SURGICAL ETHICS CHALLENGESJames W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor

Ethics of unprofessional behavior that disrupts:Crossing the line

James W. Jones, MD, PhD, MHA, and Laurence B. McCullough, PhD, Houston, Tex

Law is necessary because men are subject to passions; if allmen were reasonable, law would be superfluous.

Will Durant (The Story of Philosophy)

As chief of surgery, you have been contacted by themanaging operating room (OR) nurse about Dr FrankN. Stein’s behavior earlier this morning. Dr Stein, asenior surgeon, has long had a reputation for outland-ish behaviors in the OR. He is the impeccable gentle-man outside that environment, loved by patients andnonoperating personnel alike. He has an internationalreputation as a master technical surgeon, operates asefficiently as anyone on the planet, and has the largestpractice at the medical center. He has survived beyondthe generation of tolerance because he has retained thesame OR crew that over the years have callousedenough to regard his scurrilousness as just being Dr S.Today, he crossed the line. Dr. Stein, known for hiscolorful diatribes, trounced decorum when he orderedthe operative team, excepting the anesthesiologist, outof the OR and demanded that a new team be substi-tuted. This resulted from a shouting match with a newcirculator when she took issue with a personal insult.The transition was accomplished, causing delays inboth Dr Stein’s OR and several other ORs wheresubstitute nurses were commandeered. At least oneother faculty surgeon has complained about the incon-venience. In your office, Frank, long a colleague, insiststhat the nurses involved are assassins and refuses towork with them from this day. What should be done?

A. Assign ex-bouncers to assist him.B. Get him what he needs. The support people are there for

support not to disrupt the surgeon.

From The Center for Medical Ethics and Health Policy, Baylor College ofMedicine.

Competition of interest: none.Correspondence: James W Jones, MD, PhD, MHA, Center for Medical

Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza,Houston, TX 77030 (e-mail: jwjones@bcm.tmc.edu).

J Vasc Surg 2007;45:433-50741-5214/$32.00Copyright © 2007 by The Society for Vascular Surgery.

doi:10.1016/j.jvs.2006.11.043

C. Survey the nurses, physicians, administrators, and allsupport personnel to determine institutional relations.If the problem is part of a pattern, require Dr Stein toundertake remediation in professionalism as part of aninstitutional program.

D. Dismiss Dr Stein from the staff.E. Make working in a difficult surgeon’s OR voluntary and

give combat pay.

In this issue, Dr Whittemore emphasizes the detrimen-tal effects that serious deficiencies of professionalism haveon patient care.1 He provides examples of such morallyshocking behaviors as to render the use of “unprofessional”damning with faint praise. He corrects misconceptions ofthose in the trenches who may well regard others withbehavioral problems as eccentric, amusing, or patheticallymisguided. Instead, he emphasizes that those behaviorscrossing the line damage patient care.

Aberrant outlandish behavior is part of the fading ma-cho surgical stereotype. In the not so remote past of the lastcentury, surgeons were given more latitude in the work-place; one classification involved whether or not surgicalinstruments became projectiles. Generally, one’s behaviorwas not reported unless injury or the possibility of injury tocoworkers was involved. Crass assertions by surgeons werecommonplace and still are in some ORs, albeit with steadilylessening frequency.

Medical professionalism has received much attentionrecently from statements by medicine’s major professionalorganizations whose goals are to codify and improve behav-ioral standards.2 Extremes such as behaviors that disruptmedical care are not mentioned, just as ethics essays do notroutinely discuss why murdering innocents is wrong; theirethical unacceptability should be obvious. Formalized pro-fessionalism codes and charters concentrate on dealingswith the patients and economic issues, whereas professionaldisruption is more related to interactions with coworkers,usually without the patient’s knowledge. According toWilhelm, “Disruptive behaviors include repeated episodesof: sexual harassment; racial or ethnic slurs; intimidationand abusive language; and persistent lateness in responding

to calls at work.”3

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Although the surgeon is the captain of the team, surgi-cal therapy is dependent on the proper functioning of allthe members of the health care team. The introduction ofbehaviors by members of the team that disrupt the team’sfunctioning, especially by the captain, clearly is unaccept-able.4 Ethically, this is so because disruptive behavior makesthe surgeon’s own ego needs the surgeon’s primary con-cern and motivation and attempts to make meeting thoseneeds the primary concern and motivation of the othermembers of the surgical team. However, as Dr ThomasPercival put it when addressing the ethics of potentiallydisruptive relationships among consulting physicians (oneof the most persistent topics in the history of medicalethics), “the good of the patient is the sole object in view.” 5

Disruptive behavior obscures the patient from view alto-gether in circumstances in which the ego needs of thesurgeon can never plausibly be construed to be more im-portant that the surgeon’s primary responsibility to and forthe patient’s health.

We live in an era in which we are skeptical about theconnection between behavior and character. In particular,we are skeptical about whether we can reliably infer fromgood behavior to good character and vice versa. This crisisof manners dates from the late 18th century. Fissell notesthat at this time, “medical manners and morals becameunglued; no longer were codes of conduct based on cour-tesy functional.”6 Despite our skepticism, patterns of dis-ruptive behavior of physicians invite the inference from badbehavior to deficient professionalism (ie, defects in charac-ter). Such disruptive behavior, from the perspective of theethics of professionalism, is a very serious matter indeed,calling for serious responses by physician leaders.

