Physicians Behaving Badly: Is It Arrogance, Insecurity, or Stress?

This transcript has been edited for clarity.

John Whyte, MD, MPH: Welcome, everyone. I'm Dr John Whyte. I'm the chief medical officer at WebMD. The past 2 years have been stressful, haven't they? We've seen behavioral issues. We've seen them in our kids, but we've also seen them in our colleagues, and that includes physicians. You probably have met a physician in the past that maybe was rude to you, or you felt too rushed.

Is it getting worse? Well, Medscape put out a report to find out what the status is of misbehavior in physicians. The report is entitled Physicians Behaving Badly: Stress and Hardship Trigger Misconduct. We interviewed 1500 physicians, and the most startling statistic was that 41% said they have seen physicians behaving inappropriately in the workplace. Another 30% said they've seen it on social media. These are higher numbers than in previous years.

Helping me unpack it all and make sense of it is my good friend, Dr Drew Ramsey. Dr Ramsey is an assistant clinical professor of psychiatry at Columbia University. It's great to see you. Thanks for joining me.

Drew Ramsey, MD: Dr Whyte, it's great to be with you again. Thank you. I think we should all thank WebMD for asking these questions. These are hard questions, but they're very important for us to look at as physicians and as a community, so that we all keep improving.

Whyte: Are you surprised by these data? Let's be real — we all know some colleagues who aren't exactly the best behaved, even pre-pandemic. These numbers I find somewhat striking, when 40% of our colleagues are saying they've witnessed it. Does this surprise you? Can we say it's just due to the pandemic?

Ramsey: No, John, we can't say it's just due to the pandemic. I think we need to recognize that physicians — and I'm going to broaden that to healthcare providers in America and around the world — are dealing with a set of stressors, and a level of trauma, and a level of scrutiny that we just never have before. Not only are we more aware of bad behavior, but we're also dealing with so much right now that I think there is more of it.

I think we also need to really understand that, for physicians watching this who are part of this survey, who saw some of that behavior, that this is your opportunity right now — today, this year — to grow as a physician.

Whyte: And to speak up, perhaps, if we're witnessing it. You and I always like to look at data. It begs the question, who defines bad behavior? You and I may witness something that we think is bad and rude, but someone else may say they've seen worse — that's not so bad.

Who's the referee of this? Who says, "You were inappropriate, and no, you were not inappropriate?" Does it matter?

Ramsey: Well, it certainly matters for physicians within a setting, or if you move to a new institution, because cultures within institutions shift about what is appropriate. Some emergency rooms love to give Klonopin, others love to give Ativan. There are little differences. That also applies to how we think about interacting with colleagues, and how some institutions think about gender or race. It does matter that institutions are clear about that.

What's even more important, and this is where our institutional leaders are really navigating something that's new, is how to have those conversations and keep those conversations happening in the workplace. I think about Jean-Marie Alves-Bradford, who's at Columbia, who's really shepherding this process to think about race and equity within a department during a time of crisis.

Those are the leaders we want to be looking to as we think through how to have this conversation where we decide what's appropriate and not appropriate, and how to make sure that all voices are heard so the behavior just doesn't perpetuate. That's what medicine's been so guilty of.

Whyte: You're an expert in psychiatry. What do you think is the root of it when we're seeing it in physicians? Some people will say — and we reference it in the report, and you've commented in the report — that it's arrogance. Actually, it's not arrogance. It's insecurity. That's the reason why doctors talk to people badly or they misbehave when they're out in public. Is it arrogance or is it insecurity?

Ramsey: It's a behavior for us to understand that each individual is going to have some personal meaning to that. In general, arrogance and narcissism are a defense and an expression of profound insecurity. If I need to dominate you — you're a nurse, you're a patient — and tell you exactly what's right, as opposed to partnering with you; meeting you where you are; understanding, of course, you have the lived experience and you have the key to health, which is changing your behavior. So we have to partner together.

I think that's from insecurity. You're a physician, John. What do you think? As psychiatrists, we love these explanations. It's that unconscious again. What do you think?

Whyte: I think you explained well that it's arrogance that's really reflecting insecurity — not for everyone, but for a large number of clinicians who, as you know, sometimes when you're not sure of an answer, if you say it more vociferously and more boldly, people will assume it's true. We know that's not the fact.

