Strategies for coping with a disruptive physician

When a hospital’s top brass met recently to discuss how to cope with errors, the chief of surgery gathered her courage and confessed a mistake she’d made years earlier. While the surgeon’s error wasn’t fatal, she’d still felt guilt and shame.

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“It had eaten away at her for years, but she was finally willing to share to make it easier for us to have that discussion,” recalls John Henry Pfifferling, Ph.D., who led the meeting. But the response wasn’t what the surgeon expected.

The other doctors criticized her and even questioned whether she should continue as chief of surgery. “She was so vulnerable,” Dr. Pfifferling says, “and they couldn’t stand it. She violated the code that said don’t be vulnerable, don’t share, don’t feel.”

Dr. Pfifferling, who’s spent decades fighting the menace of the “disruptive physician,” was appalled. But he wasn’t surprised. Too many physicians, he says, continue to isolate themselves and either ignore or discount the views of their colleagues. In a word, they disrupt.

But Dr. Pfifferling, director of The Center for Professional Well-Being, and others haven’t given up on their efforts. Prevention and communication, they say, are crucial in every doctor’s office regardless of specialty or focus.

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“No physician group is immune to this,” says Charles Samenow, M.D., M.P.H., an assistant professor in the Department of Psychiatry and Behavioral Sciences at George Washington University, who recently gave a presentation on disruptive physicians to medical professionals in Montevideo, Uruguay. “We want to help folks learn skills to improve the culture of medicine.”

NEXT: Who is the disruptive physician?

Who is the disruptive physician?

The first step is to understand the lingo of the doctor well-being movement. To a large degree, “disruptive physician” is a fancy term for a simple concept: The doctor is being a jerk.

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“It refers to somebody who is causing a problem in the workplace,” says Michael F. Myers, M.D., professor of clinical psychiatry with the Department of Psychiatry & Behavioral Sciences at SUNY Downstate Medical Center.

“It usually means the doctor has acted inappropriately in the eyes of co-workers, whether they’re other physicians or trainees, nurses or secretaries,” he says.

Dr. Samenow, who helped evaluate the program for troubled physicians at the Vanderbilt Center for Professional Health, puts it this way: “At Vanderbilt, they call the disruptive physician the ‘distressed’ physician to focus on the problem of the physician as opposed to the problems they cause. All of the distressed physicians they’ve worked with have some sort of problem in terms of work/life balance, burnout, family issues or lack of interpersonal skills.”

Some types of behavior are obviously disruptive, like swearing, throwing instruments or physically hurting someone else. Just a few weeks ago, for example, Dr. Pfifferling heard from a second-year neurosurgery resident who had to get stitches after a surgeon kicked him under an operating table when he answered a question incorrectly.

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But a disruptive physician isn’t necessarily aggressive in an obviously obnoxious way. “Another type is the person who is behaving in a passive-aggressive way,” Dr. Myers says. “He’s a nice guy but he’s not showing up, we can’t find them when he’s on call, he’s slow to pick up his pager or return cell phone calls, the nurses are getting upset that things are being held up in the procedure room. He’s behaving in a way that’s causing grief to other people as opposed to the person who’s so obvious.”

NEXT: Dismissiveness is a symptom too

Dismissiveness is a symptom too

What about the colleagues of the chief of surgery who saw her vulnerability as an opening to attack her? Dr. Pfifferling says they’re disruptive physicians too. “She got shamed and isolated,” he says. “Shaming is just unacceptable.”

The severe isolation built into medicine - yes, even among dermatologists - contributes to this kind of behavior, he says. According to him, doctors don’t communicate well with physicians from other specialties, and physicians as a whole don’t communicate well with nurses, administrators and pharmacists.

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“The silo mentality prevents true teamwork,” he says, and it can lead to even more disruption because people outside the bubble feel as if they’re ignored. “You don’t listen to people from other tribes because they’re not acceptable to you, and you never get a chance to learn what they believe and give them real legitimacy.”

Even those within a silo - fellow dermatologists, for example - may neglect each other.

“Peers won’t listen to peers because they’re competitors,” he says. “You think they want to one-up you so you don’t trust them.”

Challenging the system, challenging colleagues

Within recent years the world of medicine has begun to better understand and combat the disruptive physician.

Some medical systems are evolving to encourage better communication and force physicians to accept feedback and criticism. Consultants from the airline industry, for example, have spoken to medical teams about the importance of allowing lower-level employees like nurses and residents to challenge the decisions of their superiors.

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“If you want to deal with disruptive behavior, you have to change the entire mindset of physicians,” Dr. Pfifferling says. Starting at the very beginning, in medical school, “you have learn to give positive and critical feedback to those around you.” In turn, those who are challenged, like professors, must be willing to accept criticism without retaliation, he says.

NEXT: Unique issues for dermatologists

Unique issues for dermatologists

Dr. Pfifferling has worked with dermatologists, and he says they face unique challenges on two fronts.

Firstly, they may be perfectionists who obsess about potentially missing conditions like cancer. “They do such a number on themselves that they’re exhausted,” he says.

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In fact, he says, “control is a myth,” and vulnerability about uncertainty should be encouraged instead of dismissed. “Sometimes you have a patient who dies,” he says, “and it is appropriate to go to a funeral because it tore your heart out.”

Secondly, he says that dermatologists may also feel as if doctors in other specialties dismiss them as inferior. This can isolate these physicians from dermatologists and hurt patients by preventing cross-talk between specialties, he says.

How to disrupt the disruptive

What can physicians do to avoid a disrespectful and non-professional environment in their offices? Gerald B. Hickson, M.D., senior vice president for quality, safety and risk prevention at Vanderbilt University Medical Center, says anyone running a practice should make it clear that staff and patients should speak up about problems. 

“I want everyone to feel free to tell me when they see things that are disrespectful or not consistent with the goals of our practice,” he says. “That’s also good business practice.”

Hickson cautions, however, that “we’re not seeking a culture of perfection.” Instead, the goal is an openness and willingness to address the occasional human slip.

“At Vanderbilt, team members use their eyes and ears and become our surveillance system,” he says. A total of 120 trained “peer messengers” are available to share patient and staff stories with those associated with behaviors that appears to be inappropriate. “Within two days of when one of these reports is submitted, 92% will be shared by a peer in a respectful, non-judgmental way,” he says. “These conversations take less than 3 minutes and occur as close in time to the event as possible.”

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This system also allows leaders to identify those who are associated with more than their fair share of events and to take action promoting accountability. “Two percent of our professionals account for half the staff complaints, and 5% account for 35% of patient complaints,” Dr. Hickson says. “If someone is unwilling or unable to respond to these respectful communications by peers, then we have sufficient reason to suspect that there’s an underlying problem. As fellow professionals, we need to get them to the right services and, if possible, appropriate remediation.”

If things go well, another silo - another bubble, another cage - will break down in favor of better communication and more well-being.