How to Avert Physician Misbehavior

Daniel Freedman, DO, a pediatric neurologist in Austin, Texas, recalls being stunned when a medical school surgeon threw an instrument across the room.

“I remember thinking, ‘I can’t believe people are actually doing this, a grown man in his 50s having a tantrum,'” Freedman said Medscape Medical News. But it certainly wouldn’t be the last time he witnessed bad behavior from one of his colleagues.

Findings from the recent Medscape report, Physicians Behaving Badly: Stress and Hardship Trigger Misconduct, suggest he has plenty of company. More than 4 in 10 respondents (41%) observed inappropriate behavior in the workplace in 2022, up from 35% in 2021, according to the report, which surveyed more than 1,500 doctors about inappropriate behavior around the clock and off.

Of course, 38% of respondents have seen no instances of wrongdoing; and many of the cases observed were mild or rare. In addition, cases of misconduct have decreased significantly over the past 5 years.

Freedman said he learned a lesson from his mentor and program director during the training that has stayed with him throughout his career. “If you couldn’t behave like that in any job, be it McDonald’s or any other possible place, you shouldn’t behave like that in medicine.” But he recognizes a caveat to this advice. “A lot of the people who misbehave may not have worked in any other environment before,” he said.

“They only perceive that they are at the top of the food chain, so they can misbehave without consequences.”

What Freedman described is officially called disruptive medical behavior, one of several categories of inappropriate behavior in medicine, according to Charles Samenow, MD, MPH, associate professor of psychiatry and behavioral sciences at George Washington University, who has studied this phenomenon for years.

“Disruptive medical behavior jeopardizes safety in the workplace,” said Samenow. The behavior can occur at work, outside of work, or on social media. It can hamper operations, jeopardize the safety of patients and staff, and affect morale.

“The question is to understand where this bad behavior is coming from and what the impact of this bad behavior is,” Samenow told Medscape.

One reason is pretty simple: Doctors are people, and people have a wide range of behaviors. Also, as Medscape’s survey showed, the tension, stress, hazardous conditions during COVID, burnout, and other issues have left many physicians tired, frustrated, depressed, and more reactive to situations around them.

Self-chosing characteristics become the Achilles’ heel

“Any person placed in a position of power over other people has the potential to be disruptive, harassing, etc. if they have certain personality traits.” David Gorski, MD, a professor of surgery at Wayne State University School of Medicine, said. This agrees with Samenow’s research.

Classic disruptive behavior is not usually associated with depression, mania, psychosis, or similar traits, Samenow explains. Rather, it is more personality driven. “Doctors are not immune to the normal problems that every person faces,” he says.

In Medscape’s report, physicians cited personal arrogance as a top reason for inappropriate physician behavior (56%), closely followed by personal issues outside of work (52%), a social shift toward acceptance of more casual behavior (50%), and work-related ones Stress (46%). (Respondents could select more than one answer).

One contributing factor to misbehavior that Samenow has consistently identified in his research is a history of adverse childhood experiences or family dysfunction: People who grew up in families with physical or verbal abuse learned anger as a coping skill, rather than positive, assertive communication. It is likely that some physicians, as well as the general population, have learned anger as a coping skill for this reason.

This is how you help prevent disruptive behavior in medical facilities

Samenow says coaching is a “wonderful tool” for teaching the interpersonal skills that medical school often fails to address.

In some cases, interventions can be very helpful. For example, programs that teach effective communication strategies and teamwork through a combination of culture-sensitive dialectical and cognitive-behavioral therapy and other modalities have been successful, Samenow said. While treating an illness more than treating “misbehavior,” substance use programs designed by and for physicians are also very effective.

However, fewer resources are available to address racism, classism, misogyny and other forms of bigotry, Samenow noted. “There is training on implicit bias, but not at the level that there is for disruptive doctors and addicts.” “That’s an area we need to work on.” Racist language was the third most observed bad behavior reported in the According to the Medscape survey, only bullying by employees and taunting or slurring of patients, including outside of work, were frequently reported.

The Medscape report found an increase in observed behaviors at work and on social media, although it’s difficult to pinpoint trends in prevalence over time, Samenow says. “Tolerance for this behavior has really gone down,” likely leading to more reports, he said, and there are more systems for reporting bad behavior now than in the past.

However, Freedman said inadequate regulation, disciplinary action and enforcement remain a problem.

“There are many limitations to our reporting system and our follow-up on these reports,” including hospitals that allow physicians to quietly quit and move to another facility for fear of litigation or other reasons, even with positive referrals, Freimann said.

In fact, only a third of the observed misconduct in the Medscape report resulted in disciplinary action. Half of those surveyed felt that a verbal warning was a necessary consequence, followed by an interview with management and reporting to a supervisor or HR. Although only 10% considered reporting to the Medical Association justified, this probably depends on the offense and its frequency.

“I think moving from patronizing to more patient-centric care and including patients in those conversations is a beautiful change that will make doctors more humane and approachable and hopefully make the public more forgiving that we will make mistakes and nobody is perfect,” said Freiman. But he added that if a mistake or two becomes a pattern, doctors should be held accountable.

Misinformation is professional misconduct

In particular, doctors say there is a lack of adequate accountability for one subtype of professional misconduct: the dissemination of misinformation.

While “more conventional” bad behavior includes cheating, dishonesty, abuse of subordinates, and incompetence, bad behavior should also “include the selling of quackery and anti-vaccination misinformation, as some doctors have done with various panaceas for COVID-19…” Gorski said , who regularly blogs about the spread of misinformation by doctors.

Taylor Nichols, MD, a Sacramento-based emergency medicine physician, cites the desire for attention and clout as motivations. “Saying things that are wildly and demonstrably false is professional misconduct,” Nichols said. He distinguished such statements from scientific, academic, or clinical disagreements necessary in medicine.

Still, there’s a “long tradition of looking the other way or letting people with fancy titles get away with saying nonsense just because they’re respected,” says Dr. Jonathan Howard, associate professor of psychiatry and neurology at the Grossman School of New York University Medicine, told Medscape.

“We have a duty to be trusted members of the community,” Howard said. “People listen when we say things and we have a duty to try to be accurate and humble and as honest as possible and admit mistakes when we inevitably make them.”

That extends to social media, which Nichols says has magnified the problem of promoting quackery and misinformation. He believes that medical boards and professional recognition bodies should pay attention to what is happening in the public discussion and understand that our professional responsibilities extend beyond the walls of the hospital or clinic. Physicians must present themselves professionally and uphold the standards expected of the profession.

On the one hand, Medscape respondents agreed: 70% said a doctor’s misconduct corrupts the entire profession. At the same time, 58% of respondents believed that in 2022 doctors should be able to “keep their personal lives private”. But that’s not the reality of the profession when the lines between personal life and behavior outside of work are blurring, Samenow said.

“The way a doctor behaves in public represents you,” he said. “What happens in Vegas doesn’t always stay in Vegas…”

Tara Haelle is a Dallas-based health and science writer. Follow her up @tarahaelle.

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