Members of professional organizations are required to self-monitor and to self-correct their behavior. Among physicians, self-regulation is essential for protecting patients, promulgating physician excellence, and promoting an interdisciplinary, collaborative practice. Professionalism is one of the six core competencies required by the Accreditation Council for Graduate Medical Education (ACGME). The ACGME defines professionalism as:

  1. Compassion, integrity, and respect for others
  2. Responsiveness to patient needs that supersedes self-interest
  3. Respect for patient privacy and autonomy
  4. Accountability to patients, society, and the profession
  5. Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation (

The Joint Commission requires regular review of practice trends that might impact the quality and safety of patient care, such as review of patient complaints and breaches of the professional code of conduct ( Most medical societies and organizations, including hospital medical staffs, require members to agree to and uphold written professional standards. In short, medical professionals have an obligation to evaluate their professional conduct and to self-correct when it strays from accepted norms.

Lapses in professional behavior have been variously categorized as disrespectful, inappropriate, disruptive, unprofessional, or behaviors that undermine a culture of safety. Disrespectful physician behavior is defined by The Joint Commission as using inappropriate words (insulting, intimidating, demeaning, humiliating, or abusive), shaming, making unjustified negative comments and complaints, not working collaboratively, and not returning pages promptly ( Such behavior may include physical abuse, insults, and public berating. Roughly 2%-3% of medical staff may be the subject of such complaints during their careers (Neurology 2008;70:1564-70).

Unprofessional behavior negatively impacts the delivery of health care in multiple ways. It is linked to increased stress, reduced team collaboration, reduced information transfer, and poor communication (Neurology 2008;70:1564-70). Patients whose surgeons have higher rates of unprofessional behavior are at increased risk of surgical and medical complications (JAMA Surg 2019;154:828-34). Residents exposed to uncivil or demeaning verbal abuse performed significantly worse than controls during simulated surgical crises (BMJ Qual Saf 2019;28:750-7). Physicians who received more unsolicited patient complaints have higher complication rates than peers and are at higher risk of malpractice litigation (JAMA Surg 2017;152:522-9). Rates of unprofessional behavioral events between faculty and trainees within the same specialty are highly correlated, implying that trainees mimic the behavior of their teachers – an unwelcome “hidden curriculum” (Acad Med 2018;93:1679-85). Finally, among nurses who leave their jobs, 6%-12% noted that exposure to unprofessional behavior in the workplace was a significant factor for leaving. Hospital turnover may cost hospitals $1.5 million to $4 million annually (Am J Nurs 2002;102:26-34).

It is therefore imperative that medical staffs implement and manage systems that report, track, and regulate unprofessional behavior among its members. These types of reports are often filed by our colleagues in nursing who, due to the considerable amount of time they spend in direct patient care, are often positioned to witness and to subsequently report unprofessional behavior. An unwelcome consequence is the potential for an adversarial relationship between nurses and physicians, the latter group who, paradoxically, requires this feedback to fulfill our duty as medical professionals to self-monitor and to self-correct.

Why do we see conflict arise between physicians and nurses so often? Why do nurses tend to identify behaviors as unprofessional that are often not seen as such by the involved physician?

Conflict is a clash or disagreement between two or more opposing groups, or an incompatibility, as of two things that cannot be simultaneously fulfilled ( On first blush, one might believe there is no reason for conflict. After all, both groups are focused on providing the best care for our patients. Yet it is common for nurses to report unprofessional behaviors exhibited by physicians.

These behaviors regularly occur during daily circumstances in our complex health care system. Physicians (when fatigued, hungry, or over-worked and frustrated by inefficiencies, worried about uncertainties in optimal care plans or by perceived obstructions to patient care) might lash out, speak in harsh tones, or insist on “cutting corners” to push for rapid patient care prior to dotting all the usual “I’s” or crossing all the “T’s.”

Nurse training is highly focused on following orders, protocols, and policies. The nursing requirement to strictly follow policy is reinforced on the job, with negative consequences when protocols are violated. Patient safety is always a priority, but nurses understand that “red tape” is critical to protect patients from inadvertent system errors or worse (Int J Environ Res Public Health 2020;17:2028). This is well established, as medical errors are estimated to be responsible for between 98,000 and 400,000 deaths a year in the United States (BMJ 2016;353:i2139). And this does not include other serious consequences for patients when errors result in injury or permanent disability. Steps – like surgical site marking and double-checks done in time-outs prior to surgery to ensure the proper patient is receiving the proper procedure – have been shown to reduce severe consequences like wrong-site or wrong-patient surgery (Wrong-Site Surgery: A Preventable Medical Error. 2008).

