603RADIOLOGIC TECHNOLOGY, JulyAugust 2017, Volume 88, Numb

603RADIOLOGIC TECHNOLOGY, July/August 2017,
Volume 88, Number 6
CE
Directed Reading
This article is a Directed
Reading. To earn
continuing education
credit for this article,
see the instructions on
Page 618.
After completing this article, the reader should be able to:
�� Define the concepts of leadership, followership, and
servantship.
�� Describe the importance of compassion, empathy, and
altruism in patient care.
�� Explain the ongoing need to evaluate one’s leadership and
followership in the
workplace.
�� Discuss the varying leadership and service roles of the
radiologic science professional.
�� Explain how health care professionals’ servantship can
enhance patient care.
Steven M Penny, MA, R.T.(R), RDMS
The primary role of all health
care workers is that of patient
servant. In health care, being a
patient servant requires com-

passion for the patient, and many profes-
sionals personally aspire to have empa-
thy and altruism in all patient encoun-
ters. As followers, health care workers
might be free to choose which leader
they desire to follow and a level of com-
mitment they will provide to the leader
and the organization. Lastly, health care
workers, including medical imaging
technologists, can be in leadership roles
within an organization, and workers
should study leadership concepts rou-
tinely to prepare for these roles.
Service and Leadership
A given individual’s choice to enter a
helping profession is the foundation for
patient care. Studies have reported that
nurses provided the following reasons
for their career choice1:
� Caring for people.
� Rewarding work.
� Possible career advancement.
� Family history of working in
health care.
� Career security.
� Socialization.
� Job satisfaction.
� Interest in the human body and
medicine.

An Australian study of nearly 800
nurses and nursing students identified
the top 5 reasons for entering the nurs-
ing profession as it being an interesting
job, an opportunity for caring for
others, working with people, the per-
ception that nursing was a calling, and
a sense of giving to the community.1
Although health care workers choose to
work in a field in which they take care
of others for various reasons, providing
honest patient care has been long estab-
lished as a primary motivation.
The health care culture typically
stresses that medical professionals place
the needs of their patients and soci-
ety above all other considerations.2
Servantship, also called servanthood,
relates to how health care practitioners
serve the needs of patients and the
Serving, Following, and
Leading in Health Care
Radiologic technologists
often perform diverse roles
throughout the workday, and
they should have at least a
minimal understanding of
the responsibility and effects
of these roles on the patient
and organization. Although
technologists can practice
independently or as part of

a work group, individuals
should be prepared to improve
patient care and to function
as a servant, follower, and
leader for the overall success
of the organization. This
article examines those roles,
emphasizing servantship.
604 RADIOLOGIC TECHNOLOGY, July/August 2017, Volume
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Serving, Following, and Leading in Health Care
satisfaction refers to the pleasure and gratitude an indi-
vidual feels when providing the best patient care one
can offer.4 As a result, the compassionate caregiver feels
a sense of personal benefit when generously contribut-
ing to a positive change in patient care or outcomes.5
Compassion satisfaction benefits the patient as well
and leads to gaining and sustaining patient trust when
health care professionals exhibit excellence, altruism,
skillfulness, and accountability.6
An ancient Native American teaching maintains
that “each time you heal someone, you give away a piece
of yourself until, at some point you will require heal-
ing.”7 Working with individuals in pain and distress is
a component of most caring professions, but continual
exposure to the suffering of others has a cost: compas-
sion fatigue. Compassion fatigue, often referred to as

the cost of caring, is the combination of burnout and
secondary traumatic stress.4,7 Burnout is a prolonged
response to chronic job-related emotional and interper-
sonal stressors characterized by emotional exhaustion,
depersonalization, and a feeling of decreased personal
accomplishment. Secondary traumatic stress relates to
working with people whose illness or pain is uncontrol-
lable, thus leading to a sense of powerlessness.4,8
Eventually, compassion fatigue can lead to disillu-
sionment, which has been identified as a primary reason
why nurses choose to leave health care.9 Unhappiness
at work leads to increased turnover, absenteeism,
safety risks, and poor judgment, all of which negatively
community (see Box 1). Helping professions, such as
those in patient care, offer a fitting environment for indi -
viduals who are inclined to serve others. For the radiologic
technologist, serving the needs of patients should not be
viewed simply as a job requirement, but as the norm, and
as a genuine opportunity to make a distinctive difference.
Imaging technologists play a unique role in patient
care. Whereas a nurse might spend an entire shift (often
as many as 12 hours in critical care units) with a few
patients, an imaging technologist might spend 10 min-
utes or less performing a single diagnostic examination.
However, limited time should not keep imaging profes-
sionals from providing the patient with individualized
care, and the time spent serving patients is amply
rewarded. Servantship is based on acts of compassion,
empathy, and altruism, with altruism being the ultimate
goal (see Figure).
Compassion, Empathy, and Altruism in Health Care
The compassionate nature required of health care

professionals is associated with benefits and risks.
Compassion is described as a virtue that causes an
individual to consider seriously another person’s real -
ity, inner self, emotions, and external circumstances.3
William J Bennett stated that courage allows a person
to stand by others in challenging situations, but com-
passion causes a person to stand with others who are in
painful situations.3
Freely exhibiting compassion often results in what
has been called compassion satisfaction. Compassion
Box 1
Essentials of Servantship in Health Care
Smile.
Ensure patient dignity.
Respond to patient needs appropriately.
Value the uniqueness of the patient (eg, age, race, gender,
emotional state).
Advocate patient rights and safety.
Never demonstrate disrespect towards the patient.
Thank the patient.
Serve the patient with compassion.
Help others serve the patient.
Identify patient mistreatment and demand improvement.
Portray professionalism.
Altruism
(only for others)
Empathy
(connecting with others)

Compassion
(considering others)
Honesty Integrity Trust
Increased follower
engagement, sharing
of knowledge and job
performance.
Figure. Patient care model where altruistic patient care is the
ultimate
goal. Image courtesy of the author.
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patients ultimately leads to the personal benefits of com-
passion satisfaction, personal growth, self-actualization,
and the potential to exhibit empathy.10
Unfortunately, studies have shown that empathy
in the United States is on the decline. According to
Anderson and Konrath, empathy in college students
was 40% lower in 2011 compared with 20 or 30 years
prior. This included a 48% drop in empathic concern,
which is the tendency to possess concern for others’
emotions.11 The authors stated hypothetical societal

causes of decreased empathy such as:
� An increase in reality television shows, which cen-
ter on narcissistic main characters.
� The rise of social media.
� A focus of primary education on self-esteem vs
encouraging the cultivation of empathy.
According to the authors, this is why the millenial gen-
eration has been referred to as “Generation Me.”11
Empathy is enhanced compassion. It can be defined
as an ability to recognize and feel or share the emotions
and feelings of others with a minimal distinction placed
on the difference between self and others.8 Empathy
often is confused with sympathy, which is concern
for others.8 Although sympathy demonstrates care for
another’s situation, empathy is characterized by sharing
the perspective of feelings regarding the circumstances
of another. Furthermore, empathy is the capacity to be
affected by and share the emotional state of another
person, while assessing the reasons behind the other
person’s emotional state by identifying and adopting the
person’s perspective.12
Most people have the capacity for empathy and the
concept can be seen in nature and early in human life.
In nature, mobbing demonstrates empathy. Mobbing is
an instinctive antipredator behavior that occurs when
a creature from an established colony warns the colony
or attacks a predator to save others within the group.
Infants as young as 12 months have shown the capacity
to comfort victims of distress, while by age 18 months,
they can display spontaneous helping behaviors.8
In patient care, empathy is a step above compassion

because empathy demands that caregivers put them-
selves in the patient’s situation, and that they recognize
that the caregiver could be in a similar state of ill health
a patient faces.
affect patient care.4 Physical manifestations of com-
passion fatigue have been demonstrated and include
gastrointestinal issues, headaches, physical exhaustion,
insomnia, and substance abuse.7 Burnout has been
shown to hinder patient care if the affected professional
begins to treat patients in an uncaring manner.8
According to Aycock and Boyle, health care workers
who are most at risk for compassion fatigue are those
who bring high expectations to a job, are aged 30 years
or younger, and are unmarried or lack an intimate part-
ner.8 Slocum-Gori et al demonstrated that compassion
satisfaction provides an effective counterbalance to the
risks of compassion fatigue. A negative correlation has
been established between compassion satisfaction and
compassion fatigue and burnout.5 An individual can
accomplish compassion satisfaction by acknowledg-
ing the symptoms of compassion fatigue. Compassion
fatigue can be overcome by focusing on others instead
of oneself and through activities that help reinvigorate
the passion for caring for others that once was felt.4
Stress management and relaxation techniques, exer-
cise, rest, a healthy diet, forgiveness, and taking care of
oneself all work to increase compassion satisfaction and
battle compassion fatigue.7
An individual who regularly can balance the con-
cern of self and others often is called a mature carer or
mature caregiver.10 These individuals can maintain a
healthy emotional balance, showing compassion toward
others while maintaining a professional distance. The

