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They are in every hospital--physicians and other professionals who throw tantrums, throw instruments, refuse to answer pagers, roll their eyes at colleagues, and otherwise disrupt the care of patients. Now the Joint Commission is cracking down. Under new Joint Commission standards that will go into effect in January 2009, hospitals and other health care organizations will be required to establish a code of conduct that defines unacceptable behavior and establishes clear consequences for misconduct.

Joint Commission officials decided to highlight the issue this summer through the release of a Sentinel Event Alert. The alert warns that disruptive behaviors ranging from verbal outbursts and physical threats to refusing to perform assigned tasks can cause medical errors, contribute to patient dissatisfaction, and increase the cost of care. "This is the medical version of 'road rage' and sometimes it's just little passive-aggressive things and other times it's very, very flagrant," said Dr. Peter B. Angood, chief patient safety officer for the Joint Commission.

These events are not uncommon, according to the Joint Commission. About 40% of clinicians have declined to question medication orders in the past year because they wanted to avoid interacting with an intimidating prescriber, according to a 2003 survey of more than 2,000 health care professionals conducted by the Institute for Safe Medication Practices. And even when clinicians spoke up, 49% said they felt pressured into dispensing or administering the medication despite their concerns, the survey found.

Other surveys have found similar trends. A 2004 survey of more than 1,600 physician executives, conducted by the American College of Physician Executives, found that 14% of respondents observed problems with physician behavior in their own organizations on a weekly basis.

In addition to establishing a code of conduct, the Joint Commission is recommending that hospitals and other health care organizations:

P Educate their physician and nonphysician workforce on appropriate professional behavior and provide training and coaching to managers on conflict resolution.

P Enforce the code of conduct consistently among staff members regardless of seniority or clinical specialty.

P Adhere to a "zero tolerance" policy for the most egregious incidents such as assault and put in place a progressive system of discipline for addressing lesser violations.

P Protect those who report incidents and include nonretaliation clauses into policy statements.

P Develop a system to assess the prevalence of unprofessional behaviors in the organization and implement a reporting surveillance system to detect unprofessional behavior.

Those organizations that have already successfully addressed disruptive behaviors have found it helpful to establish anonymous reporting systems, Dr. Angood said. Another essential component of a successful system is ensuring that every report will be investigated, regardless of the stature of the person involved.

The Joint Commission alert is "important" because it raises the issue, said Dr. Gerald B. Hickson, director of the Center for Patient and Professional Advocacy at Vanderbilt University Medical Center in Nashville, Tenn. Since 1996, Vanderbilt has been using the Patient Advocates Reporting System, which collects and analyzes patient complaints, to identify problem physicians. Overall, the Vanderbilt data suggest that about 4%-6% of the physician population engages in some form of disruptive behavior. It's important for organizations to offer support and counseling services but in many cases clinicians won't utilize these services until their problems have boiled over into a disruptive event, he said.

"The days when surgeons can be verbally abusive are over," commented Dr. John (Jeb) Hallett, Vascular Surgeon and Medical Director of the Roper St Francis Heart and Vascular Center, Charleston, SC. "However, personality disorders among surgeons are difficult to address successfully. Despite counseling and psychiatric intervention, some surgeons may not improve. To protect patient safety, there must be a due process and system to remove disruptive and abusive surgeons from the hospital environment before a patient is injuried. Addressing surgical "road rage" places the needs of the patient and other care providers first. It's tough to do, but must be done.