Is any of this generational? When we asked about it in the report, the perpetrators of misbehavior were primarily in their forties. I put this in the context of, have social mores changed? What might have been acceptable, in theory, 20 years ago is not acceptable now.

Ramsey: Good. Thank goodness. That's progress, John. If we're edging on the side that we're maybe encroaching, calling out a little bit too much bad behavior — I think sometimes it's called wokeness — that bothers me. I come from the Midwest. I've been in many institutions, and all of us in medicine have witnessed an incredible amount of bad behavior: sexism, racism, homophobia. In general, medicine is a very conservative culture. Things are shifting, and that's great. I think it's good to see. If our standard is going up, good.

Whyte: It's good that social mores have changed, in terms of how we behave?

Ramsey: They have to. I mean, if I think about what medicine looked like then, even just what we knew from a scientific perspective, it's radically changed. When I think about the workplace, when I think about how the women in our field are treated based on the data still, we're just beginning to change. We're not even scratching the surface.

Whyte: Social media has changed much of it in terms of behavior, but I want to reference another piece of data. When we asked, "Do physicians misbehave more in person or on social media?" 47% said "in person" in a medical situation and 35% said "on social media."

Even though in person was more than social media and is very concerning, what about the fact that people will say that social media is their own business, it's their own profile, and they're not in the office so they can do what they want?

Ramsey: That depends on you as a healthcare professional. I was an early adopter of social media, starting on Twitter, then Facebook, then Instagram. That's a question for all of us who choose to be on social media, and that's an active choice you have to make as a physician, a healthcare provider; you set those boundaries.

That said, I love that the conversation's going on, because I think, for too long, the public has not viewed physicians as people. I think about all of my colleagues, especially the parents, who get viewed just as a physician.

That's what we're here for people for. The notion that more of a physician's life is being opened up, that more medical students and residents are seeing what it's really like to be an attending, I think that's good for us as a field. I love how social media is opening things up and showing us more of what hospital life is like. It's inspiring our workforce to be more diverse. Things are shifting.

Whyte: All right, but let's say you put up inappropriate pictures on social media as a physician. You're labeled as such. Does it diminish the profession?

Ramsey: Whenever a physician is behaving badly — not leading, not showing everyone around us that we are deep and thoughtful people — I think it hurts our profession. That said, I think we're also people. I think we often need to let off steam. I think that we have a long tradition in medicine of letting off steam in a variety of not-so-appropriate ways.

Whyte: Is that okay?

Ramsey: I think what isn't okay, John, is as a field, we don't have alternatives. I think that we need to help ourselves as a field, but we also need, in our training, to make sure that we're giving people tools. If having a drink and communing with colleagues is one of your ways to unwind, great. We should somehow codify that a little bit more in medicine that, just as we have CME, just as we have the standards that we adhere to for care, we also need to have a set of standards for self-care.

Those are missing in medicine. I think that's the worst behavior that I see, the behavior that concerns me the most that isn't here. It's not about bullying. That's certainly concerning. That's always been part of medicine, unfortunately. What concerns me is that the worst behavior we have in America today is physicians aren't taking care of themselves. We see that in all kinds of different ways. Bad behavior is one way.

Whyte: I want to put a slide up. The question was, did more women or men behave badly? And the respondents said 77% were men. What's your response to that?

Ramsey: My response is that we have a male mental health crisis in America that's been unattended to. Several of us have been trying to sound an alarm about that, and we're going to keep sounding that alarm. That statistic is one of the many statistics that shows that. One in two men have an alcohol use disorder. Male physicians are the top group at risk for suicide, period.

When I see that, 77%, yeah — it's sad. Does it surprise me? No. Men engage in more externalizing behavior. Men struggle with alcohol. Men are really struggling with the shifting workplace. There's just been a complete shattering of what has been a traditional source of essentially White male power. Medicine has really been slow to adapt to that in some ways, in many ways. If you look at Christina Mangurian's work, vice chair at UCSF, you see there's just still a tremendous amount.

Whyte: Dr Ramsey, people are going to listen to this and say, okay, but do you have any data that show that behaving badly leads to bad outcomes? I can give examples where patients will say they went to see an orthopedic surgeon who didn't have the fuzziest personality but was a great technician. They were happy with that, despite some of the challenges of personality. How do we judge to say misbehavior is actually causing bad outcomes in medicine?

