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October 2014Scenario: As an otolaryngologist-head and neck surgeon with a significant hospital surgical practice, you agreed last year to become the chair of the hospital’s surgery department. The surgery department is quite large, with 82 actively practicing surgeons of all specialties. While you personally know the majority of the surgical staff owing to your long tenure at the hospital, there are some new surgeons with whom you have not yet developed a relationship. Taken in aggregation, the surgical staff physicians are felt to be quite professional in their clinical activities, and few problems came up with them in the first year of your chairmanship of the department.
Over the past two months, however, you have had an alarming number of complaints about two surgical staff members. One of them is relatively new to the surgical staff, while the other surgeon whose actions have generated complaints has had a long career at this hospital. The complaints regarding the two physicians have come from a variety of sources, including patients, hospital staff members, administrators, and fellow physicians.
Complaints about the older surgeon have focused on poor bedside manner, testiness in the operating room, unusual and erratic/inappropriate behavior, and inadequate pain management for patients. He has been observed to provide very little time for post-operative patients during hospital rounds and to dismiss their requests for additional pain medication. In the operating room, he tends to be gruff and demanding and often has inappropriate conversations with his friend, the anesthesiologist. This behavior has also caught the attention of the hospital chief of staff, who is a hospitalist and very engaged in patient-physician interactions. The surgeon’s behavior is puzzling because, previously, his professional behavior was excellent. A few of the complaints have also indicated that he had alcohol on his breath at various times in the hospital setting.
The complaints about the younger surgeon are a bit different, primarily centering around an arrogant attitude toward patients and hospital staff members (nurses, technicians, and clerks) and an air of superiority toward patients who ask questions of the surgeon. She is unwilling to take the time to teach or even interact with the medical students and resident physicians who rotate through the hospital’s surgical department, calling them “impossible to teach” and a “total waste of my valuable time.” Observations by nursing staff indicate an unsympathetic approach to patients, a rapid dismissal of patient questions regarding the surgery and post-operative plan—“just leave the thinking and planning to me; I’m the surgeon, not you”—and generally condescending attitude. She is said to brush off patient care inquiries from nurses with “I’m the surgeon, not you, so just follow my orders.”
Your primary concern is the welfare of the surgeons’ patients. Secondarily, you believe this unprofessional behavior affects hospital staff morale and cohesiveness. Thirdly, these behaviors could realistically jeopardize the surgeons’ careers. The hospital chief of staff is requesting your plan for managing the complaints.
—G. Richard Holt, MD, MSE, MPH, MABE, D BE
Hippocrates
The Unprofessional Physican
Discussion: This ethical dilemma can be a challenging one, with ramifications for patient care, interprofessional conflicts, medico-legal liabilities, and risks to careers. Proper physician behavior in the conduct of professional activities has been a precept (and duty) throughout the history of medicine, especially in modern times. Teaching professionalism in graduate medical education is mandated as one of the Accreditation Council for Graduate Medical Education’s Six Core Competencies. Proper modeling of professionalism by academic faculty and community preceptors is seen as foundational to the proper inculcation of desirable traits in a physician.
Medical professionalism does not have a precise definition but is a composite of appropriate behavior that encompasses a wide range of elements, including decorum, bedside manner, duties to patients (honesty, humility, respect, communication), respect of all members of the medical team, and proper adherence to the fundamentals of medical ethics in patient care (autonomy, beneficence, nonmaleficence, and social justice). Patients expect their physician(s) to exhibit proper professional behavior in the healthcare milieu while providing excellent clinical care. Patients can accept a physician’s shortcomings if their medical/surgical care is adequate; however, they should not have to settle for unprofessional behavior by their physicians.
Unprofessional behavior by physicians can include a spectrum of misconduct—a continuum of poor behavior ranging from the occasional inappropriate comment or attitude to frank, egregious conduct that jeopardizes patient well-being and safety. Increasingly, both healthcare professionals and the public are looking for evidence of “self-policing” of improper conduct by physicians and other healthcare providers, which is, of course, our profession’s fiduciary responsibility. In the absence of self-policing, regulatory agencies can, and do, step in to discipline physicians. In the scenario presented, the examples of unprofessional behavior cover a range of misconduct, from arrogance and poor communication to actual quality of care and patient safety issues. The larger the medical facility or practice, the greater the likelihood that physician leaders will have to deal with such issues. Depending on the nature of the misconduct, staff morale can be adversely affected and medical liability could be a possible concern.
