'Disruptive Physician' Needs a Better Definition

When I used to hear the term "disruptive physician," I pictured an angry doctor berating a nurse for no reason or, in extreme cases, a surgeon throwing a scalpel across an operating room.

It is, after all, the image invoked in articles like the one about disruptive doctors in this week's New York Times.

But that was before I spoke with Gil Mileikowsky. I interviewed the California-based obstetrician a couple of months ago while researching physician whistleblower candidates for our upcoming feature about 20 people who make healthcare better, and it has since made me think twice when I hear a physician called disruptive.

Like a lot of whistleblowers, Mileikowsky paid a high price for attempting to expose a flaw in the healthcare system. Very shortly after bringing up what he perceived to be systemic quality issues at his hospital and agreeing to serve as an expert witness in a related trial, he received the "disruptive" label and was informed by the hospital CEO that he would be escorted by security guards while on hospital grounds.

It's a familiar story to physician whistleblowers, and the disruptive label can, when abused, be a potentially powerful weapon for hospital administrators looking for a little leverage or, in some cases, revenge.

Not that there aren't plenty of disruptive doctors. As the New York Times piece points out, recent research suggests a wide-spread problem. A survey of healthcare workers from 2004 to 2007 found that 67% thought there was a link between disruptive behavior and medical mistakes, and 18% knew of a mistake that occurred because of an "obnoxious" doctor. Another survey by the Institute for Safe Medication Practices, found that 40% of hospital staff members reported withholding their concerns about orders for medication that appeared to be incorrect because of doctor intimidation. As a result, 7% said they contributed to a medication error.

Physicians who are truly disruptive put patients in danger, are a drain on an organization, and need to be dealt with. But given the term's ambiguity and potential for abuse, are hospital administrators really the best enforcers?

This seems like a problem ideally suited for physician leadership, whether from a medical director or through peer-to-peer physician intervention. If physicians are the first line of defense against disruptive peers, it is less likely to be a wedge issue between physicians and hospital administrators.

The Joint Commission's new standard requiring accredited institutions to address disruptive behavior is a step in the right direction because it formalizes the process, but it only vaguely calls for a code of conduct and processes for dealing with "disruptive and inappropriate behaviors," without a clear indication of what that means. And perhaps more importantly, it doesn't address physician involvement in the process.

The hospital is still free to define disruptive behavior as it pleases, and that can leave good physicians susceptible to unfair punishment.

Everyone's ultimate goal is to root out the doctors that are causing problems for patients and other providers. But to do that we need a much clearer definition of disruptive behavior, and physicians need to be involved in defining it.