Ramsey: I think there's a difference between misbehavior and not being friendly. There's a difference between not being friendly and not being professional. I asked one of my colleagues here, a local hospitalist, Dr Marcia Lux, about her focus and expertise at this period of her career, and she said the bedside. It really just hit me in the heart of — such a nice thing to hear. I think so many of you watching know that.

You can be an expert technician, taciturn, not the friendliest person, and still look your patient in the eye and connect with them. I think many of the physicians watching know that. That's not misbehavior.

Misbehavior is when you treat those around you with disrespect, when you don't model the best values of medicine, that we are caring, we are loving, we are healing, we are generous and thoughtful. We listen. That's what it means to be a great doctor. Sure, to not do that is not misbehaving, but it's not doing what we all do. In my mind, you're not hitting the mark then.

Whyte: What do we do about it? We asked if physicians should face higher behavioral standards, and 66% said, yes, they should. What's interesting, Dr Ramsey, is that was a decrease in what it was the year previously. In the previous year, 77% said that they should face higher standards. Fewer people are saying that now.

Ramsey: Medicine and physicians are — I wouldn't even say we're in recovery. Every day, I look at The New York Times and I think about all our colleagues around the country who've been at the bedside in some ICU, and 350 Americans still died yesterday from COVID-19. Many people, myself included, talked about post–COVID-19, going into recovery. We have to recognize that so many of our colleagues watching are manning the front lines of a horrible pandemic still.

I think it's a hard time to ask that question — can we do better, can we do more — because so many of our colleagues are burned out, just getting by. Many institutions are struggling with staffing. We always need to do better. I think 100% of us should say that we need to do better in medicine. Our country continues to be in the midst of a horrible health and mental health care crisis.

Whyte: Should we ever consider referring physicians who misbehave to medical boards for disciplinary action?

Ramsey: For certain things, for sure. If we see repeated behaviors where people are violating one of the fundamental oaths of medicine, people are abusing patients, doctors are pill mills, people aren't seeing patients and looking at their patients in the eye — digitally or otherwise — when we see people who repeatedly break the law and can't follow some of the basic rules of society, yes.

Whyte: Given these data, given this report and what we've been talking about, what's the future of the physician workforce, the healthcare community workforce? Do you expect that we'll see more misbehavior as we continue to recover? Is it going to get worse before it gets better? What's your prediction, Dr Ramsey?

Ramsey: I'm very hopeful. I think we will have the strongest, smartest, most resilient, most well-trained workforce in the world when it comes to US physicians. I say that not as a lobbyist but as a physician. It's a wonderful profession. I think that we are working so hard. I see so many of my colleagues around the country working so hard to make sure that our institutions are diverse, and that there are appropriate vetting and questioning systems in place so people can have a voice.

In terms of disciplinary action, there's always been a large amount of that in medicine. I would say this: If you're a colleague watching this who's struggled with your behavior and suffered some consequences of that, it's an opportunity for you to shine and to improve and to grow. It probably doesn't feel that way.

For institutions, it's important to let us know all the things that you're doing to help physicians — not just to punish doctors or catch misbehavior, but to prevent that and to make sure there's a conversation going on to help us.

There's a new landscape that I think many doctors are, in some ways, frightened of. Many doctors weren't raised, or didn't come of age, or haven't been professionals in an era where pronouns matter. There are strong opinions, but when it's your patient and it matters to them, it should matter to you. There is a large amount of new training and education to help us understand the difference between misbehavior and physicians being misinformed and needing to learn.

Whyte: Well, Dr Drew Ramsey, thank you, as always, for taking the time and helping us understand what's going on with our minds and our bodies, whether it's physicians, healthcare workers in general, or just our everyday selves. You offer us good insight all the time. Thank you.

Ramsey: Thank you so much, John. It's a treat to be with you. Thank you for drawing our attention to this. It's easy to put our heads in the sand and ignore that everyone struggles with behavior, period, and that part of understanding our behavior is becoming a great physician. I really appreciate this conversation. Thank you again.

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Cite this: Physicians Behaving Badly: Is It Arrogance, Insecurity, or Stress? - Medscape - Dec 28, 2022.