SURGICAL ETHICS CHALLENGES
James W. Jones, MD, PhD, MHA, Surgical Ethics Challenges Section Editor
Ethics of unprofessional behavior that disrupts:
Crossing the line
James W. Jones, MD, PhD, MHA, and Laurence B. McCullough, PhD, Houston, Tex
Law is necessary because men are subject to passions; if all
men were reasonable, law would be superfluous.
Will Durant (The Story of Philosophy)
As chief of surgery, you have been contacted by the
managing operating room (OR) nurse about Dr Frank
N. Stein’s behavior earlier this morning. Dr Stein, a
senior surgeon, has long had a reputation for outland-
ish behaviors in the OR. He is the impeccable gentle-
man outside that environment, loved by patients and
nonoperating personnel alike. He has an international
reputation as a master technical surgeon, operates as
efficiently as anyone on the planet, and has the largest
practice at the medical center. He has survived beyond
the generation of tolerance because he has retained the
same OR crew that over the years have calloused
enough to regard his scurrilousness as just being Dr S.
Today, he crossed the line. Dr. Stein, known for his
colorful diatribes, trounced decorum when he ordered
the operative team, excepting the anesthesiologist, out
of the OR and demanded that a new team be substi-
tuted. This resulted from a shouting match with a new
circulator when she took issue with a personal insult.
The transition was accomplished, causing delays in
both Dr Stein’s OR and several other ORs where
substitute nurses were commandeered. At least one
other faculty surgeon has complained about the incon-
venience. In your office, Frank, long a colleague, insists
that the nurses involved are assassins and refuses to
work with them from this day. What should be done?
A. Assign ex-bouncers to assist him.
B. Get him what he needs. The support people are there for
support not to disrupt the surgeon.
From The Center for Medical Ethics and Health Policy, Baylor College of
Medicine.
Competition of interest: none.
Correspondence: James W Jones, MD, PhD, MHA, Center for Medical
Ethics and Health Policy, Baylor College of Medicine, One Baylor Plaza,
Houston, TX 77030 (e-mail: jwjones@bcm.tmc.edu).
J Vasc Surg 2007;45:433-5
0741-5214/$32.00
Copyright © 2007 by The Society for Vascular Surgery.
doi:10.1016/j.jvs.2006.11.043
C. Survey the nurses, physicians, administrators, and all
support personnel to determine institutional relations.
If the problem is part of a pattern, require Dr Stein to
undertake remediation in professionalism as part of an
institutional program.
D. Dismiss Dr Stein from the staff.
E. Make working in a difficult surgeon’s OR voluntary and
give combat pay.
In this issue, Dr Whittemore emphasizes the detrimen-
tal effects that serious deficiencies of professionalism have
on patient care.1 He provides examples of such morally
shocking behaviors as to render the use of “unprofessional”
damning with faint praise. He corrects misconceptions of
those in the trenches who may well regard others with
behavioral problems as eccentric, amusing, or pathetically
misguided. Instead, he emphasizes that those behaviors
crossing the line damage patient care.
Aberrant outlandish behavior is part of the fading ma-
cho surgical stereotype. In the not so remote past of the last
century, surgeons were given more latitude in the work-
place; one classification involved whether or not surgical
instruments became projectiles. Generally, one’s behavior
was not reported unless injury or the possibility of injury to
coworkers was involved. Crass assertions by surgeons were
commonplace and still are in some ORs, albeit with steadily
lessening frequency.
Medical professionalism has received much attention
recently from statements by medicine’s major professional
organizations whose goals are to codify and improve behav-
ioral standards.2 Extremes such as behaviors that disrupt
medical care are not mentioned, just as ethics essays do not
routinely discuss why murdering innocents is wrong; their
ethical unacceptability should be obvious. Formalized pro-
fessionalism codes and charters concentrate on dealings
with the patients and economic issues, whereas professional
disruption is more related to interactions with coworkers,
usually without the patient’s knowledge. According to
Wilhelm, “Disruptive behaviors include repeated episodes
of: sexual harassment; racial or ethnic slurs; intimidation
and abusive language; and persistent lateness in responding
to calls at work.”3
433

434 Jones and McCullough
Although the surgeon is the captain of the team, surgi-
cal therapy is dependent on the proper functioning of all
the members of the health care team. The introduction of
behaviors by members of the team that disrupt the team’s
functioning, especially by the captain, clearly is unaccept-
able.4 Ethically, this is so because disruptive behavior makes
the surgeon’s own ego needs the surgeon’s primary con-
cern and motivation and attempts to make meeting those
needs the primary concern and motivation of the other
members of the surgical team. However, as Dr Thomas
Percival put it when addressing the ethics of potentially
disruptive relationships among consulting physicians (one
of the most persistent topics in the history of medical
ethics), “the good of the patient is the sole object in view.” 5
Disruptive behavior obscures the patient from view alto-
gether in circumstances in which the ego needs of the
surgeon can never plausibly be construed to be more im-
portant that the surgeon’s primary responsibility to and for
the patient’s health.
We live in an era in which we are skeptical about the
connection between behavior and character. In particular,
we are skeptical about whether we can reliably infer from
good behavior to good character and vice versa. This crisis
of manners dates from the late 18th century. Fissell notes
that at this time, “medical manners and morals became
unglued; no longer were codes of conduct based on cour-
tesy functional.”6 Despite our skepticism, patterns of dis-
ruptive behavior of physicians invite the inference from bad
behavior to deficient professionalism (ie, defects in charac-
ter). Such disruptive behavior, from the perspective of the
ethics of professionalism, is a very serious matter indeed,
calling for serious responses by physician leaders.
