AMA Journal of Ethics^®

Case

After 18 years of marriage, however, Dr. Wells divorced and returned to the US. She was dismayed to learn that she had to complete residency again in the US despite her years of successful practice and her fine reputation.

By the time Dr. Wells had finished her US surgery residency and gained staff privileges at Women's Hospital, she was almost 50. She is now 58 and is angry at the US medical education system for delaying her career; furious at US health insurance system for demanding justification of her clinical judgments, and disgusted at the young medical students and interns who have their whole lives ahead of them and complain all the time anyway.

Dr. Wells is impatient and cross with the OR nurses and has been known to throw an instrument back at a trainee who hands her the wrong one. On rounds, she asks patients how they are doing and cuts them off in the middle of their answers. She asserts, "I'm going to have a look at the incision," after she has already begun to remove the dressing and expose the incision. She has never been heard to say, "With your permission, I'd like Dr. So-and-So, and Dr. So-and-So (the residents) to have a look also." Dr. Wells has dictated false information for medical charts so that her patients could receive insurance reimbursement for an extra day or 2 in the hospital that she believed they needed. "When I have to explain medicine to some pencil pusher, that's when I'm out of here," she says. If a colleague questions a decision or suggests another possible course of action, Dr. Wells usually says, "You want to do it that way? Do it that way. I'm going ahead as planned."

Setting aside her gruffness and sometimes surly manners, Dr. Wells is a highly skilled surgeon. Her rate of complications and returns to the OR is extremely low. She has an intuition about each patient's anatomy and a deftness that, together, minimize the surgery's insult to the body she is operating on. The classes of residents are usually divided in their reactions to Dr. Wells. Some say that her insults to staff and rudeness to patients constitute a lack of professionalism that is tantamount to incompetence. Other trainees advise, "Ignore all that bedside manner stuff and watch her work. You'll learn something about surgery."

Commentary 1

Over the years, the window for acceptable physician behavior in the workplace has narrowed considerably. Perhaps it's not as narrow as that for ordinary human beings—and I use this phrase with my tongue in cheek—but we may be expected to behave according to usual civilized standards at some time in the future. On the surface, and the surface is quite important, Dr. Wells is behaving with arrogance, disdain for the opinions of colleagues, rudeness to nursing staff, belittling and dangerous behavior towards trainees, and a lack of empathy and respect for patients. She is compromised in her attention to the principles of medical practice that relate to interpersonal respect and care. In falsifying medical documentation she is further expressing her arrogant disregard for the rules we live by, but she is also undermining the principles of medical practice that relate to honoring the truth—the science we live by. She is endangering medicine by dishonoring herself, her colleagues, and associates. She is endangering students by throwing instruments at them and requiring them to tolerate humiliation. She is endangering patients by running over important personal boundaries, such as the consent to be examined. She is endangering her hospital by exposing it to risks of law suits by patients (malpractice) and by employees (hostile work environment) and to sanctions leveled by government agencies and insurers associated with trying to manipulate patients' benefits by falsifying information. Dr. Wells's behavior poses serious problems.

Dr. Wells is also, evidently, a talented if not brilliant surgeon who, but for these problems, would be an asset to her profession, and who has undoubtedly contributed to the health and well-being of thousands of patients. Students, too, have benefited from exposure to her, though I gather it is mainly those with enough social callus to ignore her style and behavior who are able to profit from working with her, and those more sensitive may learn little and/or be traumatized by associating with her. So we have a situation that is commonly faced by our medical community, a physician with much to offer but who is also very problematic, in this instance because of destructive attitudes and behaviors. How do we, as a community, conceptualize and approach such a problem?

Let's consider the "differential diagnosis." Is Dr. Wells's behavior a product of her personality? One can see signs of both obsessive-compulsive and narcissistic personality traits. If so, this kind of behavior should be relatively constant over time. Is her behavior a product of embitterment caused by having to retrain in a specialty in which she was previously highly regarded, going back to what she may feel are the indignities of being a trainee and losing her previous prestige? This could prove quite traumatic. If so, her difficult behavior is likely to have occurred only since she moved to the US. Could her behavior be related to a mood disorder such as depression which can reduce a physician's patience and tolerance and make her more irritable? Could she be using alcohol or other drugs excessively? Addictive disorders often present with behavioral problems even while the technical aspects of medical practice are intact. Could she be suffering from some other serious illness that she has not disclosed to any of her colleagues? If she is ill, did her depression, or addiction, or other illness begin after her move, or before? Why did she divorce and leave her adoptive country after 18 years? What happened in her marriage? Did she have behavioral problems at work in Egypt? Obviously, we have more questions than answers. To determine what is wrong beneath the surface, Dr. Wells needs expert evaluation. We cannot really prescribe an approach to the deep causes of her problems, because the "treatment" depends on the "diagnosis."

But we are not at a place where Dr. Wells's deeper issues can be addressed. Dr. Wells's difficulties must be met at the superficial level first, which means confronting her with the inappropriateness of her behavior and insisting on improvement. Because physicians are often powerful and intimidating people, this is not an easy thing to do. Often, such physicians are left alone for as long as possible which results in their engendering much hostility and fear in those around them and causes the physician to become isolated and suspicious, creating a vicious cycle and more avoidance of the problem. It is much easier to address problems early, soon after they become manifest. And addressing the problematic behavior must occur before the doctor in question can get any help.

The techniques for confronting such a physician are fit subjects for discussion, but not in this short space. The point of such a meeting is to identify the problematic behaviors, outline the expected improvements, and note the consequences of not complying. Expressing the wish to help is also essential. Referral for clinical evaluation of the problem is often appropriate, out of which treatment recommendations may flow. Referral to the state Physician Health Program will facilitate this process.

There are a couple of expressions, buzz-words of medicine, which bear discussing. Physician impairment is the inability to practice medicine with reasonable skill and safety as a result of illness or injury. Most ill physicians are not impaired at work, because, especially in chronic illness, they adapt to their condition and protect the workplace for as long as possible. The corollary of this is that if the workplace is impacted it is likely a late stage of the illness. In Dr. Wells's case, her work is impacted. Her social skills and judgment are affected. But we don't know whether or not she is ill, so as of now, technically, I would not describe her as impaired. I would simply say that she has behavioral problems and poor judgment with intact technical skills. Physicians with behavioral problems are often termed "disruptive physicians." I don't like this term because not all behavioral problems manifest as disruption; plus, it sounds judgmental. The term reflects the anger or upset which Dr. Wells's colleagues, students, patients, and administrators likely feel toward her. It is important for those trying to intervene and help Dr. Wells to be cognizant of such anger, and to speak to and work with her from a more balanced stance.