self-awareness and self-confidence of mature caregivers
strengthens their ability to care.10 By contrast, caregiv-
ers distraught with compassion fatigue appear to create
a protective yet invisible emotional barrier between
the caregiver and the patient. As the caregiver begins
to unintentionally build up a defensive emotional for-
tification, compassion begins to erode. Establishing an
emotional barrier between caregiver and patients can
support self-preserving efforts. The analogy of building a
barrier resembling a window vs a wall demonstrates how
best to handle emotional barriers. A window provides
the opening for compassionate care while simultaneously
providing an emotional barrier to maintain a professional
distance. The caregiver can continue to see the patient’s
pain and point of view through the metaphorical window
to provide compassionate care. Honest compassion for
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altruism in patient care focuses less on the monetary
rewards, professional recognition, or even patient appre-
ciation, but is purely for the sake of the other, or patient.10
Servantship Within the Code of Ethics
Examples of servantship can be found in the
Standards of Ethics established by the American
Registry of Radiologic Technologists (ARRT). Within

the standards is a code of ethics, which the ARRT says
can guide radiologic technology professionals in how
they “evaluate their professional conduct as it relates to
patients, healthcare consumers, employers, colleagues,
and other members of the healthcare team.”15 The
code of ethics is considered aspirational, or conduct
that radiologic professionals should constantly strive
to meet.15 Several key points within the code of ethics
relate to servantship.
The ARRT’s first ethical code states that profession-
als should respond to patient needs and offer support
for other team members.15 Responding to the needs
of the patient requires a considerate approach from
the health care professional and continual mindful-
ness of the changing health needs of each patient. In
this regard, imaging professionals must serve others by
being completely available and accountable to patients.
Accountability is the willingness to accept responsibil -
ity for and the consequences of one’s actions.16 Dealing
with the various and changing needs of each patient
requires radiologic technologists to appreciate the
dynamic environment in which they are engaged. Those
interested in enhancing servantship should strive to
augment existing knowledge in their fields of expertise
beyond the minimal requirements imposed by certifica-
tion organizations. Lifelong learning directly benefits
the patient and the technologist. The support role of
the imaging technologist encourages teamwork and all
health professionals should share in the concern for the
patient, working together for the patient’s benefit.
The ARRT’s second ethical code articulates that
the imaging technologist should strive “to provide
services to humanity with full respect for the dignity
of mankind.”15 Every individual has dignity, which can

be fragile and easily bruised.17 Wounding a patient’s
dignity erodes trust, making serving the patient more
difficult.17 As the technologist demonstrates respect
At the core of patient care is the ancient maxim of
treating others as one would like to be treated—often
referred to as “the golden rule.” Yet health care profes-
sionals can face decreased empathy, emotional burnout,
and reduced altruistic motivation, resulting in less
productive and effective patient care.12 Like compas-
sion fatigue, a caregiving individual must recognize and
address decreased empathy. Empathy is much like a
muscle that can atrophy but regrow and regenerate if an
individual chooses to focus on others instead of self.11
Focusing more on the needs of others typically results
in an increase in personal and professional satisfaction.4
The empathy-altruism hypothesis claims that
empathy directed toward improving another person’s
welfare evokes altruistic behavior.12 Altruism, rooted
in the French word autrui, meaning “other people,” is
a human quality synonymous with self lessness, taking
others’ perspectives, and showing concern for others for
the sake of the other people rather than for oneself.10,13
The opposite of altruism is egoism. Egoism includes
social reward-seeking behavior and punishment avoid-
ance.12 Narcissism can be considered an extreme form
of egoism. Narcissists have high emotional aptitude in
that they can identify the emotions of others, but rather
than aligning themselves with the other person’s emo-
tions and feeling empathetic, narcissists use the other
person’s emotions for personal gain or to manipulate.11
These self-serving individuals tend to prey upon the
perceived weaknesses of others.
According to some authors, an entire generation of

individuals once served the United States and the world
in a manner that might never be matched. For example,
in his book The Greatest Generation, Tom Brokaw
describes the story of the servant-minded Chuck Van
Gorder, MD. Gorder, who was a World War II field
surgeon, returned to America after the war to continue
offering his medical expertise in a small community. In
the early days of his struggling medical practice, Gorder
accepted garden vegetables or wild game as payment for
the care he provided to the less fortunate patients in his
community.7 Gorder stated that in the past, “medicine
was more altruistic.”7
An altruistic individual is someone who is a servant
intrinsically.14 True altruistic care is ideal in that the act
is unconditional, spontaneous, and selfless.10 Possessing
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supports the leader while simultaneously meeting the
mission of the organization and the professional direc-
tives or standards of ethics placed upon the individual
by the profession. The imaging technologist is an
example of a frontline follower in health care. Followers
perform the fundamental, yet vital, functions that
involve commitment to the leadership of the organiza-
tion, while simultaneously satisfying customer needs.
As a result, everyone in the health care workplace could

be described as a follower, even the chief executive offi -
cer, who typically reports to a board of directors.
Some might perceive followers as those individuals
within an organization who lack power, authority, or
influence, but who are led from 1 task to another by a
leader.19 Further, society’s view of leadership means that
followership positions might be considered ancillary
to accomplishing an organization’s overall mission.20
But a leader with a group of helpful, competent fol-
lowers can accomplish a great deal, while a leader with
a dysfunctional group of followers will struggle and
likely fail. The most valuable followers are said to be
skilled, self-directed individuals who invest time and
energy in the work group and who use critical thinking
effectively.4 The courageous follower model sugges ts
that effective followers share and assume responsibility
for a common purpose with their leaders, support the
leader, constructively challenge the leader, participate
in transformational needs required to fulfill the leader’s
mission and organization, and take a moral stand when
warranted (see Box 2).21
for a patient’s dignity, a reciprocated respect is created
between the caregiver and patient, resulting in mutual
trust and a commitment to the common aim of appro-
priate diagnosis and recovery.10 Patients who have high
trust in their caregivers tend to have better quality of
care and outcomes.18 This person-oriented approach to
professionalism compels a technologist to invest him-
self or herself in patient interactions and to commit to
doing the best possible job for the person in need.10
In the third and fifth codes, the ARRT states that
the technologist should deliver “patient care and service
unrestricted by the concerns of personal attributes or

the nature of the disease or illness, and without dis-
crimination on the basis of sex, race, creed, religion, or
socio-economic status.”15 Truthful servantship regards
all patients as equals, regardless of whether the patient
reciprocates the sentiment. Many patients have under-
lying emotional needs that are not evident at the time
of the first encounter. Although some patients exhibit
rudeness or disrespect, technologists should always act
“in the best interest of the patient,” particularly when
the reasons for the patient’s behavior can be unknown
or beyond health care professionals’ understanding.15
In the eighth ethical code, the technologist is encour-
aged to practice “ethical conduct appropriate to the
profession” and protect “the patient’s right to quality
radiologic technology care.”15 The rules of ethics, which
are mandatory standards of professional conduct, also
are found in the ARRT’s Standards of Ethics. These rules
help ensure the competence of the technologist as well as
patient protection, safety, and comfort.15 Technologists
who aspire to practice honest service follow these rules
and ensure that others follow the rules as well.
Followership
Business literature is replete with research on
leadership and models or suggestions for leaders. By
comparison, followership research appears to be lack-
ing. However, followership is a vital component of
overall leadership effectiveness because leaders need
followers in order to lead. Although many radiologic
technologists serve as leaders at some point in their
careers, the overwhelming majority of a radiologic
technologist’s time is spent as a follower.4,19 In the clini -
cal setting, followership relates to how the follower

