Disruptive Workplace Behavior: Truly Transgressive or Personal Perception?

One of the most challenging aspects of managing disruptive or unprofessional behavior is defining what it looks like. While these concepts are largely abstract, there are established definitions. Opinion 9.4.4 of the AMA’s Code of Medical Ethics said physicians exhibit disruptive behavior when they “…speak or act in ways that may negatively affect patient care, including conduct that interferes with the individual’s ability to work with other members of the health care team, or for others to work with the physician” (asamonitor.pub/44JVsSS). “Every hospital has a policy on disruptive behavior that is mandated by The Joint Commission. Every anesthesiologist and hospital staff member should be familiar with the policy for their hospital,” said Joseph F. Kras, MD, DDS, MA, FASA, HEC-C, an Associate Professor of Anesthesiology at Washington University School of Medicine in St. Louis, Missouri. He is a member of his hospital’s ethics committee and has been on the ASA Committee on Ethics since 2010. Dr. Kras has presented on this topic, as has Richard L. Wolman, MD, an Emeritus Professor of Anesthesiology at the University of Wisconsin School of Medicine and Public Health, who has been on the ethics committee of the university hospital since shortly after joining their staff. Dr. Wolman has also been a member of the ASA Committee on Ethics for over 20 years. He said while examples of disruptive behavior in hospital policies can start off very concrete, issues of perception quickly make these definitions nebulous. Drs. Wolman and Kras observed an increase in accusations of inappropriate workplace behavior post-COVID due to “increased production pressures, decreased autonomy, and increased depersonalization of those working in the perioperative space.”

The professional can quickly turn personal, especially as staff shortages cause increasing rates of personnel turnaround time across the anesthesiology field. Dr. Kras noted it is harder than ever for hospital staff to build the trust needed for care teams to function.

One’s first instinct may be to take a defensive stance, but Dr. Kras urges staff members to assume good faith: “We need to assume competence and goodwill in our colleagues, and we need to extend grace and empathy. This is not always easy to do in the heat of the moment, but one thing that helps is to remember that this is not about us. This is about the patient, and as long as we keep that at the forefront of our minds, some conflicts can be avoided.”

Dr. Kras shared an example of how plastic surgeon Dr. Susan Mackinnon, Washington University in St. Louis, has introduced “Professionalism Time-Outs” as an addition to her regular surgical time-outs. In a professionalism time-out, everyone introduces themselves and their roles before a designated speaker reads two statements confirming the patient as the top priority and a commitment to resolving issues professionally. These statements affirm that participants are entering into the space with good intentions.

Inappropriate workplace behavior cannot be ignored, especially if you believe a colleague’s words or choices could cause harm to the patient. Consider the context: was this transgression part of a pattern of inappropriate behavior, or was it an uncharacteristic slip-up? Was this a clear transgression, such as a threatening physical or verbal outburst, or something passive, such as an individual exhibiting uncooperative attitudes toward routine practices?

First and foremost, timing must be considered. “If you’re coming off bypass in a cardiac case where suddenly there’s a massive bleeder, and somebody says something inappropriate, it’s not the time to bring it up,” Dr. Wolman advised. “You may have to sit with the sting of the transgression for two hours, but you cannot endanger the patient.” Many times, conflict can be solved colleague-to-colleague without escalating the issue.

Power dynamics, however, can complicate this. If the power differential between staff members involved in a conflict is too great, it may be best to avoid a one-on-one address that could backfire. Instead, enlist help in addressing the situation from an objective ethics committee.

An accusation of disruptive workplace behavior can be a stain on a staff member’s reputation, and at its worst, it can be career-ending. Drs. Kras and Wolman emphasize the need for institutions and their ethics committees to have a process for managing workplace behavior that is thorough, fair, and consistent. “Issues of questionable workplace behavior cannot be ignored. Inappropriate behavior is harmful to anyone in the surrounding environment. There are studies that show trainees of people who are bullies learn how to be bullies and mimic their behaviors, fostering a hostile work environment. But any system that is set up needs to be a fair process, because an inaccurate perception that leads to a false accusation can ruin somebody’s career, and multiple cases of this can wind up costing a hospital millions of dollars a year,” said Dr. Wolman. Dr. Kras adds, “You want to mitigate action when possible. Understand the context in which a transgression occurred and whether it is part of a pattern of recurrent misbehavior. You don’t want to pull out the nuclear weapons of responses for something that doesn’t necessitate it.”

Most hospitals have several responses available, ranging from an informal chat with the accused, a letter of reprimand, a note on the staff member’s record, or a report to the National Practitioner Data Bank (NPDB) in a worst-case scenario.

Going to the NPDB should be a last resort for an ethics committee, according to Dr. Kras, as it is nearly impossible to have a report removed from a physician’s record, even if the hospital is proven in a court of law to have lied, or that the investigation into an individual’s behavior was conducted with a sham peer review.

The AMA’s Code of Medical Ethics warns against weaponizing the system of disruptive behavior management:

Fear of the consequences of a false accusation of disruptive behavior has caused some physicians to take drastic measures. In institutions where the systems designed to manage behavior have been maliciously weaponized, some physicians chosen to relocate, rather than risk having their career threatened by a minor disagreement with a colleague.

Many aspects of health care remain purely clinical, but like any workplace, a hospital or university is made up of humans navigating labyrinthine social networks. What sets health care apart is the patient at the heart of the work, ideally surrounded by a community of providers who have dedicated their professional lives to protecting their well-being.