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Why unprofessional behaviour is like pornography

Jude Tweedie

Like Justice Potter Stewart who famously said of pornography ‘I know what it is when I see it‘, most of us might struggle to define unprofessional behaviour but would readily recognise it. However, it is a serious and often un-discussed issue in medicine and a risk to patient safety, team-working and staff welfare. Doctors are also much more likely to find themselves facing fitness to practice proceedings for unprofessional behaviour than for any failure in clinical competence.

What is unprofessional behaviour?

The University of Nebraska Medical Centre says:

“unprofessional conduct includes disruptive and intimidating behaviours that interrupt teamwork and undermine safe care.” (University of Nebraska Medical Centre)

The College of Physicians and Surgeons of Ontario describe:

“when the use of inappropriate words, actions or inactions by a physician interferes with…teamwork and quality healthcare delivery.” (College of Physicians and Surgeons of Ontario)

If professional behaviour is

“the set of values, behaviours and relationships that underpins the trust the public has in doctors” (RCP London, 2005)

then unprofessional behaviour is the breakdown of these facets which can ultimately jeopardise that trust. So what does this look like in practice? Well, the range is wide and spans the glaringly obvious through to the much more subtle yet ultimately damaging behaviours. There is typically a spectrum of behaviours ranging from the obviously aggressive, like physical assault or aggressive language, through passive aggressive to passive. Behaviours such as consistently undermining or belittling staff, hostile or inadequate note taking or refusal to comply with policies such as hand washing can equally be as disruptive to teamwork and the delivery of safe health care. Although only a small proportion of doctors display such behaviours the same small group of individuals tend to do so recurrently.

Why does it matter?

There is increasing evidence demonstrating the detrimental effects of unprofessional behaviour on patient care.

In one American study, 17% of pharmacists reported feeling pressurised to accept a medication order despite safety concerns on at least three occasions (ISMP 2004).

A further 7% reported being involved in a serious medication error where intimidation was a significant contributory factor (ISMP 2004).

Similar results in a second American study which surveyed over 4000 doctors and nurses. Fourteen percent of respondents reported being aware of a specific adverse event related to a disruptive behaviour episode (Rosenstein AH, 2008).

Unprofessional behaviours have consequences for organisations:

One longitudinal study analysed patient complaints and the relationship to legal action in a practice of 645 doctors. Poor communication and behaviour were the most common cause of most complaints as opposed to issues with clinical competence (Hickson, 2008).

Other studies have demonstrated decreased morale and organisational engagement in teams which contain a disruptive member (Williams, 2008).

Furthermore, the evidence suggests that when patients witness unprofessional or disruptive behaviour, it weakens their confidence in the clinician and the organisation (Hickson, 2002).

What does this mean?

So why do we accept it and what can the individual clinician do? Role modelling, early intervention and reporting frameworks all play key roles and we will discuss this further in part two of this blog. In the interim please tell us your own personal stories of witnessing unprofessional behaviour and the effects this had.

In part two of this blog, we will discuss why this behaviour is often tolerated within healthcare organisations and steps we can make to ‘speak up’.

Dr Judith Tweedie is an ST7 Cardiologist and is currently a National Medical Director’s Clinical Fellow working at the Royal College of Physicians and the Faculty of Leadership and Management. She co-authored this blog with Dr Kevin Stewart  who is Clinical Director of the Royal College of Physicians’ Clinical Effectiveness & Evaluation Unit.

