Ethics Commentary: Ethical Responses to the Disruptive Physician

INTRODUCTION

Our professional obligations require that we act “for the benefit our patients,” yet we must also “recognize responsibility not only to patients, but also society, to other health professionals and to self” (1). The issues surrounding disruptive physicians reveal how ethical obligations can be in tension or conflict. Disruptive physicians demonstrate a pattern of impeding or harming patient care, actions that are counter to our professional role as physicians. The disruptive actions can result in delay of appropriate treatment, injury, or death of patients. Our role, as fellow physicians, is to recognize that disruptive behavior is occurring and to take action that would result in the cessation of the disruptive behavior. The goals of this article are to 1) increase awareness of disruptive behavior, 2) understand the differential assessments of disruptive behavior (volitional, impaired, or dyscompetent), 3) appreciate the ethical transgressions against patients and staff, 4) encourage a fair process in the assessment of the possible disruptive physician, and 5) encourage taking appropriate administrative steps to address the disruptive physician.

With attention to patient safety and appropriate clinical care, imagine that you witness the conduct of the following physicians. How would you start to think about what is improper and what action should be taken?

VIGNETTE 1

Dr. A, a 55-year-old psychiatrist, has an ongoing pattern of being demeaning to her female patients. She frequently tells her patients that they are “idiotic” or “skanky.” Several female patients have left against medical advice (AMA) stating that they had felt their wishes were discounted and felt humiliated. Dr. A would intrusively ask about their personal lives and then make demeaning comments about their choices. When the nurses attempted to describe the context of the patients' lives, she would angrily answer, “I do not have time for that crap.” The nurses noted in their documentation what the patients had said prior to leaving AMA. Dr. A wrote a scathing “rebuttal” in the medical record in which she described the nurses as incompetent and practicing beyond their scope.

VIGNETTE 2

Dr. Z, a 35-year-old psychiatrist, is known for his imperious manner toward all. His clinical chief had told Dr. Z that the nursing staff were the appropriate staff who should call in medication orders. Despite this warning, Dr. Z told his new secretary to call in a prescription for 5 mg of haloperidol for a young, male patient, who was receiving Medicaid. Dr. Z was annoyed by the recent increase of “welfare patients” in his schedule.

The secretary mistakenly called in 5 mg at three times a day, a dosage schedule for a previous patient. Dr. Z's patient, who had taken the mistaken dosage of medication, arrived in the emergency room with serious extrapyramidal side effects. The patient stated he would never take antipsychotic medication again because of his discomfort. Dr. Z's response was to tell that secretary that she was “too f****** stupid” to do her job and blamed the patient for not confirming the dosage with him.

DISCUSSION

In these vignettes, what are the elements of disruptive behavior? Common descriptions include the following volitional conduct (2, 3):

•.	Foul language
•.	Rude, loud or offensive comments
•.	Intimidation of staff, patients, and family members
•.	Sexual comments or innuendos
•.	Outbursts of anger
•.	Inappropriate chart orders or commentary
•.	Criticism of hospital staff in front of patients or in front of other staff

The above behaviors can result in the patient or staff feeling harassed, controlled, or abused (4). The broadest consideration of disruptive behavior includes both improper dealings with patients and fellow staff; the narrow definition would include only behavior that directly resulted in patient harm. For the purposes of this article, the broader approach is applied. A physician who disrupts the ability to have clear communication in a team may indirectly cause patient harm.

A deeper moral analysis of specific ethical transgressions can be done using the principles developed by Beauchamp and Childress (5). An abbreviated list of principles summarized from their work is the following:

•.	Respect for autonomy: “Autonomous actions are not to be subjected to controlling constraints by others” (5, p. 72).
•.	Nonmaleficence: “above all (or first) do no harm” (5, p. 120).
•.	Beneficence: “Asserts an obligation to help others further their important and legitimate interests” (5, p. 194).