On the other hand, physicians are trained to think nimbly and often move quickly, particularly when patients are in extremis and needing emergent care. This approach may be critical in life-threatening emergencies. Surgeons, in particular, are trained in this mindset, reinforced throughout residency and into attending practice. Every procedure is unique. Surgeons give orders quickly and expect them to be followed immediately as they respond to ever-changing circumstances in the OR. Their focus is on the patient, and all extraneous communication represents a distraction. It is no surprise that surgeons and other proceduralists are the more frequently cited physicians for “unprofessional” communication and behaviors (

Physicians, especially proceduralists, bark orders. Nurses must follow protocols. This creates a perfect storm of training and cultural differences and incompatible perspectives, ensuring conflict.

A common perception in these circumstances is that the physician was rude or, frankly, aggressive. When physicians blow up in the work environment, lashing out at the team that is there to help them, they actually create a situation that makes effective teamwork and communication much worse ( Multiple studies have shown that nurses often do not notify physicians about patient issues because they are intimidated by physicians who “lash out.” This creates huge patient safety issues (J Ky Med Assoc 2007;105:165-9). Studies have also shown that rudeness and aggression in the work environment wreak havoc on the ability of team members to focus, think clearly, and communicate well with each other (Pediatrics 2015;136:487-95). The effects are seen on all team members present, not just the target of the aggressive behavior (

One might think it would be easy for people to speak up at the time of these behaviors, call out the concerns they raise, and continue with the air cleared. However, this scenario ignores the very real authority gradient present in medical care. Nurses traditionally have been trained to and are expected to follow physician orders. This mindset can extend beyond taking off patient care orders, as nurses may subconsciously defer to the physician in more general work circumstances. The physicians are seen to have power over the environment, making it very difficult to speak out when issues occur (Anaesthesist 2012;61:857-66). Power imbalance associated with an unspoken hierarchy has been associated with creating conflict itself ( All of this contributes to safety concerns (Br J Anaesth 2019;122:233-44). Indeed, the authority gradient is a safety issue in aviation as well, seen as at least partially responsible for some infamous accidents such as the Tenerife disaster, where 583 people on two commercial airliners died (Why Hospitals Should Fly: The Ultimate Flight Plan to Patient Safety and Quality Care. 2008).

Nurses and physicians also have different goals, which sets the stage for conflict. Doctors focus on treatment and curing the patient. Nurses spend far more time interacting with awake patients, and they focus on taking care of the whole patient. As a result, nurses may feel a responsibility to advocate for the patient’s wishes, rather than just treating their current disease process. Thus, a conflict can occur in what different members of the health care team deem “important.”

The result is that physicians may act out for a variety of reasons. Nurses bear the brunt of poor behavior as they stand up for their patients and insist on following policy and standard protocols, while feeling unable to speak out about their concerns. To help rectify this, reporting systems have been developed to enable any team member to report inappropriate/unprofessional behaviors, allowing those in authority in the system to respond and hopefully change behaviors that create less safe and less efficient working environments (Jt Comm J Qual Patient Saf 2016;42:149-64).

At our institution (Stanford), nurses complete these reports much more frequently than physicians. Though they are available to all members of the team, they tend to be seen as a tool to help nurses respond to concerns. This is also embedded in nursing training. Physicians are aware of these reporting systems, but they are not pushed as a primary mode of dealing with conflicts. Thus, we see an imbalance in how the systems are used. Physicians may worry about administrative sanctions or legal implications and can begin to feel they are being scrutinized and targeted, developing close to a sense of paranoia about what they are able to say in the work environment (personal communications) (J Patient Saf 2019;15:212-7).

The way in which the reports are handled can either ameliorate this sense of targeted reprobation or exacerbate it, with a punitive culture, or blame being attributed, increasing fear of the system. However, exploration of the event and coaching can create a growth/learning mindset (Jt Comm J Qual Patient Saf 2016;42:149-64). It’s important to obtain a balanced view of the interaction from the physician involved when giving them feedback. Using a balanced approach to investigating reports, understanding that there are always at least two perspectives in any conflict, is critical to allow the system to be accepted and endorsed as a tool to support patient safety rather than a way to punish individuals. It is also critical to protect reporters from retaliation if the system is to be used (Jt Comm J Qual Patient Saf 2016;42:149-64).

In summary, conflict is common in health care, increased by stress in the system, overworked team members, a fundamentally different approach to patient care between nurses and physicians, and intrinsic barriers to effective communication in the moment. Reporting has become the norm, often used predominantly by nurses in response to perceived inappropriate behaviors in physicians. When these systems are not carefully administered, when attention is not given to ensuring the “offending” physician’s voice is heard, a sense of weaponization of the system can occur.

These reporting mechanisms are critical to help support a safe working environment for patients and care teams. But unless the responses are appropriate, they may inadvertently increase the stress felt by physicians and exacerbate the burnout and loss of physicians in our system.