“History is a relentless master. It has no present, only the past rushing into the future. To try to hold fast is to be swept aside.”
– John F. Kennedy
Although “disruptive physician behavior” is a relatively new term that first appeared in the literature in 1995,(1) it is not a new concept. In 1875, The New York Times published an article titled “Pugnacious Physicians.” After an Academy of Medicine meeting, several physicians were charged with threatening personal assault to each other through the use of “deadly weapons.”
Three days after President Garfield was shot on July 2, 1881, The New York Times published an article titled “Physicians Quarreling,” detailing the behavior of two physicians who were treating the wounded president in an adjacent room. One physician called the other a liar, and the accused physician quickly jumped to his feet with “hostile intent.” No doubt, these stories captivated the public’s attention but also highlighted the lack of what we today call professionalism.
One must appreciate that medical education and training in the United States in the late 1800s and early 1900s was a for-profit enterprise that produced many poorly trained physicians. With no educational standards, anyone with the economic means could become a physician. That changed after the Flexner Report was released in 1910.(2) This report, written by Abraham Flexner for the Carnegie Foundation, found a majority of medical schools were providing substandard education and training. In fact, nearly 30% of medical schools closed as a result of Flexner’s findings and recommendations.
It is easy to imagine some of these physicians were guilty of performing unnecessary surgeries and taking advantage of their status. The idea of poorly trained physicians preying on an ignorant public for personal gain brought forth a necessary change in how doctors were trained. In essence, this was the first step in recognizing the need for physicians to become professionals in the true sense of the word.
Throughout most of the 20th century, disruptive physician behavior was tolerated and became an engrained part of the “culture of medicine.” Ten years prior to the Joint Commission’s Sentinel Alert 40, the Council on Ethical and Judicial Affairs presented a report on “Physicians with Disruptive Behavior” to a committee of the American Medical Association. The report provided definitions, interventions, and recommendations.
Recognizing a problem is different from solving a problem, however. Despite widespread recognition and awareness, disruptive physician behaviors continue to negatively affect patient care and the work environment. Our healthcare system, hospitals, and licensing and governing boards lack a standardized, consistent, universally recognized definition of disruptive behavior, code of conduct, and process for managing disruptive physicians.
Definition of Disruptive Behavior
You cannot become a peacemaker without communication. Silence is a passive-aggressive grenade thrown by insecure people that want war, but they do not want the accountability of starting it.
– Shannon Alder
In its simplest terms, disruptive behavior is any behavior or action that interrupts or compromises the professional work environment, workflow, or patient care. The Joint Commission’s Alert clearly defines and describes disruptive behaviors that impact patient safety and the work environment. The American Medical Association, in their code of medical ethics, defines disruptive behavior as “personal conduct, whether verbal or physical, that negatively affects or that potentially may affect patient care.”(3)
Until 2009, egregious behaviors often were the only precipitating event leading to disciplinary action, and many healthcare organizations did not consistently enforce clearly defined expectations, rules, and codes of conduct. Fortunately, over the past decade, most, if not all, healthcare organizations have adopted formal codes of conduct and processes to address disruptive behaviors.
A recent concern for some physician staff leaders and medical staff organizations is the misuse of the term “disruptive.” Disagreeing with and engaging in constructive criticism of C-suite executives or colleagues is not disruptive behavior. Choosing not to participate or volunteer on a committee is not disruptive behavior. Huntoon wrote a brief editorial published in the Journal of American Physicians and Surgeons specifically addressing the possibility of gross overreach in defining disruptive physician behavior.(4)
To avoid misinterpretation and misuse, codes of conduct must include clear, well-defined examples of conduct and expectations. Without clear definitions, a code of conduct can be weaponized by administrators or staff members who deliberately report violations or minor infractions that are not explicitly defined in the conduct document.
As an example, a code of conduct that includes in its definition of disruptive behaviors “and any other behavior not delineated but deemed inappropriate by the Medical Executive Committee, Chief of Staff, or CEO” is a potential legal landmine and a setup for medical staff conflict.
Petrovic and Scholl posit that one of the reasons disruptive behavior continues to be a problem is the plurality of terms used to define disruptive behavior.(5) I agree. The lack of a single definition hinders validated research on causes and effective interventions.
Despite these challenges, Petrovic and Scholl’s research identified the frequency of commonly used terms in their literature search (Table 1).(5)
Conclusion
Disruptive physician behavior has deep historical roots, reflecting longstanding challenges in professionalism within the medical field. While reforms such as the Flexner Report and the establishment of codes of conduct have brought progress, the persistence of disruptive behaviors continues to negatively impact patient care and workplace environments. The lack of a universally accepted definition and standardized approach to addressing these behaviors complicates efforts for resolution. Moving forward, clear policies, consistent definitions, and proactive interventions are essential to fostering a culture of professionalism and ensuring the highest standards of care in healthcare settings.
Excerpted from Physicians and Professional Behavior Management Strategies: A Leadership Roadmap and Guide with Case Studies (American Association for Physician Leadership, 2022).
References
Veltman L. The disruptive physician: the risk manager’s role. J Healthc Risk Manag. 1995;15:11-16.
Flexner A. Medical Education in the United States and Canada. Boston: Merrymount Press; 1910.
American Medical Association. AMA Code of Medical Ethics. www.ama-assn.org/delivering-care/ethics/code-medical-ethics-overview .
Huntoon L. The insulting physician “code of conduct.” Journal of American Physicians and Surgeons. 2008;13(1):2-4.
Petrovic M, School A. Why we need a single definition of disruptive behavior. Cureus. 2018;10(3): E2339.