Box 2
Courageous Follower Model21
The follower should have the courage to:
� Support the leader and do everything possible to
contribute to the leader’s success.
� Assume responsibility for the common purpose and act
independently.
� Challenge constructively the leader or group’s behaviors or
policies if these threaten the common purpose.
� Participate in any transformation needed to improve
the leader-follower relationship and the organization’s
performance.
� Take a moral stand when warranted to prevent ethical
abuses or, at the very least, to refuse to participate in them.
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In almost every situation, followers outnumber lead-
ers. Consequently, it is clear that a group of inharmonious
followers can disrupt the productivity of an organization,
ultimately negating the overall effectiveness of the leader

and the organization. Therefore, although followers do
not have to be eternally happy, they need their leaders
to provide a clear vision, perhaps with an explanation of
collective goals. Failing to provide the connections and
direction needed to maintain follower engagement could
be the difference between effective and ineffective leader -
ship. Thus, for the leader to be effective, the leader and
follower must view their shared fundamental mission
similarly. In effect, it is easier for a follower to develop a
secure pattern of attachment to a leader when the leader
and follower share a strong degree of synergy in values,
goals, work, and communication styles.23
Followership requires a personal commitment to
contribute within a collaborative environment.24 Being
a team player with personal accountability is crucial
for the follower to excel. Birds demonstrate teamwork
in nature when they f ly in the “V” formation. The lead
bird works the hardest, helping the entire group benefit
from the aerodynamics of the formation. However,
birds instinctively appreciate the need to cooperate
and share the lead position in a group for the benefi t of
all, so they rotate positions throughout their migratory
f lights. Like birds, followers should occasionally rise to
a casual leadership position when needed for the better -
ment of the group. Serving as an efficient follower and a
valued employee also is linked (see Box 3). Employers
want to hire individuals who consistently28:
� Demonstrate honesty and integrity.
� Have positive attitudes.
� Are reliable, professional, and intrinsically moti -
vated.
� Convey cheerfulness and friendliness in the work-

place.
Choosing to be an efficient follower can improve leader-
ship potential and place the follower in a position that
might improve his or her opportunity to advance within
the organization.
Leadership
The word leader originates from the word leden,
which means to travel or to show the way.27 The idea of
Examples of followership styles and types range from
the follower offering the leader diminutive support and
challenge just to maintain employment, to high support
and challenge in which the follower serves more as a
partner with the leader than an employee to accomplish
shared goals and uphold the overarching mission of
the organization (see Table 1).21 Followership types
also relate to the view from the leadership position.
According to Thomas, the most effective or valuable
followers tend to be those who are talented critical
thinkers.22 These individuals do not have to be told
what to do and often practice informal leadership.22
Bureaucratic followers, commonly referred to as
“brown nosers,” are conformists who follow the rules but
lack leadership and critical thinking skills.22 Slackers are
followers who do the minimum required or less than the
minimum. Criticizers are followers who are disgruntled,
pessimistic, and who work to manipulate the work envi-
ronment negatively by using petty tactics of disruption.
Leaders must thus appreciate the fact that if followership
styles and types are perceptible, then followers should not
be viewed simply by the leader as perfunctory subordi-
nates, but rather as individuals with the freedom to choose
which leader they want to help be successful.22 Equally, it

also is evident that followers can choose which leader to
undermine. Both must share in the recognition and reme-
diation of work troubles, as the dysfunction of a follower
is not always the sole fault of the follower, but it could be a
symptom of ineffectual leadership.
Table 1
Followership Styles1
Style Explanation
Resourceful Will do enough to retain position but no
more.
Individualistic Will speak up when others are silent, but
voice is marginalized because it is too
chronically contrarian.
Implementer Will do whatever the leader wants them to
do regardless of the consequences. They
tend to not challenge the leaders authority.
Partner Assumes full responsibility for their own
actions and leader's behavior and acts
accordingly.
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leaders’ charge, or followers, in a desired manner to
achieve specific goals. That is, leaders know what they
need from followers, and effective leaders know how to
get the desired results. This fundamental description
of leadership acknowledges that leadership exists in all
aspects of life—at home, work, and even in associations
with strangers.
If everyone has some leadership skills required and
used in daily practice, then it stands to reason that
everyone has some degree of leadership potential.
However, on observation, it also is clear that some
people are more likely to excel as leaders than are oth-
ers.35 One must accept that although leadership can be
learned, and that most people have evident or dormant
skills that must be honed, leadership manifests more
naturally in some individuals.36 Further, although some
leadership skills are innate, most appear to be learned
over the course of life experiences.18
Great acts of leadership exist throughout history.
On April 15, 1912, as the Titanic began to sink and
people fought for survival, 8 musicians played a solemn
harmony as they stood on the deck of the plummeting
leadership dates to Plato’s time (427 to 347 bc).26 Plato
recognized 3 leadership concepts or laws in his early
work The Republic; these are the rules of reason, desire,
and spirit.29 Since Plato, many others have sought to
define leadership and to consequently acknowledge the
need to study leadership as a component of essential
human existence. The term leader was noted as early
as the 13th century, but the term leadership was not
used until the 17th century.30 The organized study of
leadership is essentially a novel endeavor, with the true

scientific research beginning early in the 20th century.30
Subsequently, much has been written about leader-
ship and the construction of numerous definitions and
theories, including the study of traits, qualities, and
behaviors of effective leaders as they encourage others
to participate, grow, and commit to an organization
(see Table 2).30
Leadership has been characterized broadly as the
ability to influence others to accomplish a specific goal.33
When one seeks to influence the thoughts, behaviors, or
development of others, he or she is adopting the role of
a leader.33 Leadership is a process that requires a group
context and the aim to reach a defined goal.29
According to Fioravante, leadership consists of 2
fundamental functions: offering a clear vision and the
ability to incentivize others to follow.34 Consequently,
effective leaders influence those who are under the
Box 3
Qualities of an Efficient Follower25
� Aligns personal goals with those of the organization and
commits to achieving those shared goals.
� Recognizes connections between own work and the
broader mission of the organization.
� Competent at completing a job.
� Seeks opportunities to advance skills without being told to
do so.
� Can self-manage and self-assess.
� Uses critical thinking effectively.

� Appreciates and respects the leader.
� Is compliant, but unafraid to offer a different viewpoint from
the leader respectfully, along with suggestions.
� Interacts constructively with the leader and others in the
workplace.
� Leads by example.
Table 2
Overview of Historical Leadership Theories2,3
Leadership
Theory
Time of
Study Explanation
Trait Early 20th
century
Sought to define effective
leaders by analyzing shared
personality traits or qualities.
Behaviorist Late
1940s
Concentrated on leader
actions vs personal qualities.
Contingency 1960s Refined version of situational
leadership emphasizing that
situation best predicts appro-
priate leadership style.

Transactional 1980s to
present
Focuses on the contractual
leader-follower relationship
and the mutual benefits
derived.
Transformational 1980s to
present
Focuses on follower change
and personal growth and
development.
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Truly great leaders develop their skills over a life-
time.40 The consequence of a manager taking on a true
leadership role represents a focus shift. Whereas the
manager’s primary obligation is to produce accept-
able end results for overall organizational success, the
manager-leader also must concentrate on creating
personal connections to engage followers.27 Essentially,
management is solely about building business, and lead-
ership is about building business and relationships. If a
manager desires to be a leader, then the manager should

strive to include relationship building as part of the
management skill set because it is clear that people are
the most significant resource in an organization.41
Demonstrating Leadership
Through study of leadership skills of renowned
individuals, scholars have developed an extensive list
of characteristics to describe the qualities of great lead-
ers. These qualities also are called leadership traits. In
many situations, these traits also are called virtues. Trait
theories of leadership arose as a way to identify specific
characteristics of a successful leader; although the list
is expansive, several are common throughout the litera-
ture. These trait theory skills include33:
� Technical skills.
� Friendliness.
� Task motivation.
� Social skills.
� Emotional control.
� General charisma.
� Intelligence.
Other common leadership skills identified include
creativity, diplomacy, verbal f luency, knowledge, orga-
nization, persuasiveness, and the ability to understand
abstract concepts.31
The virtues of honesty and integrity should be evident
in leaders. Honesty is truthfulness, being free of fraud or
deception. Thus, honesty is a virtue that can be honed to
become an essential part of an individual’s character. The
most successful leaders are honest and are accountable for
their own actions.42 Honesty is accomplished through a
conscious effort to live in truth. Honesty breeds integrity,

