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Aggressive behaviors are obvious and include yelling, the use of foul and abusive
language, threatening gestures, public criticism of coworkers, insults and shaming
others, intimidation, invading one’s space, slamming down objects, and physically
aggressive or assaultive behavior. Fortunately, most of these are unusual [ 7 ]. What
are much more common are passive-aggressive behaviors such as hostile avoidance
or “cold shoulder” treatment; intentional miscommunication; unavailability for pro-
fessional matters, e.g., not answering pages or delays in doing so; using a conde-
scending language or tone; expressing impatience with questions; indulging in
malicious gossip; adopting a sarcastic tone of voice; and/or resorting to implied
threats, especially retribution for making complaints [ 7 ].
There is a wealth of literature to demonstrate that these behaviors contribute to
medical errors, poor patient satisfaction, and preventable adverse outcomes, as well
as increasing the cost of care. They also lower morale to the extent that other health-
care professionals particularly nurses and administrators seek new positions in more
professional environments [ 8 – 11 ]. While these studies refer to practicing physicians
and not necessarily to residents, physicians in practice who behave in an unprofes-
sional manner frequently exhibited those same unprofessional behaviors during
residency and during medical school [ 12 ]. One barrier to addressing such behavior
is that disruptive physicians are often successful and accomplished practitioners,
who profess high standards of patient care and clinical practice. Aside from their
interpersonal behavior, they are valuable members of the profession because of their
knowledge and technical expertise.
Prevalence
Although disruptive physicians consume considerable attention, 50% of the con-
cerns are associated with only 9–14% of physicians [ 13 ], and this minority is
responsible for 50% of malpractice claim costs [ 14 ]. Leape and Fromson [ 15 ] report
that 3–5% of physicians present with a problem of disruptive behavior. According
to a 2004 survey of physician executives, more than 95% reported regularly encoun-
tering disruptive physician behaviors, and 70% reported that such behaviors nearly
always involved the same physicians and most commonly involved conflict with a
nurse or other allied healthcare staff. Nearly 80% of the respondents said that dis-
ruptive physician behavior is underreported because of victim’s fear of reprisal or is
only reported when a serious violation occurs [ 16 ]. Physicians, when evaluating
themselves, are less likely to perceive such problems. Sexton et al. found that 75%
surgeons, but only 45% of anesthesiologists, and 30% of surgical nurses expressed
satisfaction with the relationship they had with colleagues [ 17 ].
Anecdotal data suggest that allowing residents to graduate on time without ade-
quate remediation is not unusual, particularly when the deficiency is in interper-
sonal communication or professionalism [ 18 ]. In a single-institution study, 25% of
residents, who graduated on time and passed the American Board of Surgery exami-
nations on the first attempt, received marginal performance evaluations [ 19 ].
Nationally, the cumulative risks of termination are 3.0–19.5%, respectively, for all
surgical residents [ 20 ]. Although many “voluntary” resignations may not be entirely
H. Sanfey