Domhnall MacAuley is a CMAJ Associate Editor and a professor of primary care in Northern Ireland, UK
Throwing surgical instruments across a theatre, idiosyncratic single handed practice, refusing to see patients in clinic without notes. I didn’t think physicians could get away with this sort of practice anymore. While these were hypothetical examples explored in a recent seminar discussing doctors’ disruptive and unprofessional behaviour, the audience clearly recognised that it still happens. Dr Kevin Stewart, Clinical Director of the Clinical Effectiveness and Evaluation Unit at the Royal College of Physicians in London and a geriatrician in Winchester, England, facilitated discussions on how to manage doctors who display difficult behaviour. His approach was to focus more on patients than doctors and to recognise how such behaviour affects patient safety. It’s not just about working with difficult colleagues, interpersonal stress, team disruption, or an unhappy work environment, but when we recognise the implications for patient safety, unprofessional conduct is seen quite differently.
If a surgeon loses his temper, judgement is impaired, the surgical team is affected, others may be less willing to point out mistakes, errors or opportunities to improve care - and patients suffer. If a doctor in a community setting is disorganised, difficult to contact, makes inadequate notes, is not good at writing to colleagues and has no peers, they can become professionally isolated and out of touch with contemporary clinical practice - and patients suffer. A high flying clinician, who attracts major research grant funding, clinically excellent with a national reputation, may have impossibly high standards that makes others’ lives intolerable, may be rude and intolerant, intimidate juniors and create a dysfunctional unit where clinical care is not collegial - and patients suffer. While such caricatures may seem extreme, contributions to the discussion by clinicians in senior management positions suggested that such behaviour was more common than one might expect. In the past, medicine may have tolerated behaviour like this and put it down to eccentricity or personality, but this is no longer acceptable, particularly in the context of patient safety.
Where does the problem start and what should we do? And, this is where I may differ from many of my colleagues. Most of the discussion around these examples centred on, “some” and “they”. But, perhaps the problem is “We”. Most of the interventions suggested were about managing someone in the present, or about teaching junior doctors during postgraduate training. But, perhaps the problem is the professional culture within medicine - a systematic failure to recognise our failings, and a generic lack of insight, that is ingrained from our first days in medical school. One of the privileges of working on the margins of medicine is the opportunity to see us almost as others see us. And, sometimes it’s not pretty. Medical undergraduates and graduates are habitual high achievers, who have self-selected to the top of a competitive hierarchy, where the focus of education is often so sharply honed on performance that there is little time for other activities and social interaction in school or at university. Could we be the ones who are out of step? Medicine exists in its own little orbit and learned behaviour becomes the norm. Medical students often have little time for sport, few cultural activities, and minimal opportunity to interact socially with others outside the medical circle. Maybe we have created this dysfunctional culture ourselves.
In a a Montreal medical student, identified by faculty for unprofessional behaviour, challenged his exclusion from undergraduate studies at medical school. I know nothing of the individual or the circumstances other than what is reported. But I did feel some sympathy for the student, who believed so strongly that he had been unfairly treated and so determined to pursue a medical career that he brought it to this legal endpoint. In one sense he is a victim- some individuals may be unsuited to particular careers. But, what made this case so unusual for me, was that colleagues and staff identified the problem, recognised that this may be the wrong person in the wrong career, and were prepared to do something about it. In my experience this rarely happens. Most of the time we do nothing.
We all know of doctors who are clearly unsuited to a medical career. Wouldn’t it have been better for everyone, and especially our patients, if someone - we, or I - had spoken up earlier?