Prescription for Change

Throwing 'invisible scalpels': A different take on disruptive physician behavior

Go ahead and ask anyone in a health system: “is disruptive behavior a problem?” An estimated 100% of respondents will say yes.

Yet despite widespread acknowledgement that disruptive behavior is a big problem, we see two barriers preventing leaders from taking action.

1. Ignoring the full spectrum of disruptive behavior. A common refrain is, “Yeah, we have some disruptive physicians.” Yes, you do. But more than that, you have a ton of disruptive behavior, most of it more subtle and therefore more insidious, than throwing a scalpel.

The Joint Commission defines disruptive behavior as:

“conduct by a healthcare professional that intimidates others working in the organization to the extent that quality and safety are compromised.”

In addition to verbal outburst and physical threats, the question is whether the following are disruptive behavior:

  • Quietly exhibiting uncooperative attitudes during routine activities
  • Reluctance or refusal to answer questions, return phone calls or pages
  • Condescending language or voice intonation
  • Impatience with questions

The answer is yes—all of these characteristics are disruptive. We have been correctly identifying extreme behavior as disruptive, but incorrectly tolerating less-extreme behavior for far too long.

2. Not knowing how to personally contribute to this big problem. Our research uncovered the major psychological barrier to action: “I can’t solve this by myself.” Good news—you don't have to. In every incident, there are multiple “characters,” each with a specific role in the corrective action.

Explore The Clinical Transformation Leader's Toolkit: Disruptive Stakeholder Diagnostic

The key initial steps are to diagnose and diagram disruption. To help you do that, consider the following questions:

Check #1: Are we responding to the full range of disruptions?

The vast majority of disruptive incidents are much less severe than throwing a scalpel. I tend to think of them as the “underwater” portion of the iceberg that sinks our ships. Are such behaviors, like the ones listed below, common at your organization? Do you classify and respond to them as disruptive behavior?

  • The senior physician that intimidates junior physicians into silence
  • The nurse that lies to the doctor
  • The surgeon that humiliates staff in the OR

Check #2: What are the norms?

A striking aspect of disruptive behavior is that the “disruptor” often believes the behavior to be legitimate—partly because in most cases, such behavior has been legitimized. Every time we let disruptive behavior go unchallenged, it reinforces acceptance and normalizes the behavior. And the probability of worse safety and quality outcomes rises.

Check #3: Where do I suspect the bystander effect?

Our research surfaced two interesting data points:

  • 85% of health care professionals report working with people who demonstrate disrespect
  • 35% of managers have spoken with staff when the concern is severe disrespect

So, despite the widespread prevalence of disrespectful behavior, we rarely do anything about it. This is somewhat to be expected—it is human nature to underreact when we witness conflict. (Type “bystander effect” into your preferred Internet search engine and in about a quarter-second, you’ll have all the literature you need.)

You can't guarantee that anyone can avoid this effect—including yourself. It’s powerful. The upshot is that you can’t assume your staff will act heroically. To be safe, assume the opposite. You can’t totally inoculate against bystanding, but one successful tactic we’ve seen is to create stories and narratives about instances when colleagues acted rather than stood by. Making these stories part of the culture can swing the odds in your favor.

Check #4: Am I enabling this?

Instead of trying to solve this problem by yourself (or standing idly), figure out what role you can play. Maybe it’s to step in at the crucial moment. Or, it might be to file the official report, or to sit down with HR and Legal. Or it might be to have the “strategic confrontation” after the fact.

Explore The Clinical Transformation Leader's Toolkit: Stakeholder Management Guide

At minimum, your role as a leader is to prod the protocol forward by:

  • Documenting anything you witness directly
  • Encouraging staff to report incidents
  • Protecting those who have provided input and stand up against retaliation

You can’t fix all disruptive behavior on your own, but you can set the tone and ensure that you are, at least, not making things worse with inaction.

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