and integrity develops credibility.42 Ultimately, integrity
is honesty demonstrated, as integrity is open-mindedness
in thought, word, and deed.43 For the leader, honesty and
ship. The musicians’ calm offering in a time of human
tragedy demonstrated noble leadership. Unfortunately,
all 8 musicians died in the frigid waters of the North
Atlantic Ocean.37 On September 11, 2001, in the midst
of the hijacking of United Airlines Flight 93, passenger
Todd Beamer declared “let’s roll!,” which portrayed
leadership in the midst of a horrifying situation. That
day, the hijacked plane was headed toward any number
of susceptible targets in the nation’s capital, but it is
believed that Beamer and others onboard overtook the
hijackers. Although the plane crashed in a field, the pas-
sengers prevented the loss of additional human lives had
the original target been hit.38
These historical examples demonstrate extraordi-
nary leadership in practice, but routine leadership also
is evident in everyday lives. For example, parents influ-
ence their children, and therefore are leaders. At work, a
health care professional can be a leader among a group
of coworkers.39 Still, when asked for an example of a
leader within an organization, many people often look
to those who have significant power within the chain of
command.40
True leadership has nothing to do with one’s occu-
pation or level within an organization.40 Anyone can
display leadership skills at anytime. Thus, leader-
ship can be formal or informal. Formal leadership is
exhibited by an individual in an assigned role who has
allocated powers within an organization, but informal
leadership can be demonstrated by members of a work
group, such as a collection of staff technologists, who

share a leadership role to accomplish routine tasks.4
Often, definitions of management and leadership
overlap, yet there is a clear distinction between leader-
ship and management. Management has been described
as preparing, arranging, staffing, and controlling
actions of followers to achieve specific goals.4 Managers
often focus on outcomes, make the best possible deci-
sions for a group, and concentrate on the bottom line.
However, managers are placed at optimal power levels
within organizations to exercise leadership simply
because managers oversee, and therefore lead subordi -
nates in day-to-day organizational tasks and efforts.27
Holding a manager title does not necessarily make
someone a leader. However, managers can study and
cultivate their individual leadership styles.
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research a revolutionary concept referred to as emotion-
al intelligence (EI). Although EI has been defined and
then redefined by others, the 5 domains of emotional
intelligence are54:
� Knowing one’s emotions.
� Managing one’s emotions.
� Motivating oneself by organizing emotions.
� Recognizing the emotions of others.

� Managing the emotions of others.
EI and leadership have been linked throughout the
literature, and authors often establish direct relation-
ships between leadership effectiveness and EI.50 A
statistically significant correlation between EI and
the leader’s job performance has been reported.50
Researchers consistently report that the leader who has
higher EI often is more effective.53 Batool stated that EI
can help reduce stress, develop performance, improve
sense of achievement, and enhance the productivity of
the employee by meeting organizational goals.54 Some
authors claim that EI is a better predictor of a leader’s
success than is intellectual quotient (IQ ).55
Four components make up EI: self-awareness,
self-management, social awareness, and relationship
management (see Table 3).51 A leader who is self-aware
can recognize his or her strengths, weaknesses, and feel -
ings. Being self-aware requires humility. Management
author Jim Collins described leader levels, with level 5
as the highest level of leadership. These high-level
leaders combine humility and will.56 Thus, it may
be surmised that level 5 leaders possess a higher EI
because they have the ability to appreciate the impor-
tant contributions of followers and to look in the mirror
to apportion responsibility. Being humble enough to
manage ego and power is a mark of an emotionally
strong leader. Effective leaders are willing to make well-
informed decisions to the best of their ability and are
bold enough to stand by those decisions. Leaders also
should be willing to admit when they make mistakes,
a task that requires the courage to reflect upon one’s
actions.
Emotionally intelligent leaders also can manage

relationships with followers and self-manage their own
emotions to breed an environment of trust.50 Finally,
emotionally intelligent leaders have social aware-
ness, which demonstrates the capacity to empathize
integrity are demonstrated in straightforwardness in all
interactions with followers, which in turn yields respect
and trust from followers.44
Trust is vital for the leader, and leaders who make
personal connections by establishing trust with fol-
lowers tend to be more effective.41 If a follower trusts a
leader, then trust in the organization also can increase,
and trust in an organization has been shown to be
positively associated with work engagement, sharing of
knowledge, teamwork, and employee performanc e.45
Effective leaders are true to themselves and their follow -
ers.46 John Wooden, famed University of California, Los
Angeles, basketball coach, claimed that before one can
lead others, one must be able to lead oneself.46 Because
health care professionals are responsible for the lives of
others, honest personal reflection and accountability
always should thrive in patient care, even in leadership
positions. Blanchard and Miller suggested that the lead-
er continuously gain knowledge, reach out to others,
open their worlds, and walk toward wisdom (GROW).47
In clinical practice, the application of the as low as
reasonably achievable (ALARA) concept, as it relates
to diagnostic imaging of any kind, is an example of
honesty and integrity a leader can promote consistently.
The Image Gently Alliance, which was founded by
the American Society of Radiologic Technologists,
Society for Pediatric Radiology, American College of
Radiology and the American Association of Physicists
in Medicine, operates on similar principles. Image

Gently aims to advocate on behalf of and ensure safe
and effective imaging care for children worldwide.48
Parents usually are unaware of the radiation exposure
their child receives and the potential for biological
effects from diagnostic examinations. Leaders who have
the courage to demonstrate honesty and integrity in
imaging practice know and enforce ALARA principles
and practice standards, are patient advocates, and gain
patient trust, ultimately supporting enhanced patient
care. The courage to demonstrate honesty and integrity
in leadership is not so much fearless as it is a willingness
to act out of conviction.49
Emotional Intelligence and Leadership
In the mid-1990s, psychologist and writer Daniel
Goleman helped bring to the forefront of leadership
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the changing definition of EI appears to cause some
confusion and difficulty among academic scholars, and
others denounce the existence of EI altogether.50 Still,
emotions likely play a vital role in leadership success;
leaders who are self-aware, manage themselves, and can
relate to others appear to create a work environment
favorable for success.52,54

Leadership Models
George Washington, Martin Luther King Jr, and
Mahatma Gandhi are considered impressive, efficient
leaders. Although these individuals did not know each
of their followers personally, followers were said to feel
a personal connection with the leaders because each
demonstrated an evident concern for followers.57-59
Great historic leaders in health care also have made
distinctive contributions to evoke change. Examples
include Clara Barton, the founder of the American Red
Cross; Wilhelm Conrad Roentgen, the engineer and
physicist who discovered x-rays; and Alexander Fleming,
the Scottish scientist who discovered penicillin.60-62
Leadership in health care is facing some challenges.18
Reasons suggested for these challenges include the lack
of a formal leadership model specifically for health care,
time constraints on those in leadership positions in the
health care setting that are secondary to time needed
for clinical responsibilities, and the financial limitations
of an ever-evolving health care system.18 As a result, sev-
eral leadership styles have been proposed. Transactional
leadership, transformational leadership, and servantship
are fundamental forms of leadership that are practi-
cal for use in a health care organization, although the
emphasis on the leader-follower relationship varies
markedly among them.
Transactional Leadership
Transactional refers to accordance or a contract
between people, or a group of people, that results in an
exchange.42 In business, transactional leadership is an
approach in which the leader-follower relationship is

focused on the mutual benefits when an effort-reward
contract is in place.31 For example, if one follower were
to outperform another follower on a specific task, the
transactional leader would recognize the higher achiev-
er through recognition, remuneration, or some other
with others. The common characteristic among these
concepts appears to be reflection upon self without
neglecting others. Leaders with high EI might practice
situational leadership, which emphasizes that a leader
must adapt his or her style according to the situation of
the leader’s team or organization.44
EI has been demonstrated as important for follow -
ers as well. A follower’s EI contributes to the leader’s
assessment of the follower’s potential and credibility.51
Essentially, an emotionally intelligent follower respects
the power of the leader and can delineate his or her
unique role within the organization.
Complex EI inventories, scales, questionnaires,
and online tools have been created to measure EI.50
However, since its introduction, the concept of EI
has been criticized. Although the control and malle-
ability of emotions clearly is necessary for leadership,
a definitive model for measuring EI has not yet been
established, resulting in possible ambiguity.50 Some
authors also suggest that participants can falsely self-
report, leading to skewed data. Finally, critics say that
Table 3
Dimensions of Emotional Iintelligence4,5
Dimension Capacity to Explanation

Self-awareness Appreciate
one’s individual
emotions,
strengths, and
weaknesses
Sought to define
effective leaders by
analyzing shared
personality traits or
qualities.
Relationship
management
Influence, handle
disagreement, and
inspire change
Concentrated on
leader actions vs
personal qualities.
Social awareness Relate to and
empathize with
others
Refined version of
situational leader-
ship emphasizing
that situation best
predicts appropriate
leadership style.
Self-
management

