts to address these types of issues can be very effective.

 

Physician leaders should also cultivate a culture of respect that includes providing regular feedback to physician staff. Although collegiality and mutual respect cannot be imposed, leaders can send a strong message about the importance of medical professionalism.3 Top

 

Reporting physicians

 

Physician leaders should be familiar with the legislation and college policies in their province or territory that deal with reporting physicians. Most statutes or policies require that there be reasonable grounds for reporting; however, the triggering criteria can vary considerably among jurisdictions. Doctors may have a legal duty or ethical responsibility to report a physician colleague to a health care institution, public health agency, or college when there are reasonable grounds to suspect that patients might be at risk due to a physician’s mental or physical health or where privilege suspensions or other practice restrictions are imposed.

 

Failure to report may heighten the risk of a legal action or complaint if that failure can be linked to a patient safety incident that resulted from an unreported doctor’s incapacity, health status, or behaviour. In most cases, it is preferable for the physician leader to inform the other doctor why the report must be made. Demonstrating support and empathy toward the colleague may be helpful. Top

 

Resolving conflicts

 

Conflict among physicians or between physicians and others can strain teamwork and have an impact on the delivery of care. When physician leaders become aware of colleagues in conflict, they should attempt to address the issue and recommend helpful resources.

 

Demonstrating and encouraging mutual respect is the best way to cultivate a positive workplace environment with minimal conflicts, whether among staff or with patients. The professionalism displayed by physician leaders should set an example for other health care providers. Top

 

Handling legacy complaints

 

The principles of natural justice and fair process are equally important when a physician assumes a new leadership role. For this reason, physician leaders who are new in their positions and who inherit historical complaint files need to consider a measured approach.

 

There should generally be continuity and consistency in the way such files are handled by the leadership of the facility. Consider, for example, whether it would be fair for a new physician leader who learns of a complaint regarding a doctor’s behaviour to write a strongly worded letter to the doctor without first determining what steps have already been taken by the previous administration. In most cases, a preferred approach in these circumstances is to gather existing information about the incident or complaint, determine what action has already been taken and whether the matter still needs to be pursued, plan next steps, and proceed fairly. Top

 

Consider, as well, a situation in which a new physician leader learns about historical concerns regarding a doctor who has allegedly been disruptive for many years. Where the previous administration chose not to take any action against the doctor in response to such issues, would it be fair for the new physician leader to criticize or penalize the doctor for past behaviour in the absence of any new complaints?

 

Without a new complaint, an immediate sanction based on previously unaddressed complaints would not be considered fair process. This is because the doctor would not have been given the chance to improve his or her behaviour. If there has been no new complaint, but the new leader is aware of multiple previous complaints, it may be quite appropriate for the physician leader to advise the doctor of the concern citing the previous history. Depending on the circumstances, it may be suitable to advise the doctor of the unacceptable behaviour and caution that a recurrence of the behavior could result in disciplinary action. Thus the doctor would be given a chance to correct the behaviour. On the other hand, if a new complaint is filed, the facility’s established procedures for responding to such complaints should be followed.  Top

 

Support from the Canadian Medical Protective Association

 

The CMPA monitors changes in the law and in the medical practice environment, as well as evolving leadership models. Physician leaders should ensure that they have the appropriate liability protection for their specific role in their institution, including liability protection that may be provided by the hospital or regional health authority.

 

Physicians in administrative roles within health care institutions should generally expect liability protection from their institution. Members with questions are welcome to contact the CMPA to speak with a medical officer. Top

 

References

1.Kaufmann M. The five fundamentals of civility for physicians: initiating an important conversation — series introduction. Ontario Med Rev 2014;March. http://php.oma.org/PDF%20files/Five%20Fundamentals/Fundamentals.pdf

2.Hickson GB, Pichert JW. One step in promoting patient safety: addressing disruptive behaviour. Physician Insurer 2010;Fourth quarter:40-3.

3.Sanchez LT. Disruptive behaviors among physicians. JAMA 2014;312(21):2209-10.

 

Authors

James Sproule, MD, is managing director of physician services at the Canadian Medical Protective Association (CMPA).

Tracy Murphy is senior policy advisor at the CMPA.

 

Correspondence to: tmurphy@cmpa.org

 

This is the second of three articles written by the Canadian Medical Protective Association (CMPA) for physician leaders. The topics are: natural justice and fair process; professionalism and managing physicians who exhibit disruptive behaviour; and the physician leader’s role in managing patient safety incidents. More information on all these topics can be found in the CMPA’s Medico-legal Handbook for Physicians in Canada (2015). https://www.cmpa-acpm.ca/en/legal-and-regulatory-proceedings/-/asset_publisher/a9unChEc2NP9/content/a-medico-legal-handbook-for-physicians-in-canada

 

The CMPA also has a discussion paper on The role of physician leaders in addressing physician disruptive behaviour in healthcare institutions. https://www.cmpa-acpm.ca/documents/10179/24871/13_Disruptive_Behaviour_booklet-e.pdf

 

 

This article has been reviewed by a panel of physician leaders.

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