BULLYING IN THE OPERATING ROOM

You’re a freshly trained, recently hired anesthesiologist at a new medical center. In your first week on your job, an attending surgeon in the operating room bullies you, making aggressive, sarcastic, and critical comments such as, “Are you trying to kill my patient? Have you ever done this before? Why is it taking you so long to get this patient to sleep?” or “My patient just moved. Can’t you give anesthesia better than that? Maybe I’d better ask for a different anesthesiologist.”

Does this ever happen? Unfortunately it does. What do you do?

Bullying in the medical profession is common, particularly during training years. A 1990 study (Silver HK, Medical student abuse. Incidence, severity, and significance, JAMA 1990 Jan 26;263(4):527-32) found that 46.4 percent of students at one major medical school had been abused at some point. By the time they were seniors, that number rose to 80.6 percent. In an Irish study, 30% of junior hospital physician responders to a questionnaire claimed to have been subjected to one or more bullying behaviors. (Cheema S, Bullying of junior doctors prevails in Irish health system: a bitter reality, Ir Med J. 2005 Oct;98(9):274-5).

The traditional medical education hierarchy of attendings > fellows > residents > interns > medical students sets up a pecking order where senior physicians pick on junior colleagues. One might paraphrase the phenomenon as “Sh__ runs downhill.” Younger colleagues are expected to do more “scut,” that is more paper work, computer work, contacting of consultants, chasing down lab and scan results, early rounds and late rounds on patients, as well as to sleep overnight in hospitals.

As physicians become more senior and exit training programs, their lifestyle improves and junior doctors, physician assistants, nurse practitioners, or registered nurses do more of their work. The tradition of condescending behavior toward those less trained may continue. When condescension crosses the line into disruptive or inappropriate behavior, it becomes a problem. Abused physicians, nurses, or techs can become angry or depressed, lose self esteem, and their physical and emotional health may suffer. Disrespect and bullying compromise patient safety because they inhibit the collegiality and cooperation essential to teamwork, cut off communication, and destroy team morale.

Joint Commission studies have shown that communication failure between health care workers is the number one cause for medication errors, delays in treatment, and surgeries at the wrong site. A 2004 study of workplace intimidation by the Institute for Safe Medication Practices (ISMP) (www.ismp.org/pressroom/pr20040331.pdf) found that nearly 40 percent of clinicians have kept quiet or ignored concerns about improper medication rather than talk to an intimidating colleague.Rather than bring their questions about medication orders to a difficult doctor, these health care personnel said they would preferred to keep silent. Seven percent of the respondents said that in the past year they’d been involved in a medication error in which intimidation was at least partly responsible.

In 2009 the Joint Commission began requiring hospitals to have a “code of conduct that defines acceptable, disruptive, and inappropriate staff behaviors” and for its “leaders [to] create and implement a process for managing disruptive and inappropriate staff behaviors.” The rationale for the standard states: “Leaders must address disruptive behavior of individuals working at all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.”

Stanford University Hospital where I work has adopted such a Medical Staff Code of Professional Behavior (found online at medicalstaff.stanfordhospital.org/bylaws/documents/Code_of_Behavior).

Excerpts from this document include:

“Inappropriate behavior” means conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive, and subject to treatment as “disruptive behavior.” Inappropriate behavior include, but are not limited to, the following: Belittling or berating statements; Name calling; Use of profanity or disrespectful language; Inappropriate comments written in the medical record; Blatant failure to respond to patient care needs or staff requests; Personal sarcasm or cynicism; Lack of cooperation without good cause; Refusal to return phone calls, pages, or other messages concerning patient care; Condescending language; and degrading or demeaning comments regarding patients and their families, nurses, physicians, hospital personnel and/or the hospital.

“Disruptive behavior” means any abusive conduct including sexual or other forms of harassment, or other forms of verbal or non-verbal conduct that harms or intimidates others to the extent that quality of care or patient safety could be compromised.