What are our ethical obligations as fellow physicians in the above scenarios? As physicians, we have an ethical obligation to respond to those who interfere with or impede patient safety (6, 7). One of the most basic precepts in medicine is “do no harm.” Although this injunction is not as clear as one might hope, the harming of a patient because of impulsive, thoughtless, malevolent, or inept actions is unethical.

Let us think about the ethical transgressions by Dr. A. Her discussions with her patient did not demonstrate adequate respect for their autonomy because of her discounting of their wishes. Her derogatory comments to her patients did harm in pushing them toward leaving AMA and did not meet a standard of nonmaleficence. Dr. A did not take into account the needs for healing by her patients and did not meet a standard of beneficence. She failed to demonstrate adequate respect for the nursing staff.

Dr. Z's carelessness resulted in a mistaken dosage of an antipsychotic drug and significant side effects that were probably avoidable. By causing an unnecessary harm to his patient, Dr. Z did not meet the expectations of nonmaleficence. His carelessness in dealing with the Medicaid patient's prescription is a lack of beneficence. Dr. Z was callous toward his secretary by not acknowledging his part in the inaccurate prescription. If Dr. Z were less clinically attentive to his Medicaid patients than to his private pay patients, he could be transgressing a principle of justice.

Repeated, unacceptable behaviors would give strong support for considering Dr. A and Dr. Z to be disruptive physicians. The ethical appropriate action would be to “protect the patients.” The physician or fellow clinician who observed the unacceptable behavior would have a duty to speak to the offending physician, a supervisor, a departmental director or chief, or the State Board of Licensure. If there were no identifiable supervisor, a direct report to the state's Licensure Board would be appropriate.

In some states there may be a legal requirement for reporting a physician who is behaving inappropriately. The clinic or institution may need to suspend the physician's privileges until the physician is ascertained to practice appropriately. An ethical response to the physician who is initially considered “disruptive” is a matter of justice:

•.	Are the comments being made about the alleged disruptive physician true?
•.	Is there a single incident or a pattern of behavior?
•.	Is the behavior predominately an interpersonal difference between two clinicians?
•.	Is the physician merely stating an unpopular opinion about hospital policy?

There are many conflicts between clinicians that would not rise to the level of being disruptive; that is, it would be a misuse of the “disruptive physician” guidelines if some other type of issue was occurring.

Attention to fairness is important for those who have administrative responsibility. A fair assessment of the physician would need to discern whether there were issues of dyscompetency, a deficiency in the competencies defined by the Accreditation Council of Graduate Medical Education and the American Board of Medical Specialties (8). If the physician lacked necessary skills, an appropriate ethical response would be to recommend skill training or supervision to determine whether there is adequate ability to care for patients. Distinguishing impairment (an inability to perform clinical tasks) from disruption (choosing not to comply with clinical standards) is imperative (9). The goal would include the opportunity for the physician to return to practice if he or she demonstrated adequate skill, adherence to treatment, or compliance with appropriate conduct.

If Dr. A had undiagnosed bipolar disorder or Dr. Z was becoming limited because of alcohol dependence, the appropriate steps would probably include protecting the patients and requiring that appropriate treatment be obtained. A “fitness for duty” examination would be required before the physician would be able to continue seeing patients.

If the physician were deemed to be disruptive, the ethical action would include providing clear expectations on what behavior would be appropriate. The consequences for the physician of not adhering to the clinical or institutional conduct guidelines would serve as a basis for dismissal from the clinic or hospital. If the report were made to a state board, licensure restrictions could result.

In summary, the disruptive physician impairs patient care. An ethical response by fellow physicians includes ensuring the patient's safety and identifying the behavior to a responsible supervisor or board. The responsible supervisor should appropriately assess the disruptive behavior. If there is dyscompetency or impairment, the physician should have the opportunity for education or treatment to determine whether he or she would be able to return to work. If disruptive, the physician should receive a clear statement about what conduct is necessary to retain the privilege of treating patients.