The American Medical Association (AMA) has identified four distinct forms of unprofessional conduct by physicians—1) inappropriate behavior, 2) disruptive behavior, 3) harassment, and 4) sexual harassment. These misbehavior sets can be considered to “peg” the continuum of unprofessional conduct previously mentioned. Of these four, this ethical scenario addresses both inappropriate behavior and disruptive behavior. According to the AMA definition, inappropriate behavior is “conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive.” As seen from this definition, inappropriate conduct can encompass a wide range of behaviors as both physicians in the scenario exhibited. Left unchecked, such behavior can negatively affect patient care and staff morale, potentially having a cascading effect within a healthcare facility or medical group practice. In an academic setting, this will have a negative impact on role modeling and will compromise training in professionalism. Examples of inappropriate behavior include making demeaning statements, demonstrating arrogance, dismissing patient questions, and speaking disrespectfully to patients and medical team members.
Disruptive behavior is likewise characterized as “any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.” The behaviors included in this type of misconduct tend to be more serious with respect to patient care and staff morale and, if left unchecked, will assuredly lead to legal ramifications. This is why unprofessional behavior by a physician must be dealt with as soon as possible, with each case managed as appropriately as possible, according to medical staff rules of conduct. Disruptive behavior is seen with surgeons who are verbally abusive and throw instruments in the operating room, make errors in clinical judgment that could be due to impairment, or intimidate the nursing or pharmacy staff sufficiently that they are unwilling or unlikely to question an inappropriate/ineffective order or to pose a patient care or patient safety concern.
The primary goal of dealing with unprofessional behavior will be to protect patients and ensure safe and appropriate clinical care. Secondarily, the staff must be protected from the unprofessional physician. A third goal is to develop an appropriate remediation or recovery plan for the physician so that he or she has the chance to return to the practice of safe, appropriate, and professional medical care. Finally, the institution itself must manage possible medico-legal risks.
There are many potential causes for unprofessional behavior by physicians, but a few seem to be most common: 1) personal or situational stress factors in a physician’s life; 2) financial pressures (real or self-imposed); 3) medical or mental health disorders; and 4) substance abuse (drugs, alcohol). An investigation of complaints against a physician in the ethical scenario presented above would logically consider these potential predisposing factors.
Indeed, it is your responsibility, as chief of surgery, to address these complaints. If left unaddressed, they will continue to be problematic and may, in fact, worsen. In allowing this to happen, you are stepping into a very difficult and potentially risky professional confrontation; however, you need not address these situations alone—it is important to include several other surgeons who can broaden the discussion on the best approach to take with each surgeon against whom complaints have been lodged. The surgeons you take into your confidence should be well respected for their professionalism and confidentiality, and your ad hoc committee composition should comply with the medical staff bylaws.
It is important for every healthcare facility, academic medical center, and physician group practice to have a well-developed medical staff code of conduct. The AMA Model Medical Staff Code of Conduct (available at ama-assn.org) is an excellent document and blueprint for this sort of ethical dilemma. By having each physician on the medical staff review and sign the code of conduct document on a regular basis, a practice can hold its physicians to these standards. The medical staff bylaws should clearly state the procedures for reviewing and investigating complaints against medical staff members and direct the proper process for disciplining and/or remediating a physician whose misconduct has been adequately substantiated. I will refer the reader to the AMA document for details.
It is likely that some cases of unprofessional behavior will turn out to be situational or stress-related and can be remediated by informal or formal counseling. More serious inappropriate or disruptive behaviors require identifying the underlying etiology—physical or mental health issues or substance abuse—and mandating the appropriate treatment plan or facility for that physician’s disorder. There are many treatment facilities in the U.S. for physician remediation and recovery, but local resources may also be adequate and appropriate. Reinstatement is possible after successful completion of a course of therapy, usually with a period of close oversight over the physician’s practice. More serious cases of unprofessional behavior will be reported to the state medical board for its separate investigation and possible discipline.
In summary, unprofessional behavior of any type by a physician is detrimental to patient care and to the healthcare profession. An unbiased approach to investigating complaints against a physician must be linked with an obligation to protect patients and staff as well as provide due process for the physician. Medicine is an accepting and caring profession, so remediation and therapy for the physician may be in the best interests of his/her patients and gives the physician another opportunity to practice professionally and appropriately; however, severe cases of disruptive behavior, in which patient care and safety may be compromised and ethical standards of the profession have been breached, require strong action.
Dr. Holt is a professor emeritus in the department of otolaryngology-head and neck surgery at the University of Texas Health Science Center in San Antonio.
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