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inappropriate or unprofessional. Throwing instruments, dam-
aging property, or unprofessional outbursts of anger have been
determined to be disruptive. Some say hostile, angry, abusive,
aggressive, or confrontational voice or body language is dis-
ruptive. Most agree that language or criticism directed
to the recipient in such a way as to ridicule, intimidate,
undermine confidence, or belittle is disruptive behavior.
LESSONS FROM CASE LAW
Court after court has held disruptive behavior as a legitimate
reason to revoke or refuse renewal of staff privileges as has
been evidenced in several landmark cases
(7–9)
. Case law
varies slightly from state to state; however, the
aforementioned cases and other subsequent cases have laid
the groundwork for the Federal Healthcare Quality
Improvement Act of 1986
(10)
.
For example, one case involved a physician who told a nurse
that ‘‘she should get off her ass’’ and that she was a ‘‘wrench in
the works, she was obstructing patient care’’
(11)
. His privi-
leges were revoked and he sued the hospital. That court
held, ‘‘So, essentially, disruptive is to interrupt the ordinary
course of things, the normal course of things, is disruptive.
And, as defined in the Duquesne Law Review, the disruptive
practitioner is by definition contentious, threatening,
unreachable, insulting and frequently litigious. He will not,
or cannot, play by the rules, nor is he able to relate to or
work well with others,’’
(12)
.
Another case involved a surgeon who had an angry
exchange with two anesthesiologists when an operation began
3 minutes behind schedule
(13)
. When the anesthesiologists
attempted to explain why they were taking a few minutes to
reexamine the patient’s medical records before administering
the anesthesia to the patient on the operating table, he told
them that he ‘‘didn’t give a damn about incompetent people’s
excuses.’’ According to the anesthesiologists, he then launched
into a tirade of insults in loud and angry tones in front of the
still-conscious patient. His disruptive behavior continued
when he falsely reported to a nurse supervisor that one of
her patients had just hanged himself in their hospital room;
in fact, the patient was fine. He explained that he had intended
the episode as a ‘‘joke’’ to teach the nurse ‘‘responsibility.’’ On
another occasion, he slapped a surgical technician’s hands,
apparently as a reprimand for a perceived mistake in handling
a catheter, while she was assisting him in an operation. His
privileges were revoked. He sued to get them back and lost.
Another physician interfered with a lymph node biopsy
being performed by his archrival, another obstetrician/gyne-
cologist
(14)
. He strode into the operating room suite and
demanded that a nurse, who was the operating room coordi-
nator, stop another physician’s operation. He did not follow
the appropriate procedure of complaining before the surgery
to the chief of surgery or to the chief of the medical staff.
He lost his privileges. He, too, sued and lost.
Therefore, virtually all courts uphold the right of a hospital
to act whenever the physician’s disruptive conduct, in the
expert opinion of the hospital authorities, ‘‘may’’ or ‘‘could’’
adversely affect patient care. This majority view is consistent
with the Federal Health Care Quality Improvement Act of
1986, which states disruptive behavior ‘‘affects or could affect
adversely the health or welfare of a patient or patients’’
(10)
.
The potential effect on patient care may not be presumed
but must be shown by the evidence. But a hospital need
not wait for a disruptive physician to harm a patient before
revoking a medical staff member’s privileges
(15)
.
What is not disruptive behavior? One court has said, ‘‘Doc-
tors, like other people, have quirks, and some doctors are
more disagreeable than others. The mere fact that a doctor
is irascible, however, does not constitute good cause for termi-
nation of his or her hospital privileges’’
(16)
. On similar
grounds, another court concludes, ‘‘The mere fact that a
physician is irascible, however, or that he or she generally
annoys other physicians, nurses or administrators does not
constitute sufficient cause for termination of his or her
hospital privileges’’
(14)
. Criticism that is offered in good faith
with the aim of improving patient care should not be
construed as disruptive behavior
(17)
. However, the right to
criticize constructively ‘‘is not a right to malign’’
(18)
. It has
been made very clear that ‘‘a doctor should not be cut off
from staff membership merely because he or she has criticized
hospital practices and other doctors’’
(18)
.
Courts generally defer to hospitals’ peer review process
when a decision to revoke or refusal to renew staff privileges
occurs. This position is supported by the AMA, which has
argued, ‘‘The vast majority of lawsuits challenging peer review
proceedings should be dismissed at the summary judgment
stage. Suits against peer reviewers should be allowed to go
forward only when the plaintiff has rebutted the presumption
that the peer review proceeding was reasonable and fair’’
(18)
.
‘‘Any lesser standard would deter physicians from serving as
peer reviewers and would therefore undermine the purpose
of the HCQIA’’
(18)
.
Rarely, courts side with the physician. One physician lost
his privileges because he complained to governing bodies
about his hospital’s practices being outside the norm
(19)
.
Specifically, he argued the hospital did not follow appropriate
procedures in posting random on-call schedules, provided
deficient child psychiatric care, and had policies requiring
premature patient discharge when patients ran out of
insurance to cover their care. He was able to prove that his
privileges were not revoked in a reasonable belief of furthering
the quality of health care. In another case, the Tenth Circuit
upheld a district court’s finding that the peer review board
lacked immunity because the board investigated only two
patient charts before deciding to revoke the physician’s privi-
leges, which was not a reasonable effort to obtain facts
(20)
.
POTENTIAL CAUSES OF DISRUPTIVE PHYSICIAN
BEHAVIOR
In general, physicians need to have a consistent track record
of prosocial behavior to gain acceptance into medical school,
GROGAN AND KNECHTGES
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