Ft. Hood Physician was a “Disruptive Physician”

November 12, 2009

Here is a copy of an article I wrote on how to interpret changes in physician behavior that are found to be disruptive by those around them. I think you will see that Army Maj. Nidal Malik Hasan exhibited many of them before his rampage:

A physician’s behavior may be defined as disruptive when it ceases to be normative: A disruptive physician can be the surgeon who berates colleagues, residents, and nurses for not performing to his or her standards, and yet constantly violates protocol, arrives early or late for procedures, and disappears at the most inopportune moments.[1] The internist who never uses drugs on the hospital formulary but refuses to serve on the pharmacy committee may be considered disruptive. The pediatrician, a favorite of patients’ families, who never completes paperwork but lets it be known that the blame for a child not getting the care that the family believes is needed lies with the administration, nursing staff, and managed care providers who conspire together to prevent the doctor from practicing good medicine may also be considered disruptive. Such behavior takes its toll. Such disruptive physician behavior can undermine the morale of individual staff members, weaken the effectiveness of the medical team in delivering care to patients, spark lawsuits, make it difficult to hire and retain a good staff, and negatively affect the reputation of the institution as well as that of the entire profession. Results of a new survey show that when physicians exhibit disruptive behavior as this, it fuels the nationwide nursing shortage by affecting on-the-job satisfaction and morale for nurses: “The disruptive physician attempts to manipulate supervisors, staff, and patients. . . .[2]”

The disruptive physician attempts to manipulate supervisors, staff, and patients, often passive-aggressively defying their orders and requests or requiring endless repetition of the same that results in only grudging follow-through. Such physicians will have often “acted out” in some hostile manner. They exhibit verbal hostility, throwing of charts or instruments, hitting desks or computers, or slamming doors. Vague threats against staff, colleagues, and supervisors can also be attributed to such individuals, although these are usually in the form of threats of legal action or administrative action, and not physical harm. Although the physician’s ability to handle the day-to-day job requirements appears satisfactory, he or she often shows poor judgment at work by ignoring established policy or performing tasks at the mere fringes of acceptability. Although the physician is often cordial to coworkers and others, he or she is also volatile and appears overly sensitive, and may even go through periods when he or she does not talk to coworkers because they are irritating.

Contrary to tradition and opinion, such behavior should not be ignored. There are generally agreed upon definitions of disruptive behavior that can be found in the American Medical Association (AMA) Policy H 140.918-Disruptive Physician and in the Joint Commission On Accreditation Of Healthcare Organizations (JCAHO) Medical staff chapter, Physician Health, M.2.6, which will soon demand that all hospitals have well-being committees to handle just such concerns.[3] A 1972 report of the AMA Council on Mental Health defined physician impairment. Certain managed care guidelines broaden the definition of an impaired physician. Along with physicians who are unable, or potentially unable, to practice medicine with reasonable skill and safety is the “disruptive” physician. These physicians may not have identifiable substance abuse or psychiatric disorders, but may still be the subject of action. Even conditions, such as extreme fatigue and emotional distress, can cause impairment, even if only temporarily. Physicians who, because of chemical use, mental or behavioral problems, or physical illness, pose a danger to patients are, by definition, impaired. They may be unsafe to practice medicine, and the danger may be direct or indirect, such as when their interactions with other staff and patients interfere with providing medical care. Clearly, a physician who manifests aberrant behavior that appears to compromise the quality of patient care should be placed under observation. However, what if the behavior is not deemed to present an immediate danger to patient safety? In the past, medical staffs have tolerated a wide range of such behaviors. A set of parameters recognized as a broad standard needed to be identified. The standards needed to be flexible, yet offer guidelines to managers, wellness committees, and boards.

Initially the disruptive physician who attempted to manipulate supervisors, staff, and patients, often passive-aggressively defying their orders and requests or requiring endless repetition of the same with only grudging follow-through, would not have fit any description of impairment. Even physicians who acted out (in the psychiatric sense) in some hostile manner by exhibiting verbal hostility, throwing of charts or instruments, hitting desks or computers, or slamming doors were to be tolerated. Vague threats against staff, colleagues, and supervisors (usually in the form of threats of legal or administrative action) did not fit the pattern. As long as the physician’s ability to handle the day-to-day job requirements appeared satisfactory, ignoring established policy or performing his or her job at the mere fringes of acceptability was to be tolerated. As long as the physician was cordial to coworkers and others, he or she could be volatile and overly sensitive, and even go through periods when he or she does not talk to coworkers because they are irritating. Contrary to tradition and opinion, such behavior should not be ignored. On January 1, 2001, the JCAHO issued new medical staff standards (Joint Commission on Accreditation of Healthcare Organizations [JCAHO] Medical staff chapter, Physician Health, MS.2.6) that require hospitals to implement a nondisciplinary process for the identification and management of matters of individual physician health.[4,5]

The JCAHO has stated that healthcare organizations have an obligation to protect patients from harm, and that they are therefore required to design a process that provides education and prevention of physical, psychiatric, and emotional illness and facilitates confidential diagnosis, treatment, and rehabilitation of potentially impaired physicians. The focus of this process is rehabilitation, rather than discipline, to aid a physician in retaining or regaining optimal professional functioning, consistent with the protection of patients. However, the standards also direct that if, at any time during this process, it is determined that a physician is unable to safely perform according to the privileges that he or she had been granted, the matter is forwarded to medical staff leadership for appropriate corrective action. Such action includes, but is not limited to, strict adherence to any state or federally mandated reporting requirements.

