Physician Behaviour in the Professional Environment


Policy Number:#3-16
Policy Category: Practice
Under Review: No
Approved by Council: November 2007
Publication Date: Dialogue, Issue 2, 2016
Reviewed and Updated: May 2016
College Contact: Physician Advisory Service

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


Introduction

Physicians are expected to act in a respectful, courteous and civil manner towards their patients,1 colleagues2 and others involved in the provision of health care. Doing so fosters an atmosphere of trust, shared accountability and collaboration,3  and is an essential component to upholding the values and principles of medical professionalism. Conversely, behaviour that is unprofessional and/or disruptive undermines medical professionalism and the trust of the public. Literature shows that these behaviours can negatively impact both the delivery of quality health care, and patient safety and outcomes by eroding the effective communication and collaboration that underpin good medical practice.4

This policy sets out the College’s expectations of physician behaviour in the professional environment and identifies a subset of unprofessional behaviour known as disruptive behaviour.

The Guidebook for Managing Disruptive Physician Behaviour5 is the companion document to this policy, as it provides institutions and organizations with advice and tools for creating environments that foster medical professionalism, identifying disruptive behaviour, and effectively addressing disruptive behaviour in a staged approach.

Terminology

Disruptive behaviour: Disruptive behaviour occurs when the use of inappropriate words, or actions and inactions, by a physician interferes with his or her ability to collaborate, or may interfere with, the delivery of quality health care or the safety or perceived safety of others.

Disruptive behaviour may be demonstrated in a single unacceptable act but more commonly 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. Examples of behaviours that may be disruptive are set out in Appendix A.

Principles

The key values of professionalism articulated in the College’s Practice Guide – compassion, service, altruism, and trustworthiness – form the basis for the expectations set out in this policy.

Physicians embody these values and uphold the reputation of the profession by:

  1. Always acting in the best interests of their patients;
  2. Communicating effectively and with respect, sensitivity, and compassion;
  3. Collaborating effectively and respectfully with patients, colleagues, and others involved in the provision of health care;
  4. Demonstrating professional competence, which includes meeting the standard of care and acting in accordance with all relevant and applicable legal and professional obligations and expectations, to provide the highest possible quality of care;
  5. Participating in the self-regulation of the medical profession by acting in accordance with the expectations set out in this policy.

Purpose & Scope

This policy sets out the College’s expectations of physician behaviour and professionalism.

This policy applies to physicians working in a professional capacity and in their interactions with patients, colleagues and others involved in the provision of health care.

Policy

Physicians are expected to take responsibility for their behaviour and to meet the obligations and expectations set out in this policy, the Practice Guide, applicable legislation,6 along with the expectations set out in institutional Codes of Conduct, policies or by-laws. Specifically, physicians are expected to uphold the standards of medical professionalism, conduct themselves in a professional manner, and not engage in disruptive behaviours.

This dual expectation that physicians uphold the standards of medical professionalism and not engage in disruptive behaviours forms the basis for this policy and both are set out in the sections below. Where a physician’s behaviour does not meet this dual expectation, the physician is expected to change or cease his or her behaviour accordingly.

If the physician is unable to control the behaviour on his or her own, the physician is advised to seek appropriate assistance to do so. In addition to whatever resources may be available in the local setting (medical school, hospital, or other work environment), physicians and their colleagues are advised to contact the Ontario Medical Association’s Physician Health Program (PHP)7 to explore the resources available for obtaining assistance. Physicians should note that their interactions with the PHP, if any, are confidential unless a mandatory reporting obligation applies or the physician has signed an agreement with the PHP to release information to the College.

Medical Professionalism: Responsibilities

The social contract between physicians and society is the underpinning of medical professionalism. A physician’s responsibilities8 in this regard include, but are not limited to, those set out in the subsections below.

Responsibilities to the Patient

The physician’s primary responsibility is to act in the best interests of the individual patient.9 This includes acting respectfully toward patients, their families, friends or visitors, and prospective patients, even under stressful situations.

Physicians have a responsibility, individually and collectively, to advocate for their patients10 and, at times, this could lead to disagreements or conflict with colleagues or the administration of the institution in which they work. The College views advocacy as an important component of the physician’s role and recognizes that disagreements do not necessarily constitute disruptive behaviour. However, physicians are reminded that the expectation for professional behaviour remains even in the context of advocacy or conflict.

