AMA meeting: Disruptive behavior standard draws fire

Orlando, Fla. -- A Joint Commission standard on disruptive behavior could lead to "arbitrary and capricious enforcement" against physicians, the AMA House of Delegates warned.

Delegates at the Interim Meeting directed the AMA to seek a one-year moratorium on the new standard, slated to take effect Jan. 1, 2009, to allow organized medical staffs time to change their bylaws to comply with the rule. The house also adopted policy advocating that medical staffs develop their own conduct codes and investigation and appeals procedures.

Delegates directed the AMA to update its 2000 policy on disruptive behavior and work with the commission, the Federation of State Medical Boards and other entities to develop an appeals process for physicians charged with bad behavior. The AMA also will work with these groups to "develop a definition of disruptive behavior by a physician to include the actions that would rise to the level of true abusive behavior."

In July, the commission issued a sentinel event alert on disruptive behavior that said "intimidating and disruptive behaviors include overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities. ... Such behaviors include reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions."

The commission's alert cited research showing such behavior impedes communication among the health care team and can harm patients. A spokesman said the commission was contacted by the AMA and is reviewing the Association's requests.

Defining problems

The broad definition of disruptive behavior drew delegates' ire.

"The definition is very important," said Stephen L. Schwartz, MD, a delegate for the Pennsylvania Medical Society. "Intimidating colleagues is wrong; everyone would agree with that. But let me point out that intimidation is in the eye of the beholder. If I ask someone a question and they feel intimidated, did I intimidate them?"

Arthur E. Palamara, MD, a delegate for the Florida Medical Assn., agreed. "We need some absolute standard of what constitutes disruptive behavior."

He and other delegates expressed concern that some health care organizations are using disruptive behavior policies to retaliate against physicians who are outspoken about quality of care. When "we say something about it, we are now titled disruptive physicians," Dr. Palamara said.

Jay A. Gregory, MD, a general surgeon and chair of the AMA Organized Medical Staff Section Governing Council, said the commission's definition is workable. But the new standard allows health care entities too much latitude with their own definitions. It is imperative, he added, that medical staffs exert control over any complaints against physicians.

Other delegates also said the rule can be used against physicians who have competing economic interests.

"This is just another tool these health care entities might find to use against staff physicians," said John O. Cletcher Jr., MD, a delegate for the American Academy of Orthopaedic Surgeons.

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