By Jayne O'Donnell and Laura Ungar

Society may be getting more politically correct, but there's new evidence that hasn't trickled down to hospital operating rooms.

A medical journal published an anonymous report last month by a physician recounting other doctors' crude and sexual comments and behavior with patients during obstetric and gynecologic surgeries.That prompted five Pittsburgh doctors to respond that their residency program director's inbox was flooded with confessions of bad behavior after she asked everyone in the program to comment on the article. In June, a Virginia colonoscopy patient was awarded $500,000 in a court case because the audio tapes of his colonoscopy procedure showed the anesthesiologist crudely disparaged him throughout.

Whether it's angry outbursts, lewd remarks or passive aggressiveness, bad conduct by those in the medical community is called "disruptive behavior." It's considered such a risk to patient safety that hospitals must have a system for addressing it in order to meet accreditation standards. Some of the most egregious examples include:

A surgeon who disparaged a male nurse, who had a special needs son, by telling the nurse during a tense time in an operation that he was "a retard just like your boy." The nurse wrote up the complaint, because he considered the remark an "impediment to safety," and Kathleen Bartholomew, a Seattle-based nursing and safety consultant, who hand-delivered the complaint to the hospital's administration.

A surgeon at Vanderbilt University Medical Center in Nashville did not wash his hands before an operation, and when a nurse quietly offered him gloves instead of calling him out on it, the surgeon dropped the gloves in the trash.

•An OB/GYN patient was screaming in pain while the doctor stitched her up without enough anesthetic, a medical student told Bartholomew. When she asked the doctor about it, he joked that she could give her the memory-erasing drug ketamine to make her forget.

"We believe it’s very under-reported.” says Ronald Wyatt, medical director in the commission's healthcare improvement division at the Joint Commission, "I can’t overstate the importance of it."

Disruptive behavior leads to increased medication errors, more infections and other bad patient outcomes — partly because staff members are often afraid to speak up in the face of bullying by a physician, Wyatt says. That "hidden code of silence" keeps many incidents from being reported or adequately addressed, says physician Alan Rosenstein, an expert in disruptive behavior.

The anonymous essay in the Annals of Internal Medicine broke some of the silence, said Gaetan Sgro, a physician at the University of Pittsburgh School of Medicine and one of the five physicians who responded to the essay. "Our secrets started spilling," Sgro wrote. "There were accounts of physicians who needed forgiveness, and others who needed forgiving."

Hard to quantify

While workers in almost any industry could relate to the stress of financial and time pressure at their jobs, Rosenstein says the literal life-or-death situations surgeons deal with every day make bad behavior far more dangerous in the medical world.

Most experts estimate that up to 5% of physicians exhibit disruptive behavior, although fear of retaliation and other factors make it difficult to determine the extent of the problem. A 2008 survey of nurses and doctors at more than 100 hospitals showed that 77% of respondents said they witnessed physicians engaging in disruptive behavior, which often meant the verbal abuse of another staff member. Sixty-five percent said they saw nurses exhibit such behavior.

Most said such actions raise the risk of errors and deaths.

About two-thirds of the most serious medical incidents — those involving death or serious physical or psychological injury — can be traced back to communication errors, according to a health care accrediting organization called the Joint Commission. Getting nurses and other medical assistants rattled during surgery can be a big safety risk, Bartholomew says.

Medical school is "such a hazing experience," it's little surprise that the "people who make it through are not the ones with the best personalities," says Rosenstein. After all, "emotional intelligence" isn't what's rewarded, he says.

Untouchable doctors

Many people think of disruptive behavior as bullying and intimidation — “throwing, spitting and cussing," says Gerald Hickson, a doctor and senior vice president for quality, safety and risk prevention for Vanderbilt University Medical Center. He prefers a wider definition that includes any behaviors that undermine a safety culture.

Bartholomew says she spent a day consulting at a hospital where nurses complained doctors were doing "unethical surgeries" — involving very old patients with dementia — but two of the surgeons were bringing in more than $30 million a year between them "so are untouchable," she says.

