Physician Behaviour in the Professional Environment


Policy Number:#4-07
Policy Category: Practice
Under Review: No
Approved by Council: November 2007
Publication Date: February 2008
To be Reviewed by: November 2007
College Contact: Quality Management Division

Downloadable Version(s): Physician Behaviour in the Professional Environment


Purpose

As professionals, physicians are expected to act in a courteous, dignified and civil manner towards their patients, their colleagues (i.e., all those who work with the physician, whether members of a health regulatory college or not) and others involved in the provision of health care. The purpose of this policy is to provide specific guidance about the profession’s expectations of physician behaviour in the professional environment.

This policy does not offer guidance about the appropriate measures that may be taken to prevent or address unprofessional behaviour in the workplace. For advice and tools with respect to how to create an environment that fosters professionalism and deals quickly and effectively with problematic behaviour, the College recommends the Guidebook for Managing Disruptive Physician Behaviour . 1 The Guidebook offers advice about approaching potential problems in a graduated fashion which the College expects would usually circumvent the need for regulatory intervention.

Disruptive Behaviour

Disruptive behaviour occurs when the use of inappropriate words, actions or inactions by a physician interferes with his or her ability to function well with others to the extent that the behaviour interferes with, or is likely to interfere with, quality health care delivery.

In rare circumstances, disruptive behaviour may be demonstrated in a single egregious act2 but more usually such behaviour will be identified through several events demonstrative of a pattern. The gravity of disruptive behaviour depends on the nature of the behaviour, the context in which it arises, and the consequences flowing from it.

Principles

Professional behaviour and good clinical skills are both important components of physician performance.

Medical professionalism includes both the relationship between a physician and a patient and a social contract between physicians and society.3 A physician’s professional responsibilities include the following:4

  • Responsibilities to the Patient

    The physician’s responsibility is to act in the best interests of the individual patient. This includes acting respectfully toward patients and their families, friends and visitors, even under stressful situations.
  • Responsibilities to Other Members of the Health Care Team

    To promote the safe and efficient delivery of health care to all, physicians are expected to work respectfully and collaboratively with other members of the health care team. This includes other physicians, hospital staff, volunteers, students, and all other individuals who contribute to health care delivery.
  • Responsibilities to Uphold the Standards of the Profession

    Physicians have a responsibility to the medical profession to behave in a professional and appropriate manner.

Policy

The physician is expected to take responsibility for his or her behaviour. Where a physician’s behaviour is generally regarded as being disruptive, the physician is expected to cease the behaviour. If the physician is unable to control the behaviour on his or her own accord, the physician should seek appropriate assistance to do so.

Causes of Unprofessional Behaviour

There are myriad potential reasons for unprofessional behaviour: for example, such behaviour may have been learned through poor role models and entrenched through habit; it may be in response to a difficult or unhealthy work environment; or there may be physical or mental health bases for unprofessional behaviour (especially if the behaviour is new). In addition, many physicians face stress and exhaustion in their regular work which can contribute to lapses in appropriate behaviour.

It is not the purpose of this policy to explore the possible causes of the behaviour, but the College urges physicians to explore their options for obtaining assistance. In addition to whatever resources may be available in the local setting (medical school, hospital or other work environment), physicians and their colleagues are urged to contact the Ontario Medical Association’s Physician Health Program (PHP) to explore the reasons for the behaviour as well as resources for obtaining assistance.

Physicians should note that their interactions with the PHP, if any, are confidential and would be shared with the College only in the limited circumstances where a mandatory reporting obligation made it necessary.

Examples of Disruptive Behaviour

If the behaviour described below,

  1. occurs; or
  2. occurs and interferes with a physician’s ability to work with others to the extent that delivery of quality health care may be impeded,
  3. the behaviour is likely disruptive.

The following list provides examples of behaviour that may be disruptive. In the absence of repetition or interference with patient care, some of these behaviours would not ordinarily meet the definition of disruptive behaviour.5

Inappropriate Words

  • Profane, disrespectful, insulting, demeaning or abusive language;
  • Shaming others for negative outcomes;
  • Demeaning comments or intimidation;
  • Inappropriate arguments with patients, family members, staff or other care providers;6
  • Inappropriate rudeness;
  • Boundary violations with patients, family members, staff or other care providers;7
  • Gratuitous negative comments about another physician’s care (orally or in chart notes);
  • Passing severe judgment or censuring colleagues or staff in front of patients, visitors or other staff;
  • Outbursts of anger;
  • Behaviour that others would describe as bullying;
  • Insensitive comments about the patient’s medical condition, appearance, situation, etc.;
  • Jokes or non-clinical comments about race, ethnicity, religion, sexual orientation, age, physical appearance or socioeconomic or educational status.

Note: Comments that are or may be perceived as being sexually harassing which are directed at patients may fall under the definition of sexual abuse at s. 1(3) in the Regulated Health Professions Act (RHPA). Such comments which are directed at non-patients may be professional misconduct.

Inappropriate Actions/Inaction

  • Throwing or breaking things;
  • Refusal to comply with known and generally accepted practice standards such that the refusal inhibits staff or other care providers from delivering quality care;
  • Use or threat of unwarranted physical force with patients, family members, staff or other care providers;
  • Repeated failure to respond to calls or requests for information or persistent lateness in responding to calls for assistance when on-call or expected to be available;
  • Does not work collaboratively or cooperatively with others;
  • Creating rigid or inflexible barriers to requests for assistance/cooperation.

Advocacy

The College recognizes advocacy as an important component of the doctor-patient relationship. Physicians have a responsibility, individually and collectively, to advocate for their patients.8

On occasion, in the course of such advocacy, physicians may find themselves in conflict with colleagues or the administration of the institution in which they work. In such a circumstance, it may be difficult to evaluate whether the behaviour is disruptive, as defined in this policy. Each physician should carefully assess the impact of his or her conduct on the ability to deliver quality health care to the patient or patients. When the delivery of quality health care is impaired by the physician’s advocacy efforts, the physician should reevaluate whether the advocacy effort is, in fact, in the patients’ best interests.

Professional Misconduct

Under the Regulations to the Medicine Act, 1991, it is professional misconduct to fail to maintain the standard of practice or to engage in conduct unbecoming a physician.

Depending on the nature and the degree of the disruptive behaviour, as defined above (whether captured in the examples or in the definition), such behaviour may be considered to be professional misconduct.

The expectation of courteous, dignified and civil behaviour extends to interaction with the College. It is unprofessional conduct for a member to refuse to reasonably cooperate with the College. When the College makes reasonable requests for information and when attendance at the College offices is requested to deal with areas of concern, it is the professional responsibility of each member to cooperate with these requests.9

Endnotes

1Available on CPSO website under the Disruptive Physician Behaviour Initiative section.

2This is not to suggest that one incident of an inappropriate reaction to stress, exhaustion or some other reality of modern practice will necessarily attract College action. See further descriptions that follow.

3Canadian Medical Association’s policy - Medical Professionalism (Update 2005).

4See The Practice Guide: Medical Professionalism and College Policies .

5This list of examples will be added to as new issues are brought to the attention of the College through complaints and reports.

6Respectful discussions in which disagreement is expressed are not arguments.

7See the CPSO policy Maintaining Appropriate Boundaries and Preventing Sexual Abuse.

8See The Practice Guide: Medical Professionalism and College Policies .

9See the CPSO policy Cooperation with the College.

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