Be truthful
and control
emotions that
can be harmful to
relationships
Focuses on the
contractual leader-
follower relationship
and the mutual
benefits derived.
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Transformational Leadership
Whereas the transactional leader motivates via an
exchange relationship with the follower, the transfor-
mational leader clearly communicates his or her vision
and inspires followers by promoting self-respect, pride,
and mutual trust.58 For example, in his celebrated “I
Have a Dream” speech, Martin Luther King Jr provided
an example of transformational leadership through
symbolic oratory by identifying and articulating a clear
vision, providing a model for change, establishing lofty
expectations, and fostering acceptance.58

Transformational leadership strongly predicts
job satisfaction, ratings of effectiveness, high group
performance, and increased overall work effort by fol-
lowers when compared with transactional leadership.54
Clarence Francis, once the chief executive officer of
General Foods, stated that “You can buy a person’s
time; you can buy his physical presence at a given
place, but you cannot buy enthusiasm. You cannot buy
loyalty. You cannot buy the devotion of hearts, minds,
and souls. These you must earn.”65 This statement
relates to the transformational leader, because follow -
ers of transformational leaders often view the leader as
a benevolent parent who remains responsive and treats
the follower as an equal despite the disparity in knowl -
edge and experience.30
Transformational leaders ultimately acquire trust,
fondness, admiration, loyalty, and respect from fol-
lowers.30 Transformational leadership is thus rooted in
emotion and has been linked with the leader’s EI level.51
Transformational leaders with high EI use empathy to
connect with followers and work to encourage expres-
sion of emotions from individuals or group members.49
Having empathy for followers is thus a precursor for the
transformational leadership model because the leader’s
ability to express emotions is vital for the success of the
group.49
Several benefits to transformational leadership have
been reported. Transformational leaders recognize the
need for the follower to learn and evolve continually.
Govaerts et al studied 972 employees and revealed that
empowering employees to do more and learn about
their strengths encourages the employees to stay with
the organization.66 Authentic leadership is similar to
transformational leadership, but at a more personal level

established incentive. Conversely, a punishment would
follow the breaking of an established rule or agreed-
upon custom. Although financial or social rewards have
been reported to increase feelings of fairness and satis-
faction, punishment exerts a negative influence on the
follower.61
Transactional leadership has been cited as the
most common leadership model used in health care.18
However, studies suggest f laws in transactional leader-
ship. One study claimed that out of 845 employees,
only 9% agreed their performance was motivated by
transaction.30 And although transactional leadership
often helps leaders accomplish specific goals, it also
can stif le creativity and innovation by discouraging
individuality and expecting compliance.44 Disparity
between the effort and resulting reward for similar
contributions (or punishment for infractions) can
create ambiguity among followers. For example, if 1
employee’s frequent tardiness and laziness remains
unpunished, but an employee who is continually
punctual and hardworking is not recognized, the lat-
ter employee could become unhappy and lose respect
for the leader. The punctual, hardworking employee
might even feel mistreated or taken advantage of
for simply doing what is expected. Employees often
experience burnout when not recognized and offered
rewards or even gratitude.64
Transactional leadership is an impersonal form of
leadership because there is no attempt to change or
recognize the follower’s attitudes or values, resulting
in a follower who experiences a great deal of anxi-
ety and uncertainty about his or her employment.32
Transactional leadership is related to directive leader-

ship, also called autocratic, controlling, or authoritarian
leadership.36 An autocratic leader assumes complete sov-
ereignty and control of the group. Autocratic leaders do
not recognize the benefit of cultivating an intrinsically
motivated employee, but rather focus on extrinsically
motivating each employee equally to accomplish spe-
cific goals for the leader or organization.18 Transactional
leaders also fail to build trust between the leader and fol -
lower.18 Although a transactional leader might be viewed
as successful by his or her superiors, especially for pro-
ducing results, followers can feel subjugated and isolated
as they submit to the changing needs of the leader.
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and professional goals (see Table 4).67 Models of leader -
ship in which the leader’s behaviors more significantly
and positively influence a follower’s self-identity appear
to produce a positive effect on follower behaviors and
the overall success of the organization.67,69 Servant lead-
ership is a value-laden leadership model that encourages
the ethical treatment of followers, thus gaining follower
trust and increasing overall effectiveness of the group.67
Transformational leadership contrasts with servant
leadership because transformational leaders focus on
the well-being of the organization, but servant leaders,
though mandated to serve the organization, focus on
the best interests of their followers first.69

The servant leadership model appears to be ideal
in the health care setting because health care workers
typically emphasize serving patients.18 Thus, those who
accept a leadership role in a caregiving setting should
be, at their core, naturally predisposed to offering com-
passionate guidance.69
Conclusion
Patients rightly anticipate and merit the best possible
health care. Serving the needs of others with compas-
sion is the primary obligation of professionals who work
in health care. Some health care professionals might be
required to perform the functions of servant, follower,
that is based on the concept of being genuine. Authentic
leaders inspire others and motivate followers on an
intellectual level while simultaneously providing them
with individualized attention.45
Servant Leadership
Although many leadership theories focus on the
top-down approach to leadership, in which the source
of power is placed solely on the leader, the servant lead-
ership model establishes a bottom-up organizational
view in which the followers’ needs are regarded before
the leader’s desires.67 Thus, servant leadership focuses
on the welfare of the follower rather than the glorifica-
tion of the leader. This model establishes a servant-first,
leader-second attitude.30 Robert K Greenleaf often is
credited with first recognizing and espousing the value
of the self less leader (see Box 4).37 However, this form
of leadership has been demonstrated throughout his-
tory. The Bible says that Jesus espoused the concept of

servant leadership when he said, “whoever wants to be
great among you must be your servant, and whoever
wants to be first must be your slave—just as the Son of
Man did not come to be served, but to serve.”68 George
Washington often closed his letters by signing “your
humble obedient Servant.”57 Despite the fact that these
historical figures were in a position that offered them
great power over their followers, they chose to humble
themselves to promote the welfare of others first.
With servant leadership, the leader functions as
a steward, recognizing followers as individuals who
should be nurtured to achieve their highest personal
Box 4
Characteristics of Servant Leaders18
� Listening skills
� Empathy
� Healing focus
� Awareness
� Persuasive ability
� Conceptualization skills
� Foresight
� Possesses stewardship ethics
� Commitment to follower growth
� Community-building skills
Table 4
Key Ways Leaders Can Serve6
Action Purpose
See the future. Servant leaders should provide followers a

vision for the future.
Engage and
develop others.
Servant leaders put the right people in
the right positions and cultivate followers’
potential.
Reinvent
continually.
Servant leaders should never stop learning
and always encourage follower education.
Value results and
relationships.
Servant leaders obtain financial strength
and profits from enhanced relationships
with customers and employees.
Embody values. Servant leaders continually build trust
between customers and followers while
embodying the values of the organization.
Volume 88, Number 6
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8. Brennan MD, Monson V. Professionalism: good for
patients and health care organizations. Mayo Clin Proc.
2014;89(5):644-652. doi:10.1016/j.mayocp.2014.01.011.
9. Bennett WJ. The Book of Virtues. New York City, NY:
Simon
and Schuster; 1993.
10. Kelly L, Runge J, Spencer C. Predictors of compassion
fatigue and compassion satisfaction in acute care nurses. J
Nurs Scholarsh. 2015;47(6):522-528. doi:10.1111/jnu.12162.
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2009;13(2):183-191. doi:10.1188/09.CJON.183-191.
14. Hem MH, Halvorsen K, Nortvedt P. Altruism and mature
care: some rival moral considerations in care ethics. Nurs
Ethics. 2014;21(7):794-802 doi:10.1177/0969733014521094.
15. Anderson P, Konrath S. ‘Why should we care?’—what to
do about declining student empathy. Chronicle of Higher
Education website. http://www.chronicle.com/article/Why
-Should-We-Care-What/128420. Accessed May 3, 2017.
16. Decety J. The neurodevelopment of empathy in humans.