Responsibilities to Other Health-Care Professionals

To ensure the safe and effective delivery of health care and a healthy working environment,11 physicians must work respectfully and collaboratively with other members of the health-care team. This includes all who are involved in the provision of health care.

Responsibilities to the Profession

Physicians must uphold the standards of the medical profession by modelling appropriate behaviour for other members of the health-care team, in particular trainees, and fostering a culture of respect within their practice setting or workplace.

Disruptive Behaviour

Physicians must not engage in disruptive behaviours because they undermine professionalism as well as a culture of safety. These behaviours pose a threat to patients and outcomes by inhibiting the collegiality and collaboration essential to teamwork, impeding communication, undermining morale, and inhibiting compliance with and implementation of new practices.12

While there may be a myriad of reasons for disruptive behaviour, whether personal, professional, or situational, physicians are nevertheless expected to demonstrate professional behaviour at all times.

Appendix A

Examples of Disruptive Behaviour

As noted in the Terminology section of the policy, behaviour is considered disruptive when it interferes with a physician’s ability to collaborate, with the delivery of quality health care, or with the safety or perceived safety of others. 

The following list provides examples of a range of behaviours that may be disruptive:

  • Rude, profane, disrespectful, insulting, demeaning, threatening, bullying, or abusive language, tone, innuendos, and behaviour;
  • Arguments13 or outbursts of anger including throwing or breaking things;
  • Use, attempted use, or threat of violence or physical force with patients, colleagues, and others involved in the provision of health care;14
  • Comments or actions that may be perceived as harassing or may contribute to a poisoned professional environment;
  • Mocking, shaming, disparaging or censuring patients, colleagues, and others involved in the provision of health care;
  • Repeated failure to promptly respond to calls or requests for information or assistance when on-call or expected to be available;
  • Failure to work collaboratively or cooperatively with others.

This list above is not exhaustive. Notably, unprofessional behaviours captured by other College policies, such as those that could constitute sexual abuse or misconduct as set out in Maintaining Appropriate Boundaries and Preventing Sexual Abuse or discrimination as outlined in the Professional Obligations and Human Rights are not provided above. Physicians are expected to be aware of and comply with these, and other relevant College policies.

Endnotes

1. This includes the family and friends of patients.

2. Colleagues are considered all those who work with the physician, whether members of a health regulatory college or not. This includes other physicians, nurses, trainees, non-clinical staff, volunteers, and all other individuals who contribute to health-care delivery.

3. Shapiro, J., Whittemore, A., Tsen, L.C. (2014). Instituting a culture of professionalism: the establishment of a center for professionalism and peer support. Joint Commission Journal on Quality and Patient Safety, 40(4), 168-177.

4. The literature indicates a strong relationship between disruptive behaviours and poor patient safety and outcomes. The following is a representative selection of this literature.

  • Leape, L.L., Shore, M.F., Dienstag, J.L. et. al. (2012). Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Academic Medicine, 87(7), 845-852.
  • Sanchez, L.T. (2014). Disruptive behaviors among physicians. Journal of the American Medical Association, 312(21), 2209-2210.
  • Leape, L.L. & Fromson, J.A. (2006). Problem doctors: is there a system-level solution? Annals of Internal Medicine, 144(2), 107-115.

5. The Guidebook for Managing Disruptive Physician Behaviour (April 2008) has been endorsed by the College of Physicians and Surgeons of Ontario and the Ontario Hospital Association.

6. For example, physicians must abide by their legal obligations under the Occupational Health and Safety Act, R.S.O. 1990, c.0.1 (hereinafter OHSA).

7. More information on the Physician Health Program can be found at: http://php.oma.org/index.htm.

8. For further information see: Canadian Medical Association, Medical Professionalism (Update 2005).

9. Specifically, the Practice Guide notes that, “when providing care to a patient, a physician should always put that patient first.” For more information see The Practice Guide: Medical Professionalism and College Policies.

10. See page 12 of The Practice Guide.

11. Physicians may have other obligations under the OHSA both in regard to their own behaviour in the workplace, as well as specific obligations if they are employers, as defined by the OHSA.

12. Leape, L.L., Shore, M.F., Dienstag, J.L. et. al. (2012). Perspective: a culture of respect, part 1: the nature and causes of disrespectful behavior by physicians. Academic Medicine, 87(7), 845-852.

13. Respectful discussions, in which disagreement is expressed, are not arguments.

14. The policy does not intend to capture circumstances where, for instance, force may be necessary to restrain a patient who poses a threat to themselves or those providing them with care.

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