by MELINDA AQUINO, M.D., & SERGEY PISKLAKOV, M.D.
The American Psychological Association defines bullying as “a form of aggressive behavior” intended to cause distress or harm. Bullying involves an imbalance of power between the aggressor and the victim. It can be identified when someone persistently perceives him or herself to be on the receiving end of negative actions from one or several persons over a period of time. The individual at the receiving end has difficulty defending against these actions. Bullying can be physical as well as relational. It is a way to gain power.1
Physical bullying is obvious; in our society this form of bullying tends to be the province of children. Adults are more subtle and devious in their approach; their bullying can take a variety of forms, many of which may not be obvious to a third party. This allows bullies to continue their activities unchecked, enabling them to do what they want at the expense of others.
Aggressive and disruptive behavior in the workplace is fueling a nationwide grassroots legislative effort to force companies to draft and enforce policies aimed at stopping it. Bullying has been linked to higher costs in terms of turnover and insurance claims, and to decreased productivity.2 In January 2009, a new standard issued by The Joint Commission (formerly JCAHO) went into effect. It requires hospitals to have “a code of conduct that defines acceptable, disruptive, and inappropriate staff behaviors” and for its “leaders [to] create and implement a process for managing disruptive and inappropriate staff behaviors.” The rationale for the standard states: “Leaders must address disruptive behavior of individuals working at
all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.” A Joint Commission sentinel alert includes “uncooperative attitudes” and “condescending language or voice
intonation and impatience with questions” as disruptive behaviors.
The Joint Commission’s first-ever alert about the problem is the latest industry effort to address an issue that has challenged the medical community for years. Suggested actions include better systems to detect and deter unprofessional behavior; more civil responses to
patients and families who witness bad acts; and overall training in “basic business etiquette,” including phone skills and people skills for all employees.3 The lack of action against disruptive and aggressive behavior can lead to serious liabilities since these incidents sometimes constitute not only bullying, but also sexual harassment and discrimination.4
Disruptive behavior has been observed in almost all healthcare specialties. Physician behavior, however, may have the greatest impact because of the position of authority that doctors hold as members of the healthcare team.5 Out of fear of being intimidated or patronized, a team member may withhold valuable or even critical input, such as a medication error or a breakdown in adherence to safety protocols.2
Ensuring good patient care and respect among all healthcare professionals is at the very foundation of the ethics advocated by the American Medical Association.6 Intimidating, condescending, off-putting, or discouraging behavior by the physician inhibits positive teamwork. If an OR staff works suboptimally because of disruptive behavior by the physician or another team member, overall care quality is compromised and patient safety is threatened. To mitigate these risks, healthcare organizations may need to re-examine their hospital harassment policies to ensure those policies include specific prohibitions. Hospitals need to create workplace conduct policies that forbid disruptive and aggressive behavior, bullying or harassment. Once policies are in place, comprehensive training courses should be given to all supervisors and physicians. If policies are violated, appropriate action should be taken against violators to ensure proper enforcement.4
There is evidence that the prevalence of disruptive behavior in the medical world is high.7 The outburst by a physician in the OR is not uncommon. Bullying and mistreatment during training are also part of the experience for many early career doctors, medical students and residents.5 A 2004 study reported that 37 percent of doctors in 10 NYSSA — The New York State Society of Anesthesiologists, Inc. training had witnessed disruptive and aggressive behavior in the past
year.8 One of the major reasons for disruptive behavior is the lack of training in management and communication skills. Why do victims often not speak out against perpetrators? Victims often believe that a complaint would blight their professional progress; with an intentional
bully, this might be the case.9 The consequences of disruptive and aggressive behavior are far-reaching. There is evidence that this behavior is responsible for victims becoming stressed and depressed, leading to job turnover.
Although there would appear to be a difference between intentional and unintentional disruptive and aggressive behavior, the initially unintentional perpetrator may well come to gain satisfaction from this form of behavior, which will then, of course, be reinforced. Intentional bullying is a behavior that needs both decisive intervention and help.9
Approaches to unintentional bullying should be both educational and organizational. Work with the individual accused of bullying may need to include psychotherapy to explore the reasons for bullying or aggressive behavior. It should also include improving interpersonal and
self-awareness skills so that the bully can explore and adopt alternative ways of behaving.10 The organizational culture also needs to change. Hospitals, departments and individual personnel need to develop a higher level of awareness. Anti-bullying policies should be given a
higher profile. This should encourage victims to come forward so that individual bullies can be identified.
Unintentional bullies will usually, although not always, respond to the strategies outlined above and modify their behavior. They may well respond to personal approaches on the part of the victim. Victims should also approach their professional associations for advice and support. Primary preventive methods may include providing educational materials and communication skills training for residents, staff, and educators. Education on abuse, discrimination, and harassment in the workplace, and how these can be addressed and averted, can also be
presented in formal and informal curricula. Such initiatives should promote inclusive language and a culture of collegiality and respect for all faculty, staff, and trainees. Secondary preventive measures should rely in part on clear reporting mechanisms so that any occasion of abusive
or discriminatory language or behavior can be addressed as soon as it arises. In the meantime, and until further data confirm or deny the concerns identified here, we should be duly vigilant.
Melinda Aquino, M.D., is an assistant professor in the Albert Einstein College of Medicine and the Department of Anesthesiology at Montefiore Medical Center.
Sergey Pisklakov, M.D., is an associate professor and director of the neuroanesthesia fellowship in the Albert Einstein College of Medicine and the Department of Anesthesiology at Montefiore Medical Center.
1. Einarsen S, Raknes B, Matthiesen S. Bullying and harassment at work and their relationships to work environment quality: An exploratory study. European Work and Organizational Psychologist 1994; 4:381-401.
2. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. Am J Nurs 2005; 105:54-64.
3. Joint Commission - Sentinel Event Alert - Behaviors that undermine a culture of safety. Issue 40, July 9, 2008.
4. Institute for Safe Medication Practices (ISMP): Survey on workplace intimidation 2003. http://ismp.org/Survey/surveyresults/Survey0311.asp. Accessed on July 5, 2017.
5. Quine L. Workplace bullying in junior doctors: questionnaire survey. BMJ 2002; 324:878-9.
6. Physicians and Disruptive Behavior July 2004.
Behavior-Policy.pdf. Accessed on July 23, 2017.
7. Paice E, Aitken M, Houghton A, Firth-Cozens J. Bullying among doctors in training: cross sectional questionnaire survey. BMJ 2004; 329:658-9.
8. Margittai KJ, Moscarello R, Rossi MF. Forensic aspects of medical student abuse: a Canadian perspective. Bull Am Acad Psychiatry Law 1996; 24:377-85.
9. Cohen JS, Leung Y, Fahey M, et al. The happy docs study: a Canadian Association of Interns and Residents well-being survey examining resident physician health and satisfaction within and outside of residency training in Canada. BMC Res Notes 2008; 1:105.
10. Huntoon LR. Abuse of the “disruptive physician” clause. J Am Phys Surg 2004; 9:68.
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