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to complete their training, and to obtain licensure and Drug
Enforcement Agency certification. Subsequently, it is reason-
able to ask what factors may trigger disruptive behavior in this
group of individuals.
One can cite many ‘‘common sense’’ reasons such as over-
work, family strife, a dysfunctional working environment,
supervisor pressure, and anxiety. Some authors believe that
the ‘‘normal’’ stress of medical practice has been compounded
by large educational debt loads for graduating physicians,
increasing malpractice premiums, decreasing reimbursement,
and the pressure to see more patients in a shorter amount of
time (2) . According to one recent survey, ‘‘This is a difficult
time for physicians with flat or declining income, rising
expectations, rising office overhead, and diminished
autonomy. Physicians are depressed about their loss of control
and enormously frustrated by the complexity of the health
care system. They bristle at the need for regulatory oversight
and have a great deal of difficulty with any non-physicians
mandating any kind of activity or behavior, clinical or other-
wise. Their frustration boils over all too easily’’ (3).
An underlying physical, mental, or behavioral disorder
causing physician impairment may provide an explanation for
new-onset disruptive physician behavior. The AMA defines
physician impairment as, ‘‘any physical, mental or behavioral dis-
order that interferes with ability to engage safely in professional
activities’’ (21) . The 2000 AMA Report of the Council on
Ethical and Judicial Affairs addresses the subject of disruptive
behavior and physician impairment (22). It states, ‘‘Whether
the disruptive behavior is the manifestation of an underlying
pathology or not, it is important that it be addressed. In some
instances, processes that already are established for grievances
or for dealing with impaired workers may be expanded
or may serve as models to address disruptive physicians’’ (22).
Of note, the term physician impairment has sometimes been
inappropriately applied to physicians who have returned to
good health, are substance-free and in a monitoring program,
or have successfully completed a knowledge or skill remedia-
tion course. Subsequently, it is not appropriate to label these
physicians either impaired or disruptive.
Understanding the triggers for disruptive behavior has the
potential to prevent or ameliorate such behaviors when
managing the high stress medical environment. Moreover,
identifying underlying physical or behavioral disorders can
address treatable causes of disruptive behavior.
IMPACT OF DISRUPTIVE BEHAVIOR
Disruptive physician behavior can result in significant medi-
cal, economic, and emotional consequences. Examples
include disharmony and poor morale, increased staff turnover,
incomplete and dysfunctional communication, heightened
financial risk and litigation, reduced self-esteem among staff,
reduced public image of hospital, and unhealthy and dysfunc-
tional work environment (2,5).
The Joint Commission states, ‘‘Intimidating and disruptive
behaviors can foster medical errors, contribute to poor patient
satisfaction and to preventable adverse outcomes, increase
the cost of care, and cause qualified clinicians, administrators
and managers to seek new positions in more professional
environments. Safety and quality of patient care is dependent
on teamwork, communication, and a collaborative work
environment’’ (23).
One should not underestimate the impact of disruptive
behavior on morale. If the coworkers of the disruptive
physician see the behavior continue, they assume there was
no punishment. This is severely disheartening to those who
work hard, follow the rules, and are routinely professional.
Most important, problem behaviors can threaten the
performance of the health care team and subsequently can
adversely affect the safety and quality of patient care (24).
ADDRESSING DISRUPTIVE BEHAVIOR
The AMA provides the essential steps an organization should
take to deal with disruptive behavior (6). (Table 1) The Joint
Commission suggests 11 actions for addressing disruptive
behavior, including adopting a zero tolerance policy (25)
(Table 2).
Once the ground rules have been established, the hospital’s
peer review process must abide by three principles (Table 3).
First, they must operate with a reasonable belief that they
are improving the quality of patient care (26). Second, they
must only make their decision to revoke or refuse renewal
of staff privileges after a reasonable effort to obtain the facts
(27). The relevant inquiry under the second element ‘‘is
whether ‘the totality of the process leading up to the professio-
nal review action evidenced a reasonable effort to obtain the
facts,’’’ not a perfect effort (28). Last, they must provide a
fair hearing. This includes proper notice of the hearing, the
reasons for the proposed action and a summary of the physi-
cian’s rights at the hearing. The hearing shall be held before
an arbitrator mutually acceptable to the physician and the
health care entity, before a hearing officer who is appointed
by the entity and who is not in direct economic competition
with the physician involved, or before a panel of individuals
who are appointed by the entity and are not in direct
TABLE 1. Essential Steps that an Organization Should Take to
Deal with Disruptive Behaviors as Outlined by the American
Medical Association.
! Clearly state which behaviors will not be tolerated.
! Adopt bylaw provisions or policies for intervening in situa-
tions where a physician’s behavior is identified as disruptive.
! Establish a process to review or verify reports of disruptive
physician behavior.
! Establish a process to notify a physician whose behavior
is disruptive that a complaint has been made, allow the dis-
ruptive physician to respond to the complaint, andmonitor for
improvement after intervention.
Accessed at
resources/medical-ethics/code-medical-ethics/opinion9045.page .
Last accessed July 12, 2013.
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