Recently, a nephrologist was arrested and charged with assault after a verbal dispute with a cardiologist escalated.1,2 The well-publicized case spotlights the continuing problem of disruptive physician behavior.

“There can be a legitimate ethical disagreement about a patient’s care,” says Charles E. Binkley, MD, director of bioethics at Markkula Center for Applied Ethics at Santa Clara (CA) University.

A physician believes strongly it is appropriate to stop life-sustaining interventions, but a nurse, physician, or family member disagrees. It is not always an ethical dilemma. “People can be unkind to each other or not be professional, and it’s not necessarily an ethical issue,” Binkley explains. “Ethics should limit its scope to addressing the ethical issue.”

If a physician yells at a nurse or patient because of a disagreement over the treatment plan, involvement by human resources or another department is needed. “But if a physician’s belligerence or disrespect impacts someone’s decision-making, that is when you run into an ethical problem,” Binkley says.

If family members want to stop treatment and the physician is berating them to continue (or vice versa), it is an ethical issue. “It would be very appropriate to call the ethics committee if the disagreement is not being addressed in a reasonable way,” Binkley offers.

In those cases, there is a legitimate disagreement about care, but it is complicated by a lack of professionalism. A well-meaning physician has the patient’s best interest in mind, but a mental health issue or poor communication skills get in the way. “Simply punishing people for this doesn’t strike me as the best approach,” Binkley says.

Ethicists can facilitate physicians obtaining emotional intelligence training or some sort of counseling, with regular check-ins. Ethicists also can give input on disruptive behavior policies. “When behavior is unduly influencing decision-making, you want to be sure that principles of justice, nonmaleficence, and beneficence are being followed,” Binkley says.

Physician misconduct can be a significant problem “for patients, for the institutions in which they work, and for society in general,” says Philip M. Rosoff, MD, MA, former director of the clinical ethics program at Duke University Hospital. Rosoff says there are two main ethical issues at stake: Breaches of professional ethics by the physician, and breaches of organizational ethics by the institution. “When physicians act unprofessionally, it raises the question of how the institutions for which they work should respond,” Rosoff says.

Professional standards, state and federal laws, and institutional policies are fairly straightforward on what is expected of physicians. “What to do with individual transgressors is not always clear cut,” Rosoff notes.

Certain types of “unambiguously egregious” misconduct merit immediate dismissal, or at least removal of the accused offender from the hospital until the case is properly investigated and adjudicated, says Rosoff. For less clear-cut offenses, a warning, probation, or mandatory remedial education may suffice. Unfortunately, some misconduct falls under the radar entirely. “Some physicians are well-known to their colleagues and subordinates for being racists, misogynists, or just plain jerks, prone to abuse those who have less power,” Rosoff says.

Misconduct of senior clinicians, prominent researchers, or productive fundraisers may be tolerated to some extent due to the perceived value to the institution. “Others who are less well-placed may be offered the opportunity to resign without prejudice, avoiding the tiresome and often-tedious process of firing someone,” Rosoff explains. As terminating tenured physicians in academic institutions can be quite complex, accepting a resignation instead can seem like a good alternative. “Unfortunately, this just kicks the can down the road to another hospital, which offers a job to someone who hasn’t changed — and has glowing recommendations,” Rosoff cautions.

Three recent ethics consults have involved perceived inappropriate behavior by physicians at Baylor College of Medicine. Two of these consults came from nurses, and one came from another physician. “All of them seemed to be a source of moral distress for these clinicians,” says Joelle Marie Robertson-Preidler, PhD, a clinical ethics fellow at Baylor.

Inappropriate physician behavior “can lead to a whole host of negative consequences — inadequate or harmful patient care, loss of patient or family trust, poor stewardship of healthcare resources, and increased moral distress,” Robertson-Preidler says.

Ethicists are called to resolve issues such as physicians thought to be providing inadequate pain management, altering standard practice to make data look better, or taking part in implicitly discriminatory practices. “Ethicists should appreciate that these are cases of perceived inappropriate behavior,” Robertson-Preidler says.

The first step is to investigate the claims. The ethics consultant speaks with the physician directly to better understand the situation. If behavior seems to be inappropriate, ethicists can offer mediation and negotiation to come to a consensus.

“Sometimes, it can be tremendously helpful to get the stakeholders in the same room, hear out concerns, and refocus on providing the best care for the patient,” Robertson-Preidler says.

If these approaches are inadequate to resolve the issue, the situation is brought to the attention of administration, says Robertson-Preidler, “especially if patient care is at risk.”

In other situations, it is all a misunderstanding. For instance, a nurse perceives a physician is providing inadequate blood pressure medication to a patient whose family members are requesting aggressive treatment. However, the physician offers sound medical reasons to provide certain levels of medication. “The ethicist can facilitate better communication and resolve misunderstandings,” Robertson-Preidler suggests.

Good policies can lead to better physician accountability. These guidelines can help standardize practices to normalize expectations and help clinicians check their biases. For example, a policy on providing pain management after a cesarean delivery can mitigate the effects of unconscious biases around race. “Nurses may be uncomfortable confronting physicians directly due to unequal power dynamics,” Robertson-Preidler says.

If a nurse believes a physician is not giving adequate pain medication to a patient based on race, the nurse probably will feel more comfortable pointing to hospital policy than directly questioning the physician. “Policies serve as an accountability mechanism for the physician, as well as a protective mechanism for the nurse,” Robertson-Preidler explains.

Ethics consults can serve “as a type of third-party accountability mechanism,” Robertson-Preidler says. Ethicists learn the root of the problem is systemic issues. “Such issues can then be addressed at the administrative level and through education and policy development,” Robertson-Preidler adds.

REFERENCES

  1. WKBN Staff. Police arrest doctor after fight with another physician at St. Elizabeth in Boardman. WKBN 27. April 23, 2021.
  2. Tobias L. Physicians ordered to stay apart after breaking out in a fight. Scrubs Magazine. April 27, 2021.