Bad Behavior

Anyone who doubts that the image of physicians has changed in recent decades need only compare two characters from popular television shows: the caring and compassionate Dr. Marcus Welby, and the caustic and curmudgeonly Dr. Gregory House. Whether the real-life physicians of the 1970s — the heyday of Marcus Welby, MD — were really as unfailingly saintly as portrayed by actor Robert Young is open to debate. It is a fairly safe bet, however, that people today are not totally shocked by Dr. House’s ill-tempered rudeness.

According to a 2005 article in The New York Times (“When the Doctor Is In, but You Wish He Wasn’t”), bad behavior on the part of physicians may be a growing phenomenon. The article contends that this bad behavior is expressed in a variety of ways: being rude, arrogant, high-handed, dismissive, judgmental, callous, impatient or patronizing. Physicians, for their part, can be oblivious to the impact negative behavior can have — in part because patients tend to flee medical practices they’re dissatisfied with rather than fight what they see as mistreatment. “The reality is that a lot of these doctors don’t have a source of objective comments,” observed Dr. John Freedman, medical director for quality management at Tufts Health Plan in Massachusetts, in the Times article.

In 2004, the American College of Physician Executives conducted the Physician Behavior Survey, an online poll of 1,600 physician healthcare executives. According to the results of the survey (available at http://www.acpe.org), more than 95 percent said disruptive behavior by physicians was a serious problem for their organizations. Additional findings:

• Approximately three-fourths of the respondents said that chronic offenders were responsible for much of the bad behavior.
• Disrespect was identified as the most common disruptive behavior by 82 percent of those polled. The next most common problem was failure to complete tasks or perform duties (nearly 52 percent).
• More than one-third noted that behavioral problems by physicians frequently led to conflicts with other staff members, usually nurses or physician assistants.
• About half believed that the code of behavior adopted by their organization
• was applied selectively where physicians were concerned — with some 60 percent saying physicians received more lenient treatment than other staff members.

Rudeness Begets More Lawsuits

Not only can bad behavior by physicians disrupt the efficient and effective functioning of a medical practice, it can increase the probability that the offending parties will be sued for malpractice. According to a national study conducted at Vanderbilt University in 2004, the nature of the physician-patient relationship — not physician competence or actual quality of care provided — is the best predictor of whether malpractice claims will be made against specific doctors. In the study, researchers interviewed nearly 1,000 women about how satisfied they were with their obstetrician-gynecologist. (None had sued their doctor for malpractice.) The researchers compared the patients’ responses with the physicians’ history of lawsuits and their competence as evidenced by medical records.

In an article titled “Only the Rude Get Sued,” Psychology Today magazine reported that the Vanderbilt researchers “couldn’t find differences in the quality of care among the doctors who had been sued least and sued most ….” What apparently did make a difference: the physicians’ interpersonal skills. Another study — conducted at Ohio State University — involved interviewing 192 patients at two branches of the Mayo Clinic. This study arrived at a similar conclusion: Patients rate doctors on the basis of their behavior in the office rather than on their medical skills. According to MedPage Today, the Ohio State researchers observed that “patients can sense if the physician is rushed, preoccupied, tired, aloof, disinterested, or alarmed, just as they can sense a physician’s genuine interest, compassion, calmness and confidence.”

Hitting Doctors in the Pocket

A number of factors may be contributing to bad behavior by some physicians. Today’s doctors are being forced to treat more and more patients, work for lower reimbursement rates, function in a highly litigious environment and fulfill growing bureaucratic chores. The New York Times article quoted Dr. Beth A. Lown, past president of the American Academy of Physicians and Patients, as observing that “a truly heartfelt understanding of the patient’s circumstances … seems to have gotten lost as doctors get involved in medical systems that prioritize speed and technology.”

If the stressful conditions under which physicians now labor help explain bad behavior, they do not excuse it or give doctors a free ride. Indeed, The New York Times reported that an increasing number of medical groups are no longer willing to overlook such behavior by their physician members. Some medical groups, according to the Times article, are going so far as to survey patients about their treatment experiences and adjust physicians’ pay accordingly. Three examples:

• The satisfaction scores that doctors at the Rochester Independent Practice Association (New York) receive from the organization’s 3,000 patients can make up to a 20 percent difference in their paychecks.
• Bonuses for thousands of doctors at Tufts Health Plan have been withheld because of how they ranked in patient surveys.
• Eight major health insurers in California are splitting a $30 million fund among 35,000 physicians according to how patients rate them. The resulting payments to each doctor receiving part of the fund can be as high as $5,000.

Such measures point to a developing, serious focus on the bedside manner of physicians and the service they deliver. The Ohio State University research revealed that people clearly prefer the Marcus Welby model over the Gregory House approach. According to the study, the public’s image of the ideal physician is someone who is confident, empathetic, humane, personal, forthright, respectful and thorough. Something for every doctor to keep in mind.