There is a need for effective continuing medical education (CME) encompassing principles of professionalism and, specifically, disruptive behavior. For maintenance of board certification, each specialty requires competency in professionalism and communication skills, thereby increasing the focus on physician behavior.1,2 Since 2009, health care organizations have been charged with creating codes of conduct and processes for managing disruptive behavior, directly affecting practicing physicians. Yet, there is scant literature guiding professionalism education for practicing physicians, and education about disruptive behavior is lagging. Though there is literature about managing disruptive behavior, little has been written about preventing disruptive behavior through education.
CME programs are one avenue to educate practicing physicians about standards for professional conduct. We have had various experiences related to this topic, including evaluating physicians with disruptive behavior, speaking about professionalism and disruptive behavior to trainees and community providers, and reviewing patients' complaints in a large academic medical center. We have observed that efforts to discuss professionalism often elicit defensiveness. Organizational policies may be perceived as impinging on physician autonomy, and speakers may be seen as “behavior police.” The efficacy of education on disruptive behavior depends on physician “buy-in,” but physicians may feel judged, patronized, or suspicious from the outset. Some physicians are concerned about potential abuse of codes of conduct and disruptive behavior policies. Others feel that education on this topic has no relevance to their daily lives and is best left to common sense. Making the topic interesting and keeping the tone collegial and collaborative are real challenges.
One of the biggest challenges in discussing disruptive behavior is finding a clear, objective definition. As a guideline, the American Medical Association provides the following definitions:
Disruptive behavior means any abusive conduct including sexual or other forms of harassment, or other forms of verbal or nonverbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.
Inappropriate behavior means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby disruptive, and subject to treatment as disruptive behavior.3
We would clarify that a patient need not directly witness the behavior for quality of care and patient safety to be compromised.
Scope and impact
Only a small percentage of physicians are identified as disruptive, but these providers can have a profound effect on health care teams, delivery of care, and patient safety. In one study, 4% to 6% of physicians stood out as having more patient complaints than their peers.4–6 Large-scale surveys of the Veterans Health Administration estimate that 3% to 5% of physicians and nurses exhibit disruptive behaviors.7 In a survey of over 4,500 health care providers, disruptive behavior was observed in both physicians and nurses; 67% of respondents felt this behavior had led to adverse events, including stress and frustration, reduced team collaboration, communication problems, lower quality of care, medical errors, and, ultimately, patient mortality.7 Nurses cite relationships with physicians as a key factor in career satisfaction and retention.8
Some disruptive physicians meet criteria for a substance use disorder, mood disorder, or personality disorder.9–11 Even in the absence of psychopathology, disruptive physicians often lack the capacity to mentalize.9Mentalization encompasses the recognition that each person has unique life experiences, thinks subjectively, is motivated by internal states, and sees others' behavior from his or her own perspective.12,13 Disruptive physicians may lack the ability to recognize that others may perceive their behavior differently than it was intended, or to predict the impact of and response to their behavior. In these cases, further psychiatric evaluation and treatment may be indicated.9 In addition, an extended workshop specifically designed for such providers may be more appropriate than a typical one-hour CME program.4,14
Because of the potential impact of disruptive behavior on patient safety, the Joint Commission on Accreditation of Healthcare Organizations issued a 2008 Sentinel Event Alert on “Behaviors That Undermine a Culture of Safety” and new 2009 Joint Commission Leadership Standards, requiring that “the hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors” and that “leaders create and implement a process for managing disruptive and inappropriate behaviors.”15,16 Physicians have had mixed reactions to these new requirements. Although many physicians welcomed the codification of their professional values, some physicians expressed concern about potential misuse of policies.17 They feared that codes of conduct might be dangerously vague or subjective. Disagreement with hospital policies, patient advocacy, good-faith criticism, and whistle-blowing could be misconstrued as disruptive behavior. Additionally, some feared that physicians would be deprived of due process. One physician even expressed concern that physicians deemed “disruptive” might be coerced into medically inappropriate psychiatric hospitalization with compelled medications.18 Although this may represent an extreme viewpoint, it reflects the degree of concern and anxiety experienced by some physicians.
Designing effective CME for this topic is challenging. Traditional, passive CME improves knowledge, but interactive, participatory sessions with the opportunity to practice skills may be more likely to change physician practice and patient outcomes.19–21 A review of educational trials measuring professional practice or health outcomes concluded that mixed interactive and didactic education were more effective than either alone.21 In a review of randomized controlled trials of formal CME interventions, only interactive CME had any association with effect on professional practice and occasionally on patient outcomes.22 Stimulating discussions of relevant clinical vignettes optimize learning to ultimately improve professional performance.23 Further, case-based, small-group discussions promote medical students' development of moral reasoning, which can be reliably measured and is reflective of professionalism.24,25
Despite the evidence favoring interactive and sequential education,22 physicians—especially academic physicians26—seem to prefer traditional CME. Speakers, too, may find it easier to simply lecture or present slides, particularly with a large audience. Nonetheless, professionalism topics lend themselves especially well to an interactive educational model.