Option A does en passant have possible merit. A ratherfamous surgeon, who was legendary in abusing surgicalresidents, would characteristically announce in the middleof a procedure that “I can whip you with one hand tiedbehind my back.” Not knowing that a resident had beenassigned who had been a successful professional boxerbefore medical school, the contentious surgeon threwdown the gauntlet once more. When challenged, the boxerresident replied, “No sir, it is I who could whip you withbut my left hand.” The abuse stopped for the remainder ofthat rotation but restarted with the following resident.Option A would not work longtime.

Option B allows unacceptable behavior in patient careareas to continue with administrative support. Thus, it isthe least ethical answer offered. Option E is a variant of Bthat is objectionable as well but at least attempts to com-pensate those most abused.

Option D should be chosen if remedial measures arenot effective. The courts clearly support an institution’sright to remove staff privileges when it can be proven that aphysician’s behavior disrupts the institution’s ability toprovide quality medical care. Management should deal withuntoward events differently according to whether they areunique or global.

In setting up an institution-wide program, Dr Whitte-

more considers disruptive behaviors to be widespread. Is he

justified? Data from a national study showed that 74% ofhealth care professionals had witnessed disruptive behaviorof physicians.7 This figure climbed to 86% when only datafrom nurses were counted. Regarding surgeons specifically,disruptive behaviors were more common in the periopera-tive area,8 where 97% of nurses reported witnessing sur-geons behaving badly. Surgeons themselves had the thick-est skins or greatest forgiveness: only 43% reportingwitnessing such events. So it seems that although behaviorshave improved with the present generation, a problemremains.

In every published study on organizational team pro-cesses involving medical care, there is need emphasized forimprovement of the physician’s interpersonal communica-tive skills.

After the Institute of Medicine publicity regardingmedical errors, considerable literature has accumulated em-phasizing the need for improvements in communicationskills among team members in complex high-risk environ-ments such as the operating room.9,10 Direct observationof medical teams treating patients identified errors in 30%of emergency room cases11 and more than one event com-promising patient safety per surgical case.7 The main causeidentified was lack of effective communication in environ-ments with “normally behaving” surgeons.

Dr Stein’s behavior and others like him is just the tip ofthe metaphoric iceberg drawing attention to an opportu-nity medicine should not ignore.

Option C emerges as the preferred option. Dr Whitte-more outlines corrective measures that have been taken athis institution and places responsibility just where it be-longs, on the physicians. He challenges, “Physicians mustset an example for others in the institution by behavingprofessionally and respectfully towards all members of thehealth care team, acting in concert with institutional poli-cies and statutory obligations, and by taking action when itcomes to your attention that others have not done so.”1

More to the point, it stands that dysfunctional surgeonscaptain dysfunctional operating teams and should beviewed by the profession as having incapacities that must beaddressed. No surgeon would fail to take decisive action ifhe noticed a tray of unsterilized instruments being deliv-ered for use to a colleague’s OR. Disruptive behaviors canbe just as harmful, without microorganisms to fault, andshould be taken just as seriously as a threat to patientwell-being and therefore to the medical professionalism ofus all.

REFERENCES

1. Whittemore AD. The impact of professionalism on safe surgical care. JVasc Surg 2007;45:415-9.

2. Jones JW, McCullough LB, Richman BW. Ethics and professionalism:do we need yet another surgeons’ charter? J Vasc Surg 2006;44:903-6.

3. Wilhelm KA, Lapsley H. Disruptive doctors. Unprofessional interper-sonal behaviour in doctors. Med J Aust 2000;173:384-6.

4. Purtilo R, Shaw B, Arnold R. Obligations of surgeons to non-physician team members and trainees. In: McCullough L, Jones J,Brody BA, editors. Surgical ethics. New York: Oxford University

Press; 1998; p. 302-321.

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5. Percival T. Medical ethics: or a code of institutes and precepts, adaptedto the professional conduct of physicians and surgeons. London: J.Johnson & R. Bickerstaff; 1803.

6. Fissell M. Innocent and honorable bribes: medical manners in 18th centuryBritain. In:BakerR,PorterD,PorterR,editors.Medical ethics andetiquette inthe 18th Century. London: Kluwer Medical Publishers; 1993.

7. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical out-comes: perceptions of nurses and physicians. Am J Nurs 2005;105:54-64; quiz 64-5.

8. Rosenstein AH, O’Daniel M. Impact and implications of disruptive

behavior in the perioperative arena. J Am Coll Surg 2006;203:96-105.

9. Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK,Dwyer K, et al. A prospective study of patient safety in the operatingroom. Surgery 2006;139:159-73.

10. Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Error or “act ofGod”? A study of patients’ and operating room team members’ percep-tions of error definition, reporting, and disclosure. Surgery 2006;139:6-14.

11. Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al.Error reduction and performance improvement in the emergency de-partment through formal teamwork training: evaluation results of the

MedTeams project. Health Serv Res 2002;37:1553-81.