It's been five years since the Joint Commission first issued an alert warning of the dangers of disruptive and intimidating behavior in health care. While progress has been made as more doctors move to the hospital setting and into a team-based model, there's room for progress, experts say.

Vanderbilt University, which has been evaluating doctors referred to them for disruptive behavior since 2001, has seen an uptick in reports recently. A.J. Reid Finlayson, M.D., associate professor of clinical psychiatry, believes hospitals have become less tolerant of such behavior in recent years, and leaders are instilling employees with the confidence to speak up.

"The face of medicine is changing," he says. "In the old days, doctors were trained to be almost like lone rangers. You had to have the very best knowledge and a lot of confidence in yourself, and you made decisions on your own. But things are transforming so that a lot of medical practice is really contingent on working cooperatively in teams, so the emphasis has swung more and more to doctors' having leadership roles that they unfortunately weren't trained for."

Those referred to Vanderbilt's study of 381 physicians were mostly middle-aged, white and male. Disruptive behavior (40 percent), sexual boundary issues (23 percent) and substance abuse (20 percent) were the top reasons for referral. One key finding, Finlayson says, is that with the proper management, such physicians can be restored to full practice, instead of being dismissed. Hospitals must be able to detect the signs early, though, and develop a system in which it's easy to elicit comments from employees.

John Combes, M.D., senior vice president of the American Hospital Association and president and chief operating officer of the AHA's Center for Healthcare Governance, urges leaders to carefully define disruptive behavior in their policies, so that doctors aren't singled out over simple disagreements or contrarian actions. He believes that progress is being made as new clinicians enter the system who were trained in a team-based environment.

Hospitals must provide resources to doctors, though, to encourage them to work well with others. "How do you help physicians deal with the complexity of the change and the stresses that the environment is bringing to them?" Combes asks. "You don't tolerate bad or abusive behavior, and I think boards have to act very firmly in that area. But at the same time, they have to support physicians in this transition. Creating resources within the organization to support those kinds of stressors is something that's very important."

Ronald Wyatt, M.D., medical director of health care improvement at the Joint Commission, says while there have been "pockets of excellence" in addressing disruptive behavior, it remains a huge issue in most hospitals. More research needs to be done on the topic, and the industry should keep striving until it's a thing of the past, he says.

"We're not there yet. I'm not even going to say we're close to there yet," Wyatt says. "But progress is being made, and I think the more we beat the drum around this issue, the better we'll get."