Responses to CME Sessions on Disruptive Behavior
In our experience, there are often preexisting biases against topics of professionalism and disruptive behavior, igniting defensiveness in even the most professional physicians. Perhaps physicians worry that their credibility, morals, or dedication will be scrutinized. They may fear that a professionalism lapse will result in job loss or license revocation. Feeling under siege promotes the view that it is “us versus them,” leaving little room for self-reflection or growth. Providers who have been cited for behavioral problems may be especially likely to hold these views.
Recommendations for Improving CME
Knowing the audience
Knowing the audience is particularly important when discussing disruptive behavior. “Diagnosing the learner” as a way to direct the teaching process has been emphasized frequently in educational literature.27–29 In our case, the educator must attempt to understand the organization's policies, the medical staff climate, and the learners' motivation for attending the CME program. To that end, the speaker might ask to review the code of conduct and disruptive behavior policies and to talk with a physician on the executive staff or CME committee. Speakers might ask the following questions:
- Why talk about disruptive behavior now?
- What is the objective of the presentation?
- Have there been any recent disciplinary actions in the hospital or medical community?
- What are the physicians' perceptions of the code of conduct and disruptive behavior policies?
The results of this pre-presentation research can be used to facilitate a collaborative relationship with the audience, thereby enhancing learning and behavior.27,28 Depending on the climate of the audience, we propose two different viewpoints for discussing disruptive behavior, which we refer to as “rekindling of values” and “risk reduction.” We use these terms to reflect the rationale, justification, and objectives for presenting this topic. The “rekindling” strategy emphasizes altruistic values and ideals, appealing to the physician's sense of himself as a moral person. The “risk reduction” strategy emphasizes the need for awareness of the topics to protect the physician from risk.
Presented from the “rekindling” perspective, the following language might be used:
The vast majority of physicians are doing a job for which they have passion and conviction. Professionalism is built in. Without thinking about it explicitly, they prioritize patients' needs and strive to provide excellent care. Society expects this, with medical professionalism at the foundation of the trust lent to physicians by patients.24 Taking time to reflect on the privilege and responsibility of being a physician can inspire us to be our best selves.
In contrast, sample language for the “risk reduction” perspective is the following:
We all have lapses in professionalism—times when we are not at our professional best. Do we learn from those lapses or do they become a pattern of behavior? Increasing self-awareness and reducing stress and burnout can be protective. Understanding the hospital code of conduct can help avoid running afoul of the standards.
Depending on the local climate, either the “rekindling” or “risk reduction” perspective may resonate better with the audience. Medical staff members who feel persecuted or misunderstood by the administration may respond better to the “risk reduction” approach.
Engaging the audience
Once a general perspective for the program is determined, attention can be shifted to engaging the audience. Because most CME programs are a large-group format, we will focus on techniques for building audience participation. These recommendations are based on our own experiences in programs about disruptive behavior and professionalism. As discussed in Box 1, “In the Trenches,” programs that went awry have compelled us to troubleshoot to improve our teaching techniques.
Audience response technology allows participants to answer multiple-choice questions using a device similar to a small remote control. Cumulative responses are displayed immediately. Use of an audience response system may enhance attention and enthusiasm for a presentation topic.30 Responses are anonymous, removing worries about publicly choosing the “wrong” answer. Questions may elicit understanding of policies, behavioral norms, and attitudes. The speaker can take the pulse of the audience in real time and tailor the discussion as needed. This approach has the additional advantage of providing immediate feedback to “outlier” physicians about norms of acceptable behavior.
Physicians' essays and reflective writings can be quite powerful and are useful in education about professionalism topics.31–33 To increase audience “buy-in,”it can be advantageous to ask one or two local physicians, known to the audience as exemplifying professionalism, to write a few thoughts about what professional behavior means to them. Audience members can then discuss these reflections in small groups. By having local physicians provide some definitions of professional behavior, the speaker avoids the role of “behavior police.” Such discussions serve to underscore the premise that we are all invested in the behavior of our profession as well as our individual behavior.
Clear examples of disruptive behavior can help take concepts out of the abstract and make them more relatable. Deidentified composites of actual cases can be useful, especially if they depict multidimensional characters rather than “all bad” stereotypes with extreme disruptive behavior. Depicting more subtle situations is likely to be more thought-provoking and relevant to everyday experience. During the presentation, audience members can rate the acceptability of example behaviors. The audience members become the judges, reducing the perception that their own behavior is being judged. Vignettes can also make the process for managing disruptive behavior more transparent. Our “Example Vignette of Disruptive Behavior” (Box 2) depicts a case of disruptive behavior that leads to administrative intervention, evaluation, and rehabilitation.