Other experts agreed that powerful, revenue-generating doctors are often considered off-limits to hospital administrators. Physician shortages, especially in poor rural areas, make it even more unlikely that a hospital or medical practice will risk losing a doctor, particularly a big-billing one. Hickson says highly productive doctors may be more likely to bring complaints because they are busier and more stressed, meaning more things can go wrong.

Along with the safety risks, disruptive behavior can wreak havoc on hospital staffs, forcing nurses or others who have to deal with a bully to lose focus during critical medical procedures, call in sick or even quit.

Effects on patients

It can have an even more devastating effect on patients.

The Virginia patient whose anesthesiologist mocked him during his procedure had left his cellphone audio recorder on so he would remember the doctor's instructions later. Driving home with his new fiancee, he was devastated to turn on the recorder and hear the doctor suggesting he had a venereal disease and needed to be more masculine, and saying she had put a false diagnosis of hemorrhoids on his chart.

One of his attorneys, Mikhael Charnoff, said the man was so traumatized, he plans to delay getting a recommended followup another doctor said he needed.

Most anesthesiologists are well aware that patients can react differently to sedation, and that's especially true in the "twilight" form of anesthesia that's common in colonoscopies.

"Hearing is the first thing that comes back," says Ursula Munasifi, an anesthesiologist at Virginia Hospital Center in Arlington, Va. "I believe if you say negative things about the diagnosis or outcomes, it can integrate in (the patient's) memory."

She makes it a point to talk to patients about vacations as they are becoming sedated, "so if they remember something, they remember Hawaii," she says.

What to do?

At Vanderbilt, Hickson says there’s a slowly-escalating system to deal with complaints about such behavior. First, trained professionals simply talk to the alleged offender over a cup of coffee and ask the person what happened, which “has been powerful because it sends a message that we respect each other.”

A second offense brings a warning, subsequent offenses bring a letter outlining the problem and possibly interventions such as mental and physical screening, and offenders who don’t stop their behavior may eventually lose staff privileges. Complaints are made against medical professionals of all ages, research shows, with slightly more complaints against men than women.

Hickson says 90% of team members don’t get any complaints, 6-8% get occasional complaints and 2-3% account for more than 40% of complaints. Of that 2-3%, more than three-quarters turn their behavior around and don’t have recurrences. Only a couple medical professionals out of about 1,600 lose their staff privileges each year, meaning they are no longer able to see patients, for this sort of behavior, he says.

Jason Wayne Smith, a general surgeon with University of Louisville Physicians, says serious disruptive behavior cases like the one involving the Virginia man "would be out of the ordinary. You just don't see that very often." Despite stereotypes of surgeons as bossy and abrasive, he says, "in general, we try and maintain a relatively professional atmosphere no matter where we are."

Most hospitals have a system — which may or may not be anonymous — where employees can register complaints about disruptive behavior by others. Munasifi says she clicked the button on Virginia Hospital Center's computer system to complain about a nurse once and she was later fired.

Health care facilities have made strides in dealing with the problem, with strong programs at many places, including Vanderbilt, Brigham and Women’s Hospital in Boston and the University of Michigan, Wyatt says. Effective strategies aren’t just punitive, he says; they are also designed to help offenders by, for example, sending them to anger management classes or directing them to counseling — or, in some cases, getting them help with medical or addiction problems.

Another potential solution involves closer monitoring of medical professionals as they work. Wade Ayer, whose sister Julie Rubenzer died in 2003 after an overdose of a powerful anesthetic during a breast implant surgery, has been pushing for hospitals to audio and videotape surgeries. ​He believes "it should be patients' and consumers' protected right to know what happened to them and what happens in the room when they are under sedation," says Ayer.

A bill is pending in the Wisconsin state legislature that would require hospitals to do so if patients request it and the footage would become part of the permanent medical record, which could be use in court cases.

"Videotaping surgeries makes sense far beyond malpractice investigation," says Leah Binder, CEO of the Leapfrog Group, which rates hospitals on safety. "Videotaping is an excellent quality improvement tool."