KevinStewart_photo

Dr Kevin Stewart

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Discussion

  1. Dr VAPREDDY,MRCP(UK) says:

    It is concerning that the article accepts and publishes definitions of unprofessional behaviour that imply the profession itself behaves professionally at all times and that it cannot and must not be faulted because this will effect moral end cause a reduction of trust.I have whistleblowing he UK many times because the profession ultimately was guilty of the unprofessional behaviour.The fact that the leaders in Stafford used the same arguments to stop any would be whistleblower is disturbing.If there is a reason why blind trust is abusive there is nothing wrong is revoking that trust.It should be challenged .Whether one considers who are the representatives and judges of the profession are the royal colleges,the BMA, or the GMC they all allowed the NHS to slide over decades into chaos .What about the situation when the profession countenances obvious dangerous things and the whistleblower has to stand up out of a hippocratic spirit invoking the basic duty of any dr as an advocate and shouting about life threatening changes that are ignored by his or her profession? There has been a lot of downright nonsense overseen by the leaders of the medical profession who paid lip service to the warnings of Drs who were blowing whistles as loud as is possible.The issue now is the article gives ammunition to the leaders of the profession .It gives credence to a belief system that disloyalty to the profession comes before loyalty to patients,that you can be branded unprofessional because you stand up for what is right..I am talking specifically about the whistleblowers of these last few decades and the unmonitored changes implemented over the last 20 years in the NHS such as junior dr staffing levels and reduction in nursing levels and the use of undertrained nurses to take on extra unsupervised medical duties.I have whistle blown in the uk many times and know the leaders of the profession did nothing with disastrous fatal results.Where is your judgement of unprofessional behaviour here? The article suggests it hard to define unprofessional behaviour and is happy to judge by going on gut instinct with all the bias of prejudice and no objectivity.We are scientists not expedient Machiavellian politicians You imply we all know what unprofessional behaviour is.Well how come the NHS is in the mess it is ? How come the profession allowed unmonitored changes to be implemented with the resulting loss of thousands of lives.The reality of this article is that it seems to give the justification to kill of the whistleblower as unprofessional and support the leaders and consultants of the profession who have repeatedly turned a blind eye to the corporate unprofessional behaviour ie reduced nursing andmedicalstaffing levels,that caused avoiable loss of life .Remember all of these changes which were not evaluated or monitored were instigated and supported by the Royal colleges and BMA and the profession.The documentation is all there to prove my point and it is not based on subjective hearsay but objective evidence.Maybe your judgements of unprofessionalism should be based on science,empiricism and facts and not gut instincts which allows the judges ie the senior Drs to bring in their racial,sexist,and political prejudices and biases into the equation.I know but for the grace of god I could easily been judge unprofessional .Yet time vindicated my stance be it sadly also necessary for thousands of patients to have died too.Be careful with your judgements……

    Reply

  2. As an Anesthesiologist I have witnessed inappropriate sexual and rude comments while a patient is anesthetized. See my blog “Can you hear under anesthesia?” moniac15 site on WordPress. See my blogs as moniac1066. To sum up the patients are affected by offensive comments as well as other staff present creating a hostile environment. If this is not unprofessional, I don’t know what is. Recently in the USA, a patient accidentally recorded rude comments on his mobile phone while he was under deep sedation. He sued and won a penalty amount much of which was not covered by insurance.

  3. Dr shaheen akhtar says:

    Thanks very much for your analysis,its very true we as doctors need to be as honest as possible otherwise it seems to me as a waste of all my time and effort to help the vunreable people we dedicate our most precious time of our life & youth to become a doctor.It does hurt me as a concience human being when we see such senarios which is difficult to digest and just closing our eyes an
    d that is why GMC only seem to be policing doctors which needs to definitely change not helping the professionals who are willing to sacrifice their time and youth.I feel doctors must be able to discuss any unethical issue & needs to be resolved in a honest way ,not digesting everything that is erroding the main carring attitude which has become so badly tainted,we need to not only work for our patient but at the same time as doctors look after our phycological trauma that many medical student doctos nurses have to face,we are not saying we want bed of roses but belitting by GMS,GOV all is thrown to us,we need to stand together firmly for our right.

  4. Not provided. says:

    The problem with unprofessionalism is that it is subjective; my definition of it is different to yours and yours is different to the next; we all hold each other to our own set of professional standards.

    One can imagine that a doctor would feel very hard done by if held to account by senior doctors, an employer, or those who regulate you if you feel that you’ve done nothing wrong and your peers agree.

