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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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Does operating room bullying occur? 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 intimidates 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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Published in September 2017:  The second edition of 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.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan: