One staff nurse has just left your facility and others are considering resigning. At certain times, distinct unease pervades the OR. For a while, you've been hearing about one of your surgeons who yells about not having the right equipment and who treats his nurses in a condescending manner. And yet, the surgeon, who is technically proficient, accounts for 20% of your surgical volume.

Such was the situation facing one multispecialty ASC not too long ago. "There was nothing we could do right for the surgeon - ever," says the ASC nurse-administrator, who requested anonymity. "Nurses absolutely dreaded working his cases. Working with him was like walking on eggs."

Disruptive surgeons can cause major headaches for your surgery center, jeopardizing staff morale and even patient safety. Dealing with such behavior presents complex challenges. In this article, we'll discuss the reasons for such behavior, why it's important to address the conduct and how to handle it appropriately.

When it comes to disruptive behavior, nurses are often on the front lines. That's especially the case for verbal abuse. A survey in the AORN Journal (September 2001) found that 91% of perioperative nurses reported experiencing at least one episode of physician verbal abuse during the past year. Some 45% reported experiencing verbal abuse several times a year; 4.2% reported experiencing verbal abuse each day.

Disruptive behavior can take various forms: yelling or raising the voice, disrespect, condescension, berating colleagues, berating patients and use of abusive language. Then there are physicians who have engaged in fistfights, slammed chairs against each other and tumbled down staircases.

Extended effects
Like a shock wave reaching ever further orbits, disruptive physician behavior affects many different arenas. These include patients, staff and the facility itself. "This behavior is bad because it almost always interferes with effective patient care," says Peter Moskowitz, MD, physician career/life planning coach and director of Palo Alto's Center for Professional and Personal Renewal.

The most important aspect involves the impact on patients. "The disruptive physician is a threat to patient safety," says the Harvard School of Public Health's Barry C. Dorn, MD, who coaches disruptive physicians.

A physician who fights with a nurse creates an unsafe environment for the patient, argues Portland, Ore.-based Kent Neff, MD, a psychiatrist who has studied disruptive behavior for many years. Dr. Neff has seen nurses so afraid of a physician that they were afraid to tell the doctor what was going on with a patient. Such behavior invites information withholding.

Disruptive physician behavior can lead directly to staff turnover. A study of VHA West Coast, published in the American Journal of Nursing, found that 31% of respondents knew of nurses leaving the hospital as a result of disruptive behavior. On average, 2.4 nurses left the facility each year because of such behavior.

With today's nursing shortage, your facility can ill afford to lose nurses - especially experienced ones. And that cost sinks right to the bottom line: The direct cost of recruiting a new nurse is one year of a mid-level nurse's salary, says Alan H. Rosenstein, MD, MBA, vice president and medical director at VHA West Coast in Pleasanton, Calif.

Disruptive behavior might even increase the risk of a liability claim, notes Dr. Neff. That could happen if a patient who witnessed disruptive behavior suffered a poor outcome.

Below the surface
So why do intelligent, successful surgeons yell, hurl insults, throw charts and otherwise pitch fits in your surgery center? It'd be easy to say that they do so simply because they're "jerks." But the reasons, as you may suspect, are somewhat more complex.

• Circumstances. Surgeons have no immunity from the pressures changing healthcare today. The vagaries of managed care, flat or declining reimbursements and skyrocketing malpractice insurance premiums take their toll. "The stress of medical practice today is pushing more physicians over the edge," says Dr. Moskowitz. Navigating through these issues involves skills that physicians typically don't find to be their strongest suit, says Dr. Neff. Doctors didn't get into medicine to solve those problems.

For a physician under time pressure, a seemingly minor inconvenience can turn into a major difficulty, especially if it's repeated, notes Susan Rakley, MD, an associate with the Durham, NC-based Center for Professional Well-Being. Related to this is that surgeons may engage in disruptive behavior because it gets results.

• Education. For many years, surgeons have to abide by the rules of authority figures such as the chief resident. And if that authority figure models that screaming, for instance, is an acceptable way to get a response, then the surgeon might adopt the behavior when he gets out on his own.

Surgeons, says Pfifferling, have to abide by these rules for a long time - and with good reason. Surgeons are, says Pfifferling, "excruciatingly sensitive" to the potential benefits and harm of their materials and equipment for their patients.

Surgical residency, says Scott Stacy, PsyD, program director at the Professional Renewal Center, in Lawrence, Kan, breaks down self-esteem. There's so much information to learn that surgeons struggle with a "chronic feeling of inadequacy," he says. Because the residents feel weak, they're hungry to identify with power to offset feelings of inadequacy.

Standards of Behavior Here are some items that you may consider placing into your facility's code of conduct: Refrain from sexual innuendo Refrain from foul language, shouting and rudeness Refrain from racial or ethic slurs Refrain from threats of violence, retribution and litigation Refrain from criticizing staff in front of others Refrain from actions that are reasonably felt by others to represent intimidation Cooperate and communicate with other providers, displaying regard for others' dignity Address concerns about clinical judgments with associates directly Interact with others honestly and ethically at all times Use conflict management skills in managing disagreements - Peter Moskowitz, MD

• Personality. Perhaps the darkest and most difficult aspect of physicians' behavior has to do with issues they may bring to the profession from their personal histories. Experts suggest that some physicians come to medicine carrying emotional problems that harm their ability to work effectively.