    Ideally all ideas of what constitues unprofessionalism would be voted on by all doctors thereby establishing democratically what constitutes unprofessional behaviour.

    My observations from working in the NHS for over four years is that lack of transparency, abuse of power, and gossip is rife. When it comes to jobs, it’s often who you know that matters, or rather who you’ve managed not to annoy.

    Abuse of junior doctors by seniors is ubiquitous. Why? Because all juniors must obtain formal, written, confidential/anonymous feedback (MSF) from seniors, including their abusers, on the NHSePortfolios.org website. And it’s a one way street; seniors very rarely, if ever, obtain formal, written, confidential/anonymous feedback from their juniors so the widespread abuse remains largely undocumented. The GMC is failing in this area.

    I think that all of the above is unprofessional, but many others must not as they take part in these activities.

    How can we surmount these deep rooted problems??

    • Russell Cartwright says:

      Thanks for your comment – whilst a definition of professionalism is subjective, the conversations we’ve been having with doctors for the last year have shown that a lot of the issues covered do have useful examples or bits of good/bad practice we can share.

      Your point about the senior/junior system on eportfolios is very interesting. I would be interested to hear more about this if you are able to expand?

    • DIJ says:

      It is not only junior doctors that suffer under their “seniors”.
      I have worked as a GP for twenty years to find that their is a secret court called the PAG ( Performance Assessment Group).
      This is an anonymous group, who make judgements on mistakes and complaints about GPs. This group sometimes hears cases that affect GPs willingness to continue working in vital areas such as urgent care at about the same speed as GPs see their routine appointments.
      I find it strange that doctors seem to have so little protection from colleagues in a profession that is referenced by Wikipedia as having a “bullying cycle” in it’s article on Workplace bullying.
      NHSE is regularly applauding its complaints training events, and telling its appraisers to “sandwich” feedback, this is what GPs do, spending hours managing complaints and putting safer systems in place.
      NHSE gives doctors almost no rights however when managing complaints….
      The letter should be shared with the GP and an explanation requested before a decision to go to a secret medical jury.
      This Jury should have access to all documents to be discussed at least two weeks in advance.
      A letter should be dictated by an expert, rather than a newly appointed administrator, and feedback should acknowledge what went well, how difficult the scenario might have been as well as the negatives. If the PAG is unable to reference NICE guidance on clinical management then this should be stated, and fed back to NICE
      The response to my patient remains a mystery and just like my junior colleagues, I have not been asked to give feedback on the process.
      I want to reduce my exposure to urgent care, as a result. If NHSE collected feedback, of its own complaints management, from the doctor’s perspective. Then it might select cases more carefully and spend more time on them. This might slightly reduce the retirement rate!
      It is astounding that with the reduced resources at NHSE that it is deciding to become more involved in a process that needs to be handled so sensitively and is normally handled so well by GPs with our own very expensive insurance advice!

    • Kiran Jani says:

      Not Provided,
      You raise some very valid points about the junior / senior hierarchy. As a senior, for my GMC revalidation, I had to undergo an anonymous MSF. This process involves nominating peers. I made sure that I had a good spread of trainees, middle grades, nurses and fellow consultants from within and without my specialty. How common is this practice? I do not know. Perhaps GMC can mandate this for the MSF.

  5. […] General Medical Council released a blog by a junior doctor this week entitled “Why unprofessional behaviour is like pornography.” It explored the challenge of defining exactly what being unprofessional is. While […] http://rolobotrambles.com/unprofessional/

  6. LS says:

    I witness unprofessional behaviour every day amongst medical colleagues. It often goes unchallenged yet deeply affects morale, team working and ultimately patient safety. There are many external challenges on us but frankly I am ashamed and embarrassed of my colleagues at times – my children have better manners. Only we can do something to improve this. Challenge politely, behave well & be role models, try to understand how a patient would feel hearing our internal bickering. We all have a responsibility to work together in the best interests of patient care and to support and look after each other.

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