Dev Neurosci. 2010;32(4):257-267. doi:10.1159/000317771.
17. Burks DJ, Youll LK, Durtschi JP. The empathy-altruism
association and its relevance to health care professions. Soc
Behav Personal. 2012;40(3):395-400. doi:10.2224/sbp.2012
.40.3.395.
18. Oord TJ, ed. The Altruism Reader: Selections From
Writings
on Love, Religion, and Science. West Conshohoken, PA:
Templeton Foundation Press; 2008.
19. Brokaw T. The Greatest Generation. New York City, NY:
Dell
Publishing; 1998.
20. Christenson JE. Servanthood in the 21st century. Phi Kappa
Phi Forum. 2008;88(2):32-33.
21. American Registry of Radiologic Technologists. ARRT
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23. Elmer D. Cross-Cultural Servanthood: Serving the World in
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and leader simultaneously, or shift between roles to

meet the needs of employers, employees, and custom-
ers. Striving daily to satisfy these needs requires that
the health care professional be honest and demonstrate
integrity when interacting with others. Ultimately, it
is professionally warranted that health care workers
continually research and gain knowledge about the con-
cepts of service, followership, and leadership to adapt to
an ever-changing health care environment, especially to
provide the best possible individualized patient care.
Steven M Penny, MA, R.T.(R), RDMS, is the author of
several textbooks and articles related to medical imaging,
education, and patient care. His imaging specialties include
radiography and abdominal, pediatric, and obstetrical/
gynecological sonography. He is the lead instructor for the
medical sonography program at Johnston Community
College in Smithfield, North Carolina.
Reprint requests may be mailed to the American Society
of Radiologic Technologists, Publications Department,
15000 Central Ave NE, Albuquerque, NM 87123-3909, or
emailed to [email protected]
© 2017 American Society of Radiologic Technologists
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4. The ability to recognize the emotions and feelings
of others with a minimum distinction placed upon
the difference between self and others is known as:
a. advocacy.

b. self-sacrifice.
c. attentiveness.
d. empathy.
5. Health care professionals who face decreased
empathy and reduced altruistic motivation have:
a. additional focus and drive.
b. a decreased likelihood of burnout.
c. less productive and effective patient care.
d. better patient engagement.
1. Which of the following is not an element upon
which servantship is based?
a. sympathy
b. empathy
c. compassion
d. altruism
2. Compassion fatigue is the result of the combination
of ______ and ______ .
a. secondary traumatic stress; empathy
b. burnout; secondary traumatic stress
c. burnout; self-sacrifice
d. self-sacrifice; empathy
3. Someone who regularly can balance the concern of
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a. mature caregiver.
b. self-preserver.
c. follower.
d. potential caregiver.
Volume 88, Number 6

Directed Reading Quiz
10. Critiques of EI include that:
1. a definitive model for measuring EI has not
been established.
2. participants can falsely self-report their EI.
3. the changing definition of EI causes
confusion.
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
11. Which leadership style is used most in health care?
a. servant
b. transactional
c. transformational
d. situational
12. Which leadership model encourages the leader to
focus on the welfare of the follower rather than on
the glorification of the leader?
a. servant
b. transactional
c. transformational
d. situational
6. In the courageous follower model, the follower
should:
1. take a moral stand when warranted to
prevent ethical abuses or to refuse to

participate in them.
2. participate in any transformation needed
to improve the leader-follower relationship
and the organization’s performance.
3. constructively challenge the leader or
group’s behaviors or policies if these
threaten the common purpose.
a. 1 and 2
b. 1 and 3
c. 2 and 3
d. 1, 2, and 3
7. The ______ follower will do enough to retain the
current position but no more.
a. resourceful
b. partner
c. implementer
d. individualistic
8. ______ leadership is demonstrated by a member
in a workgroup, such as a collection of staff
technologists, in which a secondary leadership role
is shared.
a. Formal
b. Servant
c. Informal
d. Alternative
9. Which of the following is not a domain of
emotional intelligence (EI)?
a. knowing one’s emotions
b. recognizing the emotions of others
c. motivating oneself by organizing emotions

d. manipulating the emotions of others
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126
What Can Be Done About A Disruptive Physician?

A Legal Analysis
Samuel D. Hodge, Jr.*
House, a medical drama about an infectious disease
specialist, entertained television audiences for years as the
irascible and pill-popping physician solved medical mysteries
with the zeal of a modern-day Sherlock Holmes while playing
mind games with his coworkers. Uncanny intuition and
eccentric thinking earned the physician great respect but his
bullish behavior and antisocial tendencies were a distraction at
the hospital.1 Not only did Dr. House clash with his fellow
physicians but he also insulted patients, flouted hospital rules
and caused great conflict with the hospital administrators.2 In
fact, his actions often crossed the line into obnoxiousness and
rage causing the hospital staff to tiptoe around his dysfunctional
behavior.3
In the real world, Dr. House would be labeled a “disruptive
physician” and would be subjected to disciplinary action

including the loss of his hospital privileges. This article will
explore the problems caused by being labeled a disruptive
physician in a legal context with a focus on the peer review
process and the relevant court cases.
TABLE OF CONTENTS
I. Introduction......................................................................
127
* The author is a professor at Temple University, where he
teaches both law
and anatomy. He also serves as a mediator and neutral arbitrator
for the
Dispute Resolution Institute in Philadelphia and is considered
one of the most
popular CLE speakers in the country. Professor Hodge has
authored more than
175 articles on the intersection between law and medicine, has
published ten
books and has been named a top lawyer in Pennsylvania on
multiple occasions.
1. House (TV Series), Wɪᴋɪᴘᴇᴅɪᴀ,
https://en.wikipedia.org/wiki/House_
(TV_series), (last visited Sept. 14, 2019).
2. Id.

3. Bob Wachter, Gregory House, MD, RIP, HOSPITAL
LEADER BLOG (May
21, 2012), https://thehospitalleader.org/gregory-house-md-rip/.
1
2019 DISRUPTIVE PHYSICIAN? 127
II. What is a Disruptive Physician? .................................. 128
III. The Problem ..................................................................
129
A. Statistics .................................................................... 129
B. Conduct That Is Disruptive ....................................... 130
IV. Remedial Measures .......................................................
131
A. The American Medical Association ........................... 132
B. The Joint Commission ............................................... 133
C. Federation of State Medical Boards .......................... 134
D. Response by the States .............................................. 135
V. Peer Review Immunity ................................................. 136
VI. Court Action ................................................. .................
139

A. Immunity under the Healthcare Quality Improvement
Act (HCQIA) ........................................................................
141
B. Reliance upon Bylaws and Procedures ..................... 147
C. Disruptive Conduct as Justification for Suspension . 150
VII. Conclusion .....................................................................
152
I. Introduction
The practice of medicine is filled with stress from being
involved in life and death decisions, to declining revenues while
practicing in a heavily regulated environment.4 These facts
have
triggered the quick response by some physicians to use
regulatory schemes to advance their own personal agendas and
to protect personal interests.5 Unfortunately, these rules and
regulations, which are not well understood by most medical
professionals, have caused a great deal of animosity and
frustration, leading some doctors to become “disruptive
physicians.”6

The troublesome physician causes untold medical, legal,
and psychological problems in the workforce,7 and most health
care managers are ill prepared to deal with these doctors.8 For
4. Michael J. Grogan & Paul Knechtges, The Disruptive
Physician: A
Legal Perspective, 20 Aᴄᴀᴅ. Rᴀᴅɪᴏʟᴏɢʏ 9, 1069–73 (2013).
5. Zachary L. Erwin, Analyzing the Disruptive Physician: How
State and
Federal Courts Should Handle Whistleblower Cases Brought by
Disruptive
Physicians, 44 Dᴜǫ. L. Rᴇᴠ. 275, 275 (2006).
6. Id. at 276.
7. Id.
8. Eugene Fibuch & Jennifer J. Robertson, Bringing Value:
Dealing Fairly
With Disruptive Physicians, AM. ASS’N PHYSICIAN
LEADERSHIP (Mar. 8, 2019),
https://www.physicianleaders.org/news/bringing-value-dealing-
fairly-
2https://digitalcommons.pace.edu/plr/vol40/iss1/3
128 PACE LAW REVIEW 40.1
example, disruptive physicians can lead to a hostile work

environment, cause morale problems, increased litigation,
compromised patient care, communication issues, and
obstruction in the regular running of the organization.9 As
noted
by Alexander Vaccaro M.D., the President of the Rothman
Institute, “There is no place in medicine for disruptive
physicians and every study that has examined the issue has
concluded that a disruptive doctor increases the chance of an
adverse event. In fact, these physicians have a higher
complication rate and receive negative feedback in patient
satisfaction surveys.”10 Addressing this conduct head-on is
critical, but recognizing the proper course of remedial action
can
be a daunting task.11
II. What is a Disruptive Physician?
No single definition exits to describe a disruptive physician
but a number of organizations and court decisions have
addressed the issue. Some medical professionals claim that

they
have an “instinctive understanding” of what represents
disruptive behavior and do not need guidance.12 On the other
hand, the Court in Gordon v. Lewistown defines a disruptive
physician as one who is unruly, “contentious, threatening,
unreachable, insulting and frequently litigious. He will not, or
cannot, play by the rules, nor is he able to relate to or work well
with others.”13 It is important to note, however, that a sole
occurrence of troublesome behavior is inadequate to be labeled
a
disruptive physician and anticipating complete harmony in the
workplace is unrealistic. The tag should also not be used to
disruptive-physicians.
9. Erwin, supra note 5, at 275–76.
10. Alexander Vaccaro, M.D., Ph.D, MBA, is an orthopedic
surgeon and
the President of Rothman Institute, one of the largest orthopedic
practices in
the country. He is also the Richard H. Rothman Professor and
Chair in the
Department of Orthopaedic Surgery, and a Professor of
Neurosurgery at

