It was the middle of the night, and Laura, a nurse at a hospital in Atlanta, knew her patient was in danger. The boy had a shunt in his brain to drain fluid, but he was vomiting and had an extreme headache, two signs that the shunt was blocked and fluid was building up. When she paged the on-call resident, who was asleep in the hospital, he told her not to worry.
After a second page, Laura said, "he became arrogant and said, 'You don't know what to look for - you're not a doctor.' "
He ignored her third page, and after another harrowing hour she called the attending physician at home. The child was rushed into surgery.
"He could have died or had serious brain injury," Laura said, "but I was treated like a pest for calling in the middle of the night."
Her experience is borne out by surveys of hospital staff members, who blame badly behaved doctors for low morale, stress and high turnover. (Laura said she had been brought to tears so many times that she was trying to start her own business and leave nursing.)
Recent studies suggest that such behavior contributes to medical mistakes, preventable complications and even death.
"It is the health care equivalent of road rage," said Dr. Peter B. Angood, chief patient safety officer at the Joint Commission, the nation's leading independent hospital accreditation agency.
A survey of health care workers at 102 nonprofit hospitals from 2004 to 2007 found that 67 percent of respondents said they thought there was a link between disruptive behavior and medical mistakes, and 18 percent said they knew of a mistake that occurred because of an obnoxious doctor. (The author was Dr. Alan Rosenstein, medical director for the West Coast region of VHA Inc., an alliance of nonprofit hospitals.)
Another survey by the Institute for Safe Medication Practices, a nonprofit organization, found that 40 percent of hospital staff members reported having been so intimidated by a doctor that they did not share their concerns about orders for medication that appeared to be incorrect. As a result, 7 percent said they contributed to a medication error.
There are signs, however, that such abusive behavior is less likely to be tolerated. Physicians and nurses say they have seen less of it in the past 5 or 10 years, though it is still a major problem, and the Joint Commission is requiring hospitals to have a written code of conduct and a process for enforcing it.
Still, every nurse has a story about obnoxious doctors. A few say they have ducked scalpels thrown across the operating room by angry surgeons. More frequently, though, they are belittled, insulted or yelled at - often in front of patients and other staff members - and made to feel like the bottom of the food chain. A third of the nurses in Dr. Rosenstein's study were aware of a nurse who had left a hospital because of a disruptive physician.
"The job is tough enough without having to prepare yourself psychologically for a call that you know could very well become abusive," said Diana J. Mason, editor in chief of The American Journal of Nursing.
Laura Sweet, deputy chief of enforcement at the Medical Board of California, described the case of a resident at a University of California hospital who noticed a problem with a fetal monitoring strip on a woman in labor, but didn't call anyone.
"He was afraid to contact the attending physician, who was notorious for yelling and ridiculing the residents," Ms. Sweet said. The baby died.
Of course, most doctors do not spew insults or intimidate nurses. "Most people are trying to do the best job they can under a high-pressure situation," said Dr. Joseph M. Heyman, chairman of the trustees of the American Medical Association.
Dr. William A. Norcross, director of a program at the University of California, San Diego, that offers anger management for physicians, agreed. But he added, "About 3 to 4 percent of doctors are disruptive, but that's a big number, and they really gum up the works." Experts say the leading offenders are specialists in high-pressure fields like neurosurgery, orthopedics and cardiology.
In one instance witnessed by Dr. Angood of the Joint Commission, a nurse called a surgeon to come and verify his next surgical patient and to mark the spot where the operation would be done. The harried surgeon yelled at the nurse to get the patient ready herself. When he showed up late to the operating room, he did not realize the surgery site was mismarked and operated on the wrong part.
"The surgeon then berated the entire team for their error and continued to denigrate them to others, when the error was the surgeon's because he failed to cooperate in the process," Dr. Angood said.
A hostile environment erodes cooperation and a sense of commitment to high-quality care, Dr. Angood said, and that increases the risk of medical errors.
"When the wrong surgery is done on patients," he said, "often there is somebody in that operating room who knew the event was going to occur who did not feel empowered enough to speak up about it."
Dr. Norcross blamed "the brutal training surgeons get, the long hours, being belittled and 'pimped' " - a term for being bombarded with questions to the point of looking stupid. "That whole structure teaches a disruptive behavior," he said.
Dr. Norcross and other experts said staff members' understandable reluctance to challenge a physician, especially a popular surgeon who attracts patients to the hospital, created an atmosphere of tolerance for the bad behavior and indifference. So did a tendency among doctors to form "old boy" networks and protect one another from criticism.
But things have begun to change. Today, good communication and leadership are two of the six core skills taught in medical schools and residency programs. More nurses are challenging doctors on their inappropriate behavior, and fewer hospitals are tolerating disruptive doctors. "Today they're getting rid of that doctor or sending them to anger management," said Dr. Thomas R. Russell, executive director of the American College of Surgeons.
Hospitals have also developed more formal and consistent ways of addressing disruptive behavior, Dr. Rosenstein said. They are also trying to improve relations and mutual respect between doctors and nurses.
At John Muir Health, a nonprofit group of two hospitals in Walnut Creek and Concord, Calif., a committee of physicians, nurses and other staff members was formed to focus on collaboration and communication between disciplines.
"When complaints are submitted, we try to be proactive early to let them know there is not going to be any tolerance for that," said Dr. Roy Kaplan, John Muir's medical director for quality.
Some physicians worry that hospital administrators will abuse the stricter codes of conduct by using them to get rid of doctors who speak out against hospital policies. And the Joint Commission rulings have spawned a cottage industry of anger management centers and law firms defending hospitals or physicians.
Professionals like Laura, the nurse in Atlanta, said the change was overdue.
"We go to school, we have a very important job, but there's no respect," she said.
She recalled a particularly humiliating moment on Dec. 25, 2006. Working in the pediatric emergency room, she called a drug by its generic name rather than its brand name.
"I was quickly shouted out of the trauma room and humiliated in front of everyone," she said. But while "everyone knew the doctor was actually the one who didn't know what he was doing," she continued, no one said a word.
Lisa
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