Disruptive behavior by Medical Staff members is prohibited. Examples of disruptive behavior include, but are not limited to, the following: Physically threatening language directed at anyone in the hospital including physicians, nurses, other Medical Staff members, or any hospital employee, administrator or member of the Board of Directors; Physical contact with another individual that is threatening or intimidating; Throwing instruments, charts or other things.

This is how the Stanford policy deals with inappropriate or disruptive behavior:

          If this is the first incident of inappropriate behavior, the Chief of Staff (COS)or designee shall discuss the matter with the offending Medical Staff member, emphasizing that the behavior is inappropriate and must cease. The offending Medical Staff member may be asked to apologize to the complainant. The approach during this initial intervention should be collegial and helpful.

            Further isolated incidents that do not constitute persistent, repeated inappropriate behavior will be handled by providing the offending Medical Staff member with notification of each incident, and a reminder of the expectation the individual comply with this Code of Behavior.

          If the COS or designee determines the Medical Staff member has demonstrated persistent, repeated inappropriate behavior, constituting harassment (a form of disruptive behavior), or has engaged in disruptive behavior on the first offense, the case will be referred to the COS and/or the Committee on Professionalism (COP). The subject will be notified of this decision and given an opportunity to provide a written response both prior to and subsequent to meeting with the COS or COP.

            If it is determined that the subject has engaged in disruptive behavior, a letter of admonition will be sent to the offending member, and, as appropriate, a rehabilitation action plan developed by the COS and/or COP, with the advice and counsel of the medical executive committee as indicated. The assistance of the Wellbeing Committee may be offered at any stage of this process.

             If, in spite of this admonition and intervention, disruptive behavior recurs, the COS or designee shall meet with and advise the offending Medical Staff member such behavior must immediately cease or corrective action will be initiated. This “final warning” shall be sent to the offending Medical Staff member in writing.

            If after the “final warning” the disruptive behavior recurs, corrective action (including possible suspension or termination of privileges) shall be initiated pursuant to the Medical Staff bylaws of which this Code of Behavior is a part, and the Medical Staff member shall have all of the due process rights set forth in the Medical Staff bylaws.

What do you do when inappropriate or disruptive behavior occurs in your operating room? The specialty of anesthesia provides wonderful positives such as intellectual challenge, multiple different subspecialties, hands-on procedures, and solid financial reimbursement. A disadvantage of the specialty of anesthesia is that anesthesiologists are consultants who do not have their own patients. No patient goes to the hospital or surgery center solely to have an anesthetic. Patients are there for some invasive procedure that requires an anesthetic.

Because the patient “belongs” to the surgeon, some surgeons use this fact to lord power over the anesthesiology provider, the operating room nurses, and surgical technicians, as well as over the hospital administration. A busy surgeon with a hefty workload brings a great deal of revenue to the hospital or surgery center he or she chooses to operate at. Some surgeons feel entitled to exercise condescending behavior toward nurses and anesthesiologists who they perceive to be merely part of hospital or surgery center services. Some surgeons yell, cuss, and throw things. Some engage in more subversive behaviors such as ignoring questions, acting impatient, insulting colleagues or speaking to them in condescending tones. Only a small percent of surgeons are bad actors, but a small proportion can have a big impact.

In my 25-year anesthesia career I’ve seen multiple examples of verbally and emotionally abusive surgeons. In distant years most of these surgeons met little resistance to their behavior. Staff who opposed them were moved to different operating rooms, and more enabling nurses and techs were found. The enablers were quiet, agreeable, hard working, and rarely questioned the surgeon’s authority. Anesthesiologists who resisted surgeon bullying stopped working with that surgeon, per both the surgeon and the anesthesiologist’s wishes. Alternate anesthesia providers were tried until a subgroup of passive enabler anesthetists was found.