Thomas Jefferson University in Philadelphia, Pennsylvania. His
comments
were obtained in a telephone interview conducted by the author
on September
20, 2019.
11. Alicia Gallegos, Disruptive Physicians: Is This an HR or
MEC Issue?,
MDEDGE (Sept. 16, 2018),
https://www.mdedge.com/internalmedicine/article
/174921/businessmedicine/disruptive-physicians-hr-or-mec-
issue.
12. Grogan & Knechtges, supra note 4, at 2.
13. Gordon v. Lewistown Hosp., 714 A.2d 539, 544 (Pa.
Commw. Ct. 1998).
3
describe a doctor who has had a bad day or demonstrates an
occasional outburst that is out of character. Nor should the
label
apply to a physician who has quirks, tends to be disagreeable, or
annoys others on the medical staff.14 Rather, the
characterization should be reserved for those who show a
pattern of seriously inappropriate conduct that is “deep-seated

and habitual.”15 A single incident that is improper must still be
addressed but the label “disruptive physician” is reserved for
more sustained and inappropriate behaviors over a period of
time.16
III. The Problem
As the sophistication and intricacies of medicine and
managed health care increase, the need to work in a conducive
atmosphere of cooperation intensifies. Contemporaneously, the
pressures, burdens, and distractions involving physicians
correspondingly escalate. Because doctors occupy an esteemed
position in society, inappropriate actions by these individuals
become magnified and have a greater probability for
disruption.17
Acknowledged in the medical literature for more than a
century,18 there is little evidence to demonstrate that the
number of episodes of disruptive physicians has increased in
recent years, but the problem has moved to the forefront of

healthcare management. Likewise, doctors who demonstrate
inappropriate behavior are being sanctioned with greater
frequency.19
A. Statistics
14. Grogan & Knechtges, supra note 4, at 3; See also
Mahmoodian v.
United Hosp. Ctr., 404 S.E.2d 750 (W. Va. 1991).
15. Norman T. Reynolds, Disruptive Physician Behavior: Use
and Misuse
of the Label, 98 J. MED. REG. 1, 10 (2012).
16. Id. at 9–10.
17. Brian J. Santin & Krista L. Kaups, The Disruptive
Physician:
Addressing the Issues, BULL. AM. COLL. SURGEONS (Feb. 1,
2015),
http://bulletin.facs.org/2015/02/the-disruptive-physician-
addressing-the-
issues/.
18. Llewellyn E. Piper, Addressing the Phenomenon of
Disruptive
Physician Behavior, 22 HEALTH CARE MANAGER 335, 335–
39 (2003).
19. Santin & Kaups, supra note 17.

Most physicians and other health care workers have seen
their contemporaries engage in disruptive conduct with co-
employees, patients, and other individuals.20 In fact, more than
seventy percent of doctors surveyed indicate that disruptive
conduct happens at least once a month at their workplace, and
more than ten percent admit that such episodes occur on a daily
basis.21 This disruptive behavior runs the gamut from cursing
to
the refusal to follow established procedures.22 Most responders
expressed concern about the consequences of this inappropriate
conduct on their practices, and nearly all are of the opinion that
the disruptive physician affects patient care. Surprisingly,
twenty-six percent of doctors acknowledged that they have
engaged in disruptive conduct at some point during their careers
and the most proffered reasons for these inappropriate actions

are “workload and learned behaviors.”23
Demographically, nurses are the main victims of this
unseemly conduct,24 and a number have left their jobs as a
result.25 The greatest offenders are those with the highest
stress
level jobs, with surgeons being labeled the greatest culprits,
followed by obstetricians/gynecologists, orthopedic doctors, and
primary care physicians.26 Other specialists with less frequent
episodes include cardiologists, anesthesiologists,
ophthalmologists, cardiac/vascular surgeons, kidney specialists,
radiologists, oncologists, and psychiatrists.27
B. Conduct That Is Disruptive
20. Id.
21. Owen MacDonald, Disruptive Physician Behavior,
QUANTIAMD 1, 2
(May 15, 2011), http://www.quantiamd.com/q-
qcp/Disruptive_Physician_
Behavior.pdf.
22. Id. at 2.
23. Id.

24. Stephen Lazoritz, Don’t Tolerate Disruptive Physician
Behavior, AM.
NURSE TODAY (Apr. 11, 2011),
https://www.americannursetoday.com/dont-
tolerate-disruptive-physician-behavior-2/.
25. Charles P. Samenow et. al., ACME Course Aimed at
Addressing
Disruptive Physician Behavior, PHYSICIAN EXEC. 32 (Jan.–
Feb. 2008),
https://www.mc.vanderbilt.edu/root/pdfs/cph/Samenow.pdf.
26. Alan H. Rosenstein et. al., Legal Entanglements in Dealing
with
Disruptive Behavior, PHYSICIAN LEADERSHIP J., May–June
2016, at 46, 48 fig.
2.
27. Id.
5
Inappropriate conduct takes many forms, with the highest
level of encounters being degrading comments, insults, and
yelling. Other types of disruptive behavior are less obvious but
no less concerning. These include a physician’s refusal to

cooperate with others and the inability to adhere to established
protocols. Conduct which occurs less frequently includes
physician assaults, discriminatory behavior, incompetence,
retaliation, spreading malicious rumors, throwing objects, and
substance abuse.28 Female physicians are slightly less likely to
engage in disruptive conduct as compared to their male
counterparts.29
It is believed that disruptive physicians direct their actions
against those who are perceived as having a status below the
doctor. It is theorized that the hierarchical character of the
medical profession has produced alphas who feel compelled to
flaunt their status. Therefore, it should come as no surprise that
one study ascertained that fifty percent of the conflicts dealing
with disruptive doctors involve coworkers with less professional
clout.30
Critics of this label maintain that being designated a
disruptive physician has been applied improperly by hospital
management to jettison unwanted competition and anti-

administration practices. It is also asserted that the phrase
“disruptive physician” is buried in the bylaws and left
intentionally broad, subjective, and undefined so that health
care executives can construe it anyway they wish.31 Therefore,
it is critical that hospitals implement rules and regulations that
will assist them in the handling of disruptive doctors whil e
shielding physicians from bogus claims of disruptive conduct.32
IV. Remedial Measures
28. MacDonald, supra note 21, at 4–5.
29. Id. at 5.
30. Brian M. Peters, Disruptive or Targeted Physician?:
Compliance
Strategies, HOSP. & HEALTH SYS. INST., February 9, 2006,
Am. Health Law.
Ass’n, AHLA-Papers P0209-608 (citing David O. Weber, Poll
Results: Doctors’
Disruptive Behavior Disturbs Physician Leaders, PHYSICIAN
EXEC., Sept.–Oct.
2004, at 6).
31. Lawrence R. Huntoon, Abuse of the “Disruptive Physician”
Clause, 9
J. AM. PHYSICIANS AND SURGEONS 68, 68 (2004).