The process design should include:

Education of physicians and other hospital staff about illness and impairment-recognition issues specific to physicians;

Self-referral by a physician;

Referral by others and creation of confidentiality of informants;

Referral of the affected physician to the appropriate professional internal or external resources for evaluation, diagnosis, and treatment of the condition or concern;

Maintenance of the confidentiality of the physician seeking referral or referred for assistance, except as limited by law, ethical obligation, or when the safety of a patient is threatened;

Evaluation of the credibility of a complaint, allegation, or concern;

Monitoring of the affected physician and the safety of patients until the rehabilitation or any disciplinary process is complete and periodically thereafter if required; and

Reporting to the medical staff leadership instances in which a physician is providing unsafe treatment.[4,5]
AMA policy (H-140.918 Disruptive Physician) also provides guidance on how institutions should recognize and respond to disruptive behavior[6]:

(1) Personal conduct, whether verbal or physical, that affects or that potentially may affect patient care negatively constitutes disruptive behavior. (Criticism that is offered in good faith with the aim of improving patient care should not be construed as disruptive behavior).
(2) Each medical staff should develop and adopt bylaw provisions or policies for intervening in situations where a behavior is identified as disruptive and refer such concerns to a medical staff wellness – or equivalent – committee.
(3) Each medical staff should develop and adopt a policy describing the behavior or types of behavior that will prompt intervention.
A channel through which disruptive behavior can be reported and recorded must be provided, and a process to review or verify reports of disruptive behavior must be elaborated. Further, a process to notify a physician whose behavior is suspect that a report has been made and providing him or her with an opportunity to respond to the report are essential. It must be remembered that a single incident may not be sufficient for action, but each individual report may help identify a pattern that requires intervention and so should be recorded, at least for a time. After an intervention, a means of monitoring whether the disruptive conduct improves must be in place.[7] State physician wellness/impairment programs provide many of these services, and many a medical staff has opted to write policies immediately referring suspect behavior to such programs.

This author takes an interdisciplinary and multisourced approach to such work. Comprehensive approaches involve an analysis of biological, psychological, and social questions. The author is also careful to distinguish between involuntary distortion and intentional deception, which is important not only to identify problems but to account for inconsistencies in reports. To arrive at conclusions regarding deception, the author presents testing tools that remove much of the subjectivity that plagues investigations. For example, on occasion neuropsychiatric, neurophysiologic, and imaging studies may be indicated. Most importantly, the following information should be used:

A review of the requested background information (eg, personnel records, medical records, incident reports, or memos);

Psychological testing with assessment instruments (eg, personality, psychopathology, cognitive, or specialized) that are appropriate to the referral question(s);

A comprehensive, face-to-face clinical interview;

Collateral interviews with relevant third parties if deemed necessary by the examiner; and

Referral to, and consultation with, a specialist if deemed necessary by the examiner.
Prior to conducting collateral interviews of third parties, care should be taken to obtain informed consent from the hospital, the physician, and from the third party, as appropriate. This should include, at a minimum, an explanation of the purpose of the interview, how the information will be used, and any limits to confidentiality. Because a large proportion of new-onset disruptive behavior reflects a significant alcohol, drug, or psychiatric problem, a formal fitness-for-duty evaluation by medical and mental health professions should be the standard for interventions of this type. Contrary to the spirit of the “conspiracy of silence” that serves to hide our human frailties, it is confrontation that allows such misery to be identified, as we help to improve the lives of our colleagues, protect the public, and make the medical workplace more tolerable.

In closing, it is important to note that the potential for abuse of the system by those in the power position exists; it goes without saying that protection needs to be in place to protect the rights of the suspect physician, both because of the possibility of misinformation having generated the complaint and in deference to the suspected impairment that may, in principle, diminish the capacity of the individual. Since 1990, with the creation of physician hospital organizations, the advent of managed care and management services organizations, and increased focus on credentialing and peer-review processes in physician health programs, originally designed to help sick physicians get help and avoid discipline, has, on occasion, become inappropriately focused on practice issues that are beyond their purview and that intrude on the medical board’s prerogative to restrict physician practice. This intrusion can be limited by objective clinical guidelines that limit arbitrary and capricious decision making. Commissioning an outside review, assuming that it is objective, offers the best hope for a fair outcome that is not self-serving. Most medical staff bylaws allow that independent committees can be overruled by the Medical Education Collaborative (MEC) and Board of Trustees.[8] To be sure, physicians and hospitals need protection from potentially “troubled” physicians. The goal, however, is to place the burden of proof on the hospital, or the impairment committee, not the physician and to ensure that substantive due process is given to the accused physician and assured by administrative law experts.

When Behavior Disrupts the Physician-Healer


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