If you have a hard time confronting disruptive physicians or staff, you're hardly alone. Abrasive and abusive individuals tend to respond with the same type of aggressive behavior you're trying to address: screaming, scowling, intimidating. Since it's general human nature to avoid confrontation, we tend to leave them alone.

Therein lies the real danger. For if you postpone taking action on disruptive behavior by reasoning that it hasn't yet hurt anyone, you're playing with fire. Over time, abusive behavior can increase the risk of medical errors.

The politics of the surgical business can also interfere with effective intervention. We might tolerate the bad behavior of a physician who brings in a lot of cases more than we do that of a less-productive physician. Similarly, we might overlook interpersonal infractions from highly skilled physicians more often than those commited by less-adept, sub-par or marginal surgeons. A physician who's well-connected to a facility's owners (or who's a physician-owner himself) presents still other problems.

Action is legally supported
What disciplinary action should you take in response to these incidents? It may vary depending on the facts of each individual situation. It might be possible to resolve a disruptive behavior situation through some measure of collegial intervention. This is usually the first step, and additionally, there are numerous programs nationwide that assist healthcare providers with behavioral issues. For a more persistent pattern of wrongdoing, a termination of privileges or employment might ultimately be warranted.

Taking action against disruptive docs may result in that doctor filing a lawsuit against the facility. There may be an even bigger concern of lawsuits if your facility takes action against a disruptive physician who's not a part-owner. The courts, however, have generally supported facilities in such actions by expressly recognizing a connection between disruptive behavior and the potential for patient harm.

In Nanavati v. Burdette Tomlin Memorial Hospital (1987), New Jersey's Supreme Court held that a hospital could revoke a physician's privileges if it could demonstrate that the prospective disharmony (such as a physician's inability to work with others) would probably have an adverse impact on patient care. Two more recent cases upheld the same principle. In Guier v. Teton County Hospital District (2011), the Wyoming Supreme Court affirmed a hospital's decision to revoke a physician's privileges as a result of disruptive behavior that included berating OR team members and throwing scissors. Likewise, in Sternberg v. Nanticoke Memorial Hospital (2011), the Delaware Supreme Court backed a hospital's suspension of a surgeon who'd regularly drawn complaints from other physicians, nurses and patients. His antagonistic interactions included interrupting surgeons' meetings, verbally attacking staff over scheduling and waving a drill at an OR employee (tinyurl.com/8bdprgd).

The best defense is a good offense
The most effective way to discipline physicians is to address the problem up front in accordance with established policies and procedures that should:

• define disruptive, abusive behavior as unacceptable;
• notify physicians and staff of the consequences for engaging in such behavior; and
• provide a clear process through which you'll address it.

Accreditation agencies have addressed this issue as well. For example, the Joint Commission's standards call for a culture of safety and quality that includes developing a code of conduct to define acceptable, disruptive and inappropriate behaviors, and implementing a process for managing the latter two. Its Sentinel Event Alert No. 40, issued in July 2008, demands zero tolerance for abusive behavior and sets forth 11 steps for overcoming it, including education, reducing the fear of retaliation and investigation (tinyurl.com/26sz43u).

Where to draw the line?
Don't shy away from dealing with disruptive behavior. Early intervention is key. It protects your staff and patients, and can also help turn the perpetrator's professional career around. Even if it fails, your facility has at least demonstrated an effort to address the problem. While a physician who has lost his privileges can still sue, a policy establishing your facility's stance on disruptive behavior, backed up by a well-documented record of any incidents, will help to build you a solid defense in the event that any related lawsuits are brought against your facility.