Kids with guns
July 17, 2005 -- Today the Miami Herald published a fairly good piece by John Dorschner about recent efforts to deal with the continuing problem of abusive physicians. The article, "Nurses and staff stand up against uncivil doctors," suggests that social changes, liability concerns and the nursing shortage are helping nurses address the issue. The piece probably understates the ongoing severity of the problem. It does not seem to get that such conduct is a factor in the nursing shortage (not simply something the shortage is forcing hospitals to address), and it could have made clearer the extent to which disruptive conduct has a negative impact on patient outcomes. But the piece still deserves credit for an in-depth look at the problem, and for reporting on a promising new counseling program that has evidently improved the conduct of physicians referred to it.
The piece suggests that while physicians have long enjoyed a "godlike image" that effectively immunized their abuse of power, people no longer "look the other way" when physicians scream at nurses and patients, throw things, or behave in other abusive ways. According to a nurse at Baptist Health South Florida, the piece notes, in the past some nurses "took it upon themselves" to address the worst cases, calling a "Code Pink" in which nurses would rush to the aid of a colleague if a physician "got out of hand." Today, it reports, nurses "stand up," administrators issue ultimatums, and the worst cases are referred for treatment and possibly disciplinary action. The piece has a number of quotes from Raymond Pomm, the head of a local group that works with state agencies to place problem physicians in treatment, and psychologist Larry Harmon, who directs the Physicians Development Program (PDP), a locally-based nationwide firm that specializes in "changing the behavior of disruptive docs." Pomm describes the physician abuse of nurses, and also notes that "[w]e have surgeons beating up anesthesiologists, or anesthesiologists beating up surgeons."
The piece cites three factors that have contributed to the change in attitudes toward disruptive physicians. It suggests that the nursing shortage has forced hospitals to address nurses' workplace concerns. South Florida hospitals reportedly learned in recruitment-related focus groups that physician abuse was the "No. 1 issue" for local nurses who had recently moved there from other parts of the nation. The piece also cites liability concerns, noting that surgeons throwing instruments in the OR "can lead to errors and lawsuits." Finally, the piece suggests that the changing gender demographics of nurses and physicians have played a role, quoting a hospital executive, Wayne Brackin of South Miami Hospital, who notes that the atmosphere with today's "women physicians" and "male nurses" is "more collegial" and "not a master-slave relationship."
We don't doubt these are factors in efforts to curb the abuse, but this account understates the dimensions of the problem. Physician abuse is not just something the shortage is affecting, it is a significant cause of the shortage, as relationships among caregivers (nurses and physicians) stressed by the pressures of managed care cost-cutting have became increasingly strained over the last decade. Poor relations with physicians has been shown to be a significant factor in nursing burnout. Moreover, such problems are also a major threat to patient safety across the board, as intimidated nurses cannot provide good care. For one thing, they are less likely to pursue patient care concerns that could save countless lives, such as medication errors. As for the demographic point, we might note that nursing remains over 90% female, and that female nurses have not enjoyed strong support from most female physicians in resolving such problems with workplace conditions.
The piece reports that there is a debate about the current extent of the problem. Predictably, CEO Brackin says he and his department leaders deal with only a little over a dozen cases a year among 1,500 staff physicians, whereas nurse Maria Sanchez of Jackson Memorial calls disruptive physicians a "pretty common problem." She says the staff at her hospital, "protected by the union," does not hesitate to protest physician disruptive behavior. Harmon and Pomm, in an article in Psychiatric Annals, "cite surveys that show that more than 90 percent of nurses say they have witnessed disruptive behavior." In general, the piece probably minimizes the extent to which the problem persists in that it does not convey how strong the structural and social disincentives to nurses' speaking up about the abuse remain, especially in the many clinical settings where nurses have little power, as prominent articles in the global press have made clear. Unions may offer protection, but only about 17% of U.S. nurses are union members.
What happens to disruptive physicians? The piece says that "[v]irtually all misbehaving doctors are reported by hospitals;" after we stopped laughing, we realized that probably means that of the physicians referred to the PDP treatment program, most are from hospitals, rather than private practices. Harmon started PDP in 2002 at Pomm's request, and it has about 500 physicians in treatment at any one time, though most of those are there for substance abuse problems. The number there as "disruptive doctors" is reportedly "small" but "growing." Among the stressors on those in treatment are reportedly workplace pressures, such as those on surgeons "spurred to do more work because of lower reimbursement rates," and the pressure of legal fears where many "can no longer afford malpractice insurance." PDP receives referrals from PRN, or directly from hospitals. According to the piece, hospital staff complaints typically lead to administrators telling the problem physicians to "get treatment or be dropped from the staff." If the physicians referred to PDP through Pomm's Resource Network do not undergo treatment, they are reported to the state board of medicine for discipline. The piece does not say how many times this reporting has occurred, but no physicians have been disciplined so far. On the bright side, Harmon says that physicians in the PDP program are "often suddenly silent" when confronted with "this report" (presumably meaning the referral): "This is the moment of truth and the beginning of their rehabilitation." Pomm says that PDP has been so effective in improving such physicians' conduct that "he knows of none that have [sic] been the subject of new complaints."
The Center thanks the Herald and Mr. Dorschner for their generally helpful article on this important subject. See the article "Nurses and staff stand up against uncivil doctors."
See our FAQ on physician disruptive behavior.