At Dr. Neff's program at Abbott Northwestern Hospital, disruptive physicians were referred to him from almost every U.S. state and Canadian province. He found, he says, a profile of doctors with many significant emotional, psychiatric and medical problems that clearly were major factors in the development of their disruptive behavior. Those factors included abusive family relationships as children, drug and alcohol abuse, and emotional illness such as depression.

There were "significant red flags or markers in a majority of doctors that indicated that they had had a difficult life in some manner" prior to coming into medicine, notes Dr. Neff.

Most disruptive physicians "aren't just jerks," says Dr. Stacy, though it may look like this on the surface. He says that the factors that can predispose physicians to disruptive behavior might include childhood neglect or abuse, unresolved post-traumatic stress, perhaps an underlying depressive or anxiety disorder, and substance dependence or abuse.

Dr. Neff also found that, frequently, physicians hadn't developed interpersonal skills along with their professional surgical skills. A productive surgeon might not do so well in situations that required careful interpersonal behavior, nuance and good listening. "That's where he got in trouble."

By neglecting the socialization needs of the maturing physician at the expense of technical training, medicine sends into practice a group of technically skilled physicians whose social and interpersonal skills lag far behind, says Dr. Neff. Worse, there are few opportunities after training to develop these skills.

What to do
Given the potentially major impact of disruptive physician behavior on your facility, you can't afford to let the problem go unaddressed. With patient safety, staff morale, and, ultimately, your facility's well-being at stake, doing nothing simply isn't a viable response.

You also can't afford to just treat the behavior without addressing its causes. That amounts to only a temporary fix, suggests Dr. Neff.

With these thoughts in mind, consider handling the disruptive surgeon by using the following steps:

• Set the goal, says Dr. Moskowitz, of making the workplace safe for all professionals. Everyone should come to work feeling safe from abuse.
• Establish written behavior guidelines - a code of conduct. This document should clearly outline acceptable standards of behavior. It should be positive, respectful and commonsensical, says Dr. Neff. (See "Standards of Behavior.")

Surgery centers that are within a hospital network may find implementing these rules easier than freestanding facilities, suggests Dr. Dorn. Their stricter rules and regulations can help modify behavior.

• Don't dismiss breaches of behavior. "Take any of these things seriously and deal with them," says Dr. Neff.
• Put in place a physician peer review mechanism that reviews complaints about physicians. This takes the pressure off of one person and gives it to a committee of peers, notes Dr. Moskowitz. The panel must be viewed as advocating for physicians, not as their adversary. The problem is extremely difficult to handle if one person has to take it on his or her shoulders to be "the policeman and disciplinarian for other professionals," says Dr. Moskowitz.
• Intervene early. If addressed quickly, all parties involved can avoid a lot of pain, says Dr. Stacy. If not caught early, the consequences of the behavior "can be damaging for all parties involved," he says. "The earlier a peer intervention can occur, the better."
• When intervention occurs, describe the behavior objectively. Don't impugn motives, says Dr. Neff. Be aware that the denial may be strong. Don't be surprised if disruptive physicians "don't accept that their behavior is out of the ordinary or unacceptable or abusive," says Dr. Moskowitz.
• If the doctor refuses to deal with the problem, appropriate consequences must be in place. Being confronted by peers is, in itself, a consequence, according to Dr. Moskowitz. A loss of privileges might represent the "ultimate consequence."

Doctors must be able to confront colleagues. "You have to overcome the attitude that you can't do anything about Dr. X's personality," says Dr. Moskowitz. "Yes, you can."

Ultimately, such an approach "shows caring and concern for the doctors involved," he says.

Back to our case
Think back to the case we outlined at the start of the article. The disruptive surgeon's behavior was addressed by physician peer review at the ASC, and the medical director spoke several times to the disruptive surgeon. Still, his behavior continued. Ultimately, the surgeon and the ASC came to a gentleman's agreement. The ASC wouldn't rescind his privileges, thus protecting his reputation, but the surgeon would no longer bring his cases to the facility.

The ASC attempts to do "everything possible to mend a broken relationship with any physician, and it just wasn't possible here," the ASC's nurse-administrator says. Keeping him likely would have jeopardized nurses staying - in a location where operating room vacancies can be open for weeks if not months. The relief was "tremendous" when the surgeon left. There was an "amazing difference."

When he departed, about 20% of the ASC's surgical (but not endoscopy) volume went with him. "It was a huge chunk," according to the administrator.

Yet, the ASC found other surgeons. Its case volume at 300 patients per month is now beyond what it was when the disruptive surgeon left.

"When your staff is that unhappy and really being abused, it's important that you stand by your guns and realize that the caseload isn't always the ultimate," she says. One lesson learned: Intervene sooner and more aggressively.

Mr. Pilla ([email protected]) is a freelance healthcare journalist based near Philadelphia, Pa.