Movie or television clips are used in education to promote reflection and teach skills that are difficult to observe directly.34–36 In the opening scene of The Doctor, William Hurt portrays a likable, brilliant thoracic surgeon who makes disparaging remarks to an anesthetized patient, openly mocks colleagues, and sexually harasses a nurse. Many audience members will recognize this character from their own experiences, which allows for discussion of how we have internalized role models, both good and bad. Having the audience discuss the clip in small groups and report themes to the larger group can be an effective way to increase the relevance of the topic.
Finally, role-playing provides opportunities to practice new behaviors. We have used role-playing to practice giving feedback to peers about problematic behavior, which can be effective in preventing patterns of disruptive behavior.37 Feedback from peers may also inform and improve physicians' self-assessment.38 Brief scenarios depict typical behaviors that may be witnessed by a colleague. Participants are each assigned a role and take turns giving feedback to address the behavior. Again, this emphasizes that we are all responsible for the behavior of our profession.
The authors' example feedback scenarios:
Dr. A witnesses Dr. B make derogatory and humiliating remarks to a staff member.
Dr. A does not return repeated pages about her patient, resulting in Dr. B being called in to care for a patient he does not know.
Evaluation and Follow-up
Our aim is to increase desirable (professional) behavior and decrease undesirable (disruptive) behavior. However, meaningful assessment of these outcomes is difficult, and we have not developed a standardized evaluation tool for our programs. We have collected audience ratings, which have been generally favorable. Audience members' responses to such questions as “What will you do differently after attending this CME?” include such themes as increased self-reflection, thinking before speaking, increased empathy, greater self-awareness, and working with hospital administration to create an environment of safety. Responses also indicate the need to extend education across disciplines and not target physicians alone. Because these evaluations are largely satisfaction based, we cannot conclude that the programs have reduced disruptive behavior. Nonetheless, audience members' written comments provided valuable information about audience attitudes and spurred our thinking about ways to defuse defensiveness, in particular. Thus, the assessments have proven useful, even if they do not allow us to determine effectiveness at changing behavior.
Assessment methods used in medical education24,39,40 have not been widely used to assess professionalism in practicing physicians, and the most common assessment tools lack evidence. For example, the maintenance of certification professionalism competency is measured through self-assessment and practice assessment,2 but the accuracy of physician self-assessment is debatable.23,38,41–43 Similarly, the validity of self-assessment questions used to evaluate traditional CME and workshops has been debated.44 Further, this type of assessment is often satisfaction based. Because most physicians reportedly prefer traditional, passive-format CME,26 satisfaction-based evaluations of the interactive teaching methods suggested here may be negatively skewed.
Perhaps the most relevant evidence for a program's success is decreased incidence of disruptive behavior. CME courses aimed at providers with a history of disruptive behavior have reported decreases in disruptive behavior and impact following a three-day experiential group process.14 However, to our knowledge there are no reports of preventative educational programs for disruptive behavior aimed at general medical audiences. Given the small number of providers identified as disruptive, the “number needed to teach” to demonstrate change within a general medical audience would be quite large. As disruptive behavior is increasingly discussed, it may be possible to see a decline in reports to the National Practitioners Data Bank and medical licensing boards over time. Of course, education is not a panacea to prevent disruptive behavior. In some cases, only treatment will address the root causes of the problematic interactions.
Development of an assessment tool to accurately capture reduction or prevention of incidence of disruptive behavior is an area for future focus. Potential questions to promote self-assessment and evaluate predicted likelihood of behavioral change might include the following: How often do you witness disruptive behavior in other physicians and staff? Have you engaged in disruptive behavior? After attending this CME, how likely is it that you will be more reflective about professional behavior? If you witness a colleague's disruptive behavior, how likely will you be to intervene and provide feedback? Such questions can be adapted for either open-ended reflection or use of Likert scales.
Professionalism CME is increasingly necessary to comply with regulations and maintain board certification. Clearly defining what constitutes disruptive behavior and maintaining transparent processes for dealing with such behavior is important for health care organizations. Education about disruptive behavior may increase physicians' self-awareness and promote professional behavior.
Educational programs focusing on professionalism and disruptive behavior should be interactive to stimulate discussion and self-reflection. Case vignettes, movie clips, and reflective writings may be employed to spark lively discussions, through which audience members interact rather than passively receive information. Audience response technology provides instantaneous feedback to the speaker and participants, which can maximize the educational objectives. Role-playing allows participants to develop and practice new skills. Understanding the climate of the local medical staff can also prepare the speaker for challenges beforehand. In areas where physicians are especially defensive, it can be beneficial to solicit allies in respected local physicians.
Finally, discussions about disruptive behavior can elicit significant emotional reactions. Approaching the topic from a “rekindling” as well as a “risk reduction” position can facilitate discussions that are as pragmatic as they are inspirational. Promoting accountability for the behavior of our colleagues as well as ourselves deepens the investment we all share in our profession. This is the essence of self-regulation in medicine.
The authors thank Glen Gabbard, MD (Baylor College of Medicine, Houston, Texas) for his expertise and mentorship on this topic and for reviewing the manuscript.
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