My advice to any anesthesiologist out there is: Don’t be an enabler. You are a highly trained physician, deserving of respect. If a surgeon has an episode of acting disrespectfully to you or to any of the other operating room staff, conclude your care of that current patient without a confrontation. After the case is finished, choose a time to hold a face-to-face conversation with the surgeon. The setting could be a hallway, in the locker room, or at some other location where no patient care is being done. Tell him or her that you find their behavior toward you unacceptable, and that they need to stop it. If you get pushback, and you probably will, you have several choices: 1) have a loud verbal argument, asserting your will against theirs, 2) grin, bear it, and stop complaining about the circumstance; 3) request your scheduler to never schedule you with this surgeon again; or 4) kick it upstairs to the chief of the department and/or the chief of the surgery department.

Which option should you choose?

1) gets you a boisterous unprofessional argument with an individual who will be resistant to change. 2) results in a long-term unacceptable solution for you and your professional esteem. 3) gets you off the hook but does nothing to change the situation for others in the operating room. Only 4) will set the wheels in motion toward significant change. Stay calm and confident and refer the incident up to senior physician administrators to evoke change. If the department chairs can not impact behavioral change, take the issue higher to the Chief of Staff.

A genuine problem occurs when a bullying surgeon leaves all major medical centers and starts his or her own surgery center where he or she is the Medical Director and his or her bad behavior goes unscrutinized. If you are working in such a setting, I’d advise you to find another place to give anesthetics. Without an unbiased administrator, the surgeon bullying behaviors will never go away.

You’ll be happier working in an operating room cured of disruptive behavior, and the real winners will be the patients, who will come and go through a hospital free of disruptive behavior and bullying.

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Introducing …  THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

Publication date September 9, 2014 by Pegasus Books.

On October 2, 2014 THE DOCTOR AND MR. DYLAN became the world’s  #1 bestselling anesthesia Kindle book on Amazon.com.

To reach the Amazon webpage, click on the book image below:

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Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

REVIEWS:

5.0 out of 5 stars The Doctor and Mr Dylan, March 3, 2015
By
prabha venugopal (chicago, il USA) – See all my reviews
Verified Purchase(What’s this?)
Gripping from the beginning to the end. Very well written, bringing to the forefront all the human emotions seen in an operating room spill over into real life. I cannot wait for Dr. Novak to wrote another book! As another physician in the same profession, my admiration for his book knows no limits.

 

Bang-Up Debut Novel, November 16, 2014

By Norm Goldman “Publisher & Editor of Bookpleasures”

This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.

This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.

 

TwinCities.com PIONEER PRESS Entertainment

by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press mgrossman@pioneerpress.com, January 4, 2015

“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)

Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.

Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.

Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.

The Physician’s Late-Night Reading List

Two Pritzker alums pen captivating tales

By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine

For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.

Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.

Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”

One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.

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The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80

“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.

From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”

After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.

“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”

 

Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:

BOOK REVIEW “THE DOCTOR AND MR. DYLAN”

This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.

Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.

Rick, I can’t wait for your next book. Bravo!

From the author, Dr. Rick Novak:

Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in a small Midwestern town with an exceptional high school. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged nurse anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ FargoThe Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a series of twists that will keep readers guessing.

The book brings the issue of CRNA independent practice to a national audience, and this conflict drives the plot. Most of all, The Doctor and Mr. Dylan is a page-turning mystery, guaranteed to keep readers riveted until the final page.

 

Hibbingite writes twisted medical tale

HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.

Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.

“The dialogue is sometimes funny, and there are lots of plot twists,” he said.

Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.

“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”

Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.

 

5.0 out of 5 stars I Sense We Have Another F.Scott Fitzgerald Emerging on the Literary Scene, December 1, 2014
By
Deann Brady (Sunnyvale, CA USA) – See all my reviews
(REAL NAME)
I found Rick Novak’s first novel, “The Doctor and Mr. Dylan,” a most exciting combination of biting sarcasm, mystery and daily activity spun with fresh new phrases that made me turn my ear back to listen to the literary cadence of his words again and again even though, on the other hand, I was anxious to turn the pages to see what would happen next. His brilliant handling of scenes is reminiscent of The Great Gatsby by F. Scott Fitzgerald. A compelling read!Deany Brady, author of “An Appalachian Childhood”

 

 

By

allan mishra

This review is from: The Doctor and Mr. Dylan (Kindle Edition)

Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.

 

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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