Doctor Evil

Teaching disruptive physicians collegiality

About a year ago, at an unnamed hospital in Ontario, six nurses agreed to speak against a bullying physician to a committee that could recommend revoking his right to practise at the institution. The doctor’s supporters, fellow physicians, formed a gauntlet lining the hallway as the nurses passed through to a room where they spent the day testifying, and despite their efforts he was ultimately allowed to stay on at the hospital. Not surprisingly, stories of ongoing abuse continue to circulate. One particularly distasteful incident occurred after the doctor informed a patient in labour that he’d be giving her an episiotomy (a cut to enlarge the birth canal). The woman turned to her midwife, who said the procedure was sometimes the right decision. Perceiving her opinion, or perhaps the patient’s interest in it, as insolence, the doctor sneered, “I’ll just let you blow and stitch you later.”

These sorts of cases are not isolated; in a 2005 Statistics Canada survey, 12 percent of hospital-based nurses reported emotional abuse by a doctor in the previous year. But hospital administrators seldom make more than a superficial effort to eradicate such behaviour. That’s because doctors aren’t hospital employees; they’re independent contractors, protected from dismissal by the national malpractice insurer, the Canadian Medical Protective Association. And administrators will do almost anything to avoid a costly legal battle with the cmpa. Michael Kaufmann, the physician who heads an Ontario Medical Association counselling program for doctors, has seen files containing more than one last-chance letter. “The culture in medicine and hospitals has been ‘Put up with it for as long as you can,’” he says.

In 2005, the dangers of putting up with it were underscored when operating room nurse Lori Dupont was stabbed to death by a doctor at Hôtel-Dieu Grace Hospital in Windsor, Ontario. An internal report by the hospital described Dupont’s murder as “unforeseen,” but it wasn’t. A 2007 coroner’s inquest found that her killer, an anesthesiologist who died soon after of an overdose, had practised at the hospital despite “significant and documented complaints of serious disruptive behaviour problems.” He’d broken a nurse’s finger in the operating room, damaged equipment, verbally abused several nurses, and harassed Dupont.

Soon after the coroner concluded proceedings with a reading of the jurors’ twenty-five recommendations, including giving hospitals more control over doctors’ behaviour, the Ontario Hospital Association and the College of Physicians and Surgeons of Ontario released the first guidelines in Canada for managing “disruptive physicians.” The 2008 document encourage hospitals to record a physician’s bad behaviour and obtain a commitment that it won’t be repeated, spelling out the suggested approach in classically stilted case studies. Hospital manager: “Dr. Smith, I understand that on Tuesday you became so angry at the late OR start that you swore at the nurses, banged the side table and threw the instruments to the floor.” In response, Dr. Smith “didn’t deny that her behaviour was inappropriate…but said that it was a brief moment of frustration that passed quickly.” Counselling with a psychologist follows this interaction, but the abuse continues. And, as in the aforementioned real-life case, Smith’s lawyers block the hospital from forcing her out, until she pushes a nurse to the floor.

Obviously, guidelines don’t provide hospitals any additional leverage, but many hope they represent a step toward the kind of standards recently implemented in the US, where hospitals must now enforce explicit rules for physicians’ behaviour. It will take some time for evidence of success to emerge—or not. University of Toronto medical professionalism expert Monica Branigan is among a smaller group who think the Ontario and American strategies both miss the mark. In her view, the solution should account for the source of the problem. “Because we set ourselves up to be healers, this kind of behaviour is in the shadows. We don’t know what to do about it, so we try to disown it.” For medicine to move beyond a milieu in which disruptive physicians are tolerated, she says, doctors have to learn how to make good behaviour part of the culture. In practice, this means they can’t stay silent when another doctor makes them cringe.

For the past four years, through a program called Collegial Conversations, Branigan has been meeting with physicians on staff at U of T teaching hospitals to discuss how to address difficult situations involving their colleagues. “The case that gets the most legs,” she says wryly, involves a female medical resident under her supervision who arrived at work one morning dressed in a skimpy T-shirt and low-rise pants. “We were working with elderly people who didn’t appear to be comfortable with it,” Branigan recalls, but when she asks other doctors what they’d do, often the most direct approach involves offering the resident a lab coat; many male physicians say they “wouldn’t touch it with a ten-foot pole.”

Branigan then suggests an alternative: ask the resident why she’s underdressed. “There might be something that you don’t know; maybe she couldn’t get home last night and this is what she was wearing.” Having the conversation is what matters, she says, because it shows that both doctors share responsibility for behaviour affecting staff and patients, even when it’s not egregious. “You can’t expect people to start talking to a physician who’s stalking a nurse if they’ve never even talked to someone about what they’re wearing.” Whatever the particularities of the situation, Branigan emphasizes that dialogue is ultimately far more effective than pointing fingers, which is why doctors come out of the program not only better equipped to handle colleagues’ disruptive behaviour, but with more insight into their own.

The idea that the medical culture has to be nudged toward collegiality is gaining traction. In an unusual project in Indianapolis, leaders at the local medical school and its five hospitals successfully involved 900 people in an effort to build a respectful, collaborative environment. And Branigan’s program has begun to spread by word of mouth beyond physicians to nurses and occupational therapists, suggesting that we could soon see health care professionals across the spectrum working together more effectively, and patients receiving better care.

Miriam Shuchman