Physician Abusiveness Critically Impacts Patient Care

�The physician must respect the dignity of all persons and respect their uniqueness.� Those words are from the American College of Physicians Ethics Manual, and should serve as a guiding light for all physicians. But according to recent surveys, all too often those words ring hollow.

“The physician must respect the dignity of all persons and respect their uniqueness.” Those words are from the American College of Physicians Ethics Manual, and should serve as a guiding light for all physicians. But according to recent surveys, all too often those words ring hollow.

For example, a survey by the Institute for Safe Medication Practices revealed that 40% of hospital staff members had been so intimidated by a doctor that they did not voice their concerns over medication orders even though those orders seemed to be incorrect. And while healthcare professionals agree that most physicians do not fall into the “abusive” category, the problem is still widespread.

“When you look at it from a nurse’s point of view, and nurses tell you that verbal abuse has a prevalence rate of about 80% to 90%, and more than 50% of nurses report they have been subject to verbal abuse, it’s an important topic,” says Dianne Felblinger, EdD, MSN, WHNP-C, CNS, RN, a professor and women’s health nurse practitioner at the University of Cincinnati’s College of Nursing.

Ripple effect

So, a physician exhibits abusive behavior toward a nurse or resident during an exchange over medication orders, then later apologizes. Case closed, right? Not really, because as Alan Rosenstein, MD, MBA, vice president and medical director of the West Coast office of VHA Inc., points out, the residual effects from the encounter can have major implications where patient care is concerned.

“There are some surgeons who are truly disruptive; they feel they need to be to get things done, and they’ll apologize later,” Rosenstein explains. “But there are downstream effects of people not wanting to deal with them, which can negatively impact patient care.” Consider that in a recent survey authored by Rosenstein, 67 percent of healthcare workers at 102 nonprofit hospitals believe there is a link between disruptive behavior and medical mistakes. “When the relationship is strained between the nurse and the physician, the patient may not get [the care that] they need.”

Sometimes, says Len Rosenberg, a healthcare attorney with Garfunkel, Wild and Travis, the apology attempt only serves to pour salt on the wound. “I’ve seen plenty of occasions where [the apology] turns out to be worse than the initial incident, or just a repeat of it. The apology is viewed as insincere, dismissive, and insulting.”

The end result, says Felblinger, is the creation of a negative culture within the hospital. “Nurses are overworked and suffer a lot from fatigue,” she says. “If you add in the stress from a culture that is not supportive, or in which you are subject to disruptive behaviors, it makes the stress worse. What happens is that we end up with recurring retention problems.”

Legal ramifications

The topic of abusive physicians, says Rosenberg, is one that healthcare facilities have been grappling with for many years. A broad spectrum of remedies have attempted to address the problem, with varying degrees of success. Hospitals usually take a progressive approach, beginning with warnings and counseling sessions. If the abusive behavior is not modified, the next steps could be suspension of medical staff privileges, or an outright revocation of privileges and termination of staff membership. If the latter occurs, physicians often file a lawsuit contending that they were retaliated against and denying that they are disruptive.

“In the overwhelming majority of those cases, the courts have held that disruptive conduct does have a negative impact on quality of care, and that it’s completely reasonable for the hospital to take action to deal with that,” Rosenberg says.

The Joint Commission recently issued new leadership standards for the 2009 accreditation process, requiring hospitals to put in place processes and policies to deal with disruptive staff members. The Commission has also issued statements that disruptive conduct has a negative impact on patient care.

Working together

The survey of nonprofit hospital workers also found that 30% to 40% of medical staff are very poor communicators. Rosenstein says the results offer a good opportunity to raise the level of awareness of the problem and improve communication across a large percentage of the hospital staff.

“More organizations are recognizing that [abusive physicians is] a big issue,” he says. “From awareness and educational programs, to sensitivity training and improving communication skills, I see a lot of organizations already making improvements.”

Felblinger says one of her favorite expressions is “hard on issues, soft on people.” She says that means asking yourself the question, “Am I making the best decision for the patient?” And when dealing with colleagues, “How am I treating this person?” The latter, she says, is the soft on people part of the expression—the collaboration and communication aspect. “If people can look at a situation in that respect, often times it makes for a better collaborative situation.”

Ed Rabinowitz is a veteran healthcare writer and reporter. He welcomes comments at edwardr@frontiernet.net.