2017 HSC Section 2 - Practice Management

Academic Radiology, Vol 20, No 9, September 2013

THE DISRUPTIVE PHYSICIAN: A LEGAL PERSPECTIVE

to complete their training, and to obtain licensure and Drug Enforcement Agency certification. Subsequently, it is reason- able to ask what factors may trigger disruptive behavior in this group of individuals. One can cite many ‘‘common sense’’ reasons such as over- work, family strife, a dysfunctional working environment, supervisor pressure, and anxiety. Some authors believe that the ‘‘normal’’ stress of medical practice has been compounded by large educational debt loads for graduating physicians, increasing malpractice premiums, decreasing reimbursement, and the pressure to see more patients in a shorter amount of time (2) . According to one recent survey, ‘‘This is a difficult time for physicians with flat or declining income, rising expectations, rising office overhead, and diminished autonomy. Physicians are depressed about their loss of control and enormously frustrated by the complexity of the health care system. They bristle at the need for regulatory oversight and have a great deal of difficulty with any non-physicians mandating any kind of activity or behavior, clinical or other- wise. Their frustration boils over all too easily’’ (3) . An underlying physical, mental, or behavioral disorder causing physician impairment may provide an explanation for new-onset disruptive physician behavior. The AMA defines physician impairment as, ‘‘any physical, mental or behavioral dis- order that interferes with ability to engage safely in professional activities’’ (21) . The 2000 AMA Report of the Council on Ethical and Judicial Affairs addresses the subject of disruptive behavior and physician impairment (22) . It states, ‘‘Whether the disruptive behavior is the manifestation of an underlying pathology or not, it is important that it be addressed. In some instances, processes that already are established for grievances or for dealing with impaired workers may be expanded or may serve as models to address disruptive physicians’’ (22) . Of note, the term physician impairment has sometimes been inappropriately applied to physicians who have returned to good health, are substance-free and in a monitoring program, or have successfully completed a knowledge or skill remedia- tion course. Subsequently, it is not appropriate to label these physicians either impaired or disruptive. Understanding the triggers for disruptive behavior has the potential to prevent or ameliorate such behaviors when managing the high stress medical environment. Moreover, identifying underlying physical or behavioral disorders can address treatable causes of disruptive behavior. IMPACT OF DISRUPTIVE BEHAVIOR Disruptive physician behavior can result in significant medi- cal, economic, and emotional consequences. Examples include disharmony and poor morale, increased staff turnover, incomplete and dysfunctional communication, heightened financial risk and litigation, reduced self-esteem among staff, reduced public image of hospital, and unhealthy and dysfunc- tional work environment (2,5) . The Joint Commission states, ‘‘Intimidating and disruptive behaviors can foster medical errors, contribute to poor patient

satisfaction and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators and managers to seek new positions in more professional environments. Safety and quality of patient care is dependent on teamwork, communication, and a collaborative work environment’’ (23) . One should not underestimate the impact of disruptive behavior on morale. If the coworkers of the disruptive physician see the behavior continue, they assume there was no punishment. This is severely disheartening to those who work hard, follow the rules, and are routinely professional. Most important, problem behaviors can threaten the performance of the health care team and subsequently can adversely affect the safety and quality of patient care (24) . ADDRESSING DISRUPTIVE BEHAVIOR The AMA provides the essential steps an organization should take to deal with disruptive behavior (6) . ( Table 1 ) The Joint Commission suggests 11 actions for addressing disruptive behavior, including adopting a zero tolerance policy (25) ( Table 2 ). Once the ground rules have been established, the hospital’s peer review process must abide by three principles ( Table 3 ). First, they must operate with a reasonable belief that they are improving the quality of patient care (26) . Second, they must only make their decision to revoke or refuse renewal of staff privileges after a reasonable effort to obtain the facts (27) . The relevant inquiry under the second element ‘‘is whether ‘the totality of the process leading up to the professio- nal review action evidenced a reasonable effort to obtain the facts,’’’ not a perfect effort (28) . Last, they must provide a fair hearing. This includes proper notice of the hearing, the reasons for the proposed action and a summary of the physi- cian’s rights at the hearing. The hearing shall be held before an arbitrator mutually acceptable to the physician and the health care entity, before a hearing officer who is appointed by the entity and who is not in direct economic competition with the physician involved, or before a panel of individuals who are appointed by the entity and are not in direct https://www.ama-assn.org/ama/pub/physician- resources/medical-ethics/code-medical-ethics/opinion9045.page . Last accessed July 12, 2013. TABLE 1. Essential Steps that an Organization Should Take to Deal with Disruptive Behaviors as Outlined by the American Medical Association. ! Clearly state which behaviors will not be tolerated. ! Adopt bylaw provisions or policies for intervening in situa- tions where a physician’s behavior is identified as disruptive. ! Establish a process to review or verify reports of disruptive physician behavior. ! Establish a process to notify a physician whose behavior is disruptive that a complaint has been made, allow the dis- ruptive physician to respond to the complaint, andmonitor for improvement after intervention. Accessed at

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