Option A does en passant have possible merit. A rather
famous surgeon, who was legendary in abusing surgical
residents, would characteristically announce in the middle
of a procedure that “I can whip you with one hand tied
behind my back.” Not knowing that a resident had been
assigned who had been a successful professional boxer
before medical school, the contentious surgeon threw
down the gauntlet once more. When challenged, the boxer
resident replied, “No sir, it is I who could whip you with
but my left hand.” The abuse stopped for the remainder of
that rotation but restarted with the following resident.
Option A would not work longtime.
Option B allows unacceptable behavior in patient care
areas to continue with administrative support. Thus, it is
the least ethical answer offered. Option E is a variant of B
that is objectionable as well but at least attempts to com-
pensate those most abused.
Option D should be chosen if remedial measures are
not effective. The courts clearly support an institution’s
right to remove staff privileges when it can be proven that a
physician’s behavior disrupts the institution’s ability to
provide quality medical care. Management should deal with
untoward events differently according to whether they are
unique or global.
In setting up an institution-wide program, Dr Whitte-
more considers disruptive behaviors to be widespread. Is he
JOURNAL OF VASCULAR SURGERY
February 2007
justified? Data from a national study showed that 74% of
health care professionals had witnessed disruptive behavior
of physicians.7 This figure climbed to 86% when only data
from nurses were counted. Regarding surgeons specifically,
disruptive behaviors were more common in the periopera-
tive area,8 where 97% of nurses reported witnessing sur-
geons behaving badly. Surgeons themselves had the thick-
est skins or greatest forgiveness: only 43% reporting
witnessing such events. So it seems that although behaviors
have improved with the present generation, a problem
remains.
In every published study on organizational team pro-
cesses involving medical care, there is need emphasized for
improvement of the physician’s interpersonal communica-
tive skills.
After the Institute of Medicine publicity regarding
medical errors, considerable literature has accumulated em-
phasizing the need for improvements in communication
skills among team members in complex high-risk environ-
ments such as the operating room.9,10 Direct observation
of medical teams treating patients identified errors in 30%
of emergency room cases11 and more than one event com-
promising patient safety per surgical case.7 The main cause
identified was lack of effective communication in environ-
ments with “normally behaving” surgeons.
Dr Stein’s behavior and others like him is just the tip of
the metaphoric iceberg drawing attention to an opportu-
nity medicine should not ignore.
Option C emerges as the preferred option. Dr Whitte-
more outlines corrective measures that have been taken at
his institution and places responsibility just where it be-
longs, on the physicians. He challenges, “Physicians must
set an example for others in the institution by behaving
professionally and respectfully towards all members of the
health care team, acting in concert with institutional poli-
cies and statutory obligations, and by taking action when it
comes to your attention that others have not done so.”1
More to the point, it stands that dysfunctional surgeons
captain dysfunctional operating teams and should be
viewed by the profession as having incapacities that must be
addressed. No surgeon would fail to take decisive action if
he noticed a tray of unsterilized instruments being deliv-
ered for use to a colleague’s OR. Disruptive behaviors can
be just as harmful, without microorganisms to fault, and
should be taken just as seriously as a threat to patient
well-being and therefore to the medical professionalism of
us all.
REFERENCES
1. Whittemore AD. The impact of professionalism on safe surgical care. J
Vasc Surg 2007;45:415-9.
2. Jones JW, McCullough LB, Richman BW. Ethics and professionalism:
do we need yet another surgeons’ charter? J Vasc Surg 2006;44:903-6.
3. Wilhelm KA, Lapsley H. Disruptive doctors. Unprofessional interper-
sonal behaviour in doctors. Med J Aust 2000;173:384-6.
4. Purtilo R, Shaw B, Arnold R. Obligations of surgeons to non-
physician team members and trainees. In: McCullough L, Jones J,
Brody BA, editors. Surgical ethics. New York: Oxford University
Press; 1998; p. 302-321.
JOURNAL OF VASCULAR SURGERY
Volume 45, Number 2
5. Percival T. Medical ethics: or a code of institutes and precepts, adapted
to the professional conduct of physicians and surgeons. London: J.
Johnson & R. Bickerstaff; 1803.
6. Fissell M. Innocent and honorable bribes: medical manners in 18th century
Britain. In: Baker R, Porter D, Porter R, editors. Medical ethics and etiquette in
the 18th Century. London: Kluwer Medical Publishers; 1993.
7. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical out-
comes: perceptions of nurses and physicians. Am J Nurs 2005;105:54-
64; quiz 64-5.
8. Rosenstein AH, O’Daniel M. Impact and implications of disruptive
behavior in the perioperative arena. J Am Coll Surg 2006;203:96-105.
Jones and McCullough 435
9. Christian CK, Gustafson ML, Roth EM, Sheridan TB, Gandhi TK,
Dwyer K, et al. A prospective study of patient safety in the operating
room. Surgery 2006;139:159-73.
10. Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Error or “act of
God”? A study of patients’ and operating room team members’ percep-
tions of error definition, reporting, and disclosure. Surgery 2006;139:6-
14.
11. Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, et al.
Error reduction and performance improvement in the emergency de-
partment through formal teamwork training: evaluation results of the
MedTeams project. Health Serv Res 2002;37:1553-81.