32. Peters, supra note 30, at 4.
A. The American Medical Association
The first remedial attempt by the medical profession
occurred at the 1999 Annual Meeting of the AMA House of
Delegates who adopted Resolution 9 (A-99) dealing with the
disruptive physician. The pronouncement requested the AMA
to “identify and study behavior by physicians that is disruptive
to high quality patient care.”33 The end result was the
enactment of AMA Policy E-9.045 titled Physicians with
Disruptive Behavior. This rule of ethics labels disruptive
behavior as personal conduct, whether verbal or physical, that
negatively affects or that potentially may adversely impact
patient care. This inappropriate conduct is not limited to those
actions that interfere with one’s ability to work with others on

the health care team. Physician criticism, however, that is
provided in good faith with the intent of improving patient care
should not be classified as disruptive behavior.34
The AMA also published a Model Medical Code of Conduct
that can be used by health care facilities in drafting their
bylaws.35 This Code defines disruptive behavior as “any
abusive
conduct including sexual or other forms of harassment, or other
forms of verbal or nonverbal conduct that harms or intimidates
others to the extent that the quality of care or patient safety
likely would be compromised.”36 Inappropriate behavior is
discouraged, but if such conduct persists, it will be transformed
into disruptive behavior. Examples include:
belittling or berating patients or members of their
care team, use of profanity or disrespectful
33. Dudley M. Stewart, Jr., Physicians with Disruptive
Behavior, Report
of the Council on Ethical and Judicial Affairs, CEJA Report 3-
1-09, AMERICAN

MEDICAL ASS’N 1, 1 (2009), https://www.ama-
assn.org/sites/ama-assn.org/ files
/corp/media-browser/public/about-
ama/councils/Council%20Reports/council-
on-ethics-and-judicial-affairs/i09-ceja-physicians-disruptive-
behavior.pdf.
34. Id. at 2 (citing AMA Opinion 9.045 – Physicians with
Disruptive
Behavior).
35. AMERICAN MEDICAL ASS’N, Model Medical Staff Code
of Conduct
(2012),
https://www.slideshare.net/BarneyCohen/amamedicalstaffcodeof
conduct (last
visited Oct.4, 2019).
36. Id. at 1.
7
language, inappropriate comments written in a
patient’s chart, blatant failure to respond to a
patient’s needs, deliberate lack of cooperation
with members of the medical staff, the deliberate
refusal to return calls, and use of intentionally

demeaning language that negatively impacts
patient care.37
The Code goes on to note that complaints about a physician
should be in writing and directed to the president of the medical
staff. A copy of the complaint, Code of Conduct, and bylaws
should be given to the accused within thirty days. In turn, the
offending member shall have the opportunity to respond in
writing.38
B. The Joint Commission
The Joint Commission, which is the accrediting agency for
more than 22,000 health care organizations in the United
States,39 published Standard LD.03.01.01. This provision
acknowledges that a disruptive physician engages in “behavior
that intimidates others and affects morale or staff turnover[,]
undermines a culture of safety and can be harmful to patient
care.”40 As a result, the Joint Commission requires health care
organizations to establish a code of conduct that defines

behaviors that are “acceptable,” “disruptive,” and
“inappropriate.”41
This problem is so significant that the Joint Commission
subsequently issued a Sentinel Event Alert which notes that
intimidating and disruptive behaviors can lead to medical
errors, poor patient satisfaction, increased cost of care, and
37. Id. at 2–3.
38. Id. at 5.
39. About the Joint Commission, JOINT COMMISSION, https://
www.jointcommission.org/about_us/about_the_joint_commissio
n_main.aspx
(last visited Oct. 4, 2019).
40. LD.03.01.01: Leaders Create and Maintain a Culture of
Safety and
Quality Throughout the Hospital, JOINT COMMISSION 1, 1
https://
medschool.ucla.edu/workfiles/Site-
AcademicAffairs/Events/17.Joint-
Commission.pdf (last visited Oct. 4, 2019).
41. Stewart, Jr., supra note 33, at 1–2.

avoidable adverse outcomes.42 In response to criticism that the
term “disruptive behavior” is both ambiguous and inaccurate,
the definition was changed to “behavior or behaviors that
undermine a culture of safety.”43
C. Federation of State Medical Boards
The Federation of State Medical Boards recognized the need
to issue guidance on the disruptive physician when it issued the
2000 Report of the Special Committee on Professional Conduct
and Ethics, as well as in the 2011 Policy on Physician
Impairment.44 The Special Committee’s Report defines
disruptive behavior as “personal interaction with physicians,
hospital personnel, patients, family members, or others that
interferes with patient care.”45 Furthermore, disruptive
behavior is not a diagnosis but a descriptive label that impairs
the ability of the healthcare team to operate effectively, thereby
placing patients at risk. More specifically, it identified several

ways in which disruptive conduct interferes with the
doctor/patient relationship:
1. The physician’s inappropriate behaviors or emotional
outbursts shift the physician’s focus from the patient,
which can result in errors in clinical judgment and
performance.
2. Physician’s emotional outbursts or other inappropriate
behavior can increase apprehension and anxiety of the
physician’s patients as well as other patients who may
witness such outbursts and inappropriate behavior.
42. JOINT COMMISSION, Behaviors that Undermine a Culture
of Safety
(July 9, 2008),
https://www.jointcommission.org/assets/1/18/SEA_40.pdf.
43. Joint Commission Changes Term “Disruptive Behavior” in
the
Standards, HCPRO (Nov. 10, 2011),
https://www.hcpro.com/ACC-273165-
851/Joint-Commission-changes-term-disruptive-behavior-in-the-
standards.html.

44. Reynolds, supra note 15, at 8.
45. Federation of State Medical Boards, Report of the Special
Committee
on Professional Conduct and Ethics 1, 5, (Apr. 2000),
http://www.fsmb.org
/siteassets/advocacy/policies/report-of-the-special-committee-
on-professional-
conduct-and-ethics.pdf.
9
3. Decreased effectiveness of the entire health team.
Peers, nurses, allied health professionals, and other
members of the health care team may be intimidated and
anxious, causing a loss of their clinical focus and
productivity and thereby increasing the propensity for
medical errors.
4. Decrease in effective communications among the
health care team.46

The Report went on to note that disruptive behavior in
doctors is frequently the result of underlying pathology such as:
“(1) addiction (2) stress (3) psychiatric disorders (e.g., bipolar
disorder) or (4) personality disorders (e.g., narcissism).”47
Personality disorders seem to be the cause of most referrals for
disruptive behavior which may be treated, without or concurrent
with punitive action.48
D. Response by the States
States have also taken steps to curb unprofessional medical
conduct. For instance, New York lists a number of ways that
individuals can engage in professional misconduct under its
public health law including “willfully harassing, abusing, or
intimidating a patient either physically or verbally.”49 The
Texas Medical Association deems a health care professional
who
engages in conduct that leads to a breakdown in safety measures
or acts in an intimidating manner towards a member of the
medical staff to be engaged in disruptive behavior.50

Pennsylvania enacted the Peer Review Protection Act which
provides that one offering information to any review
organization shall be granted immunity unless the information
is not related to the functions of the review entity or if the
46. Id. at 5–6.
47. Id. at 6.
48. Id.
49. N.Y. Educ. § 6530(31) (McKinney 2008).
50. Crystal Conde, Joint Commission Tries to Regulate
Physicians’
Behavior, TEX. MED. (Dec. 2009),
https://www.texmed.org/Template.aspx?id
=8189.
materials provided are false and the individual knew or had
reason to think the material was false.51
Failure of the facility to implement remedial measure to

deal with disruptive physicians can result in expensive
litigation. This is evidenced by a number of costly
discrimination/harassment lawsuits against health care
facilities as the result of the disruptive physician.52 For
instance, Chopourian v. Mercy General Hospital involved a
federal matter in which the jury awarded $168 million to a
forty-
five-year-old physician’s assistant who claimed that she was
tormented and harassed by the surgeons and medical staff.53
The plaintiff testified that one harasser informed her, “you’ll
give in to me” and a surgeon told her that “I’m horny” and
slapped her buttocks.54 A “bullying surgeon” stuck her with a
needle and another called her a “stupid chick” in the operating
room.55
V. Peer Review Immunity
Interacting with disruptive physicians can be a time-
consuming and emotionally exhausting endeavor for both
management and the organization. Nevertheless, health care

leaders have a duty to investigate and stop unprofessional
conduct in the workplace.56 This requires the implementation
of
an organized approach such as educating the staff as to what
constitutes improper behavior and to clearly identify the
penalties for engaging in such conduct.57 For example, a code
of
conduct or bylaws should be created which applies to all
members of the health care team. These directives should
define
what constitutes appropriate and inappropriate behavior in
51. 63 PA. STAT. and CONS. STAT. ANN. § 425.3(a) (West
2019).
52. Alice Gosfield, 2013 Health Law Handbook, Section 11:2.
Scope of the
Problem, at *4.
53. Eugene Lee, Largest Sexual Harassment Verdict in History -
$168
Million, CAL. LAB. & EMP. L., https://calaborlaw.com/largest-
sexual-
harassment-verdict-in-history-168-million/ (last visited Oct. 4,
2019). See also
Chopourian v. Catholic Healthcare West, No. CIV S–09–2972,
2012 WL

1551728 (E.D. Cal. 2012).
54. Lee, supra note 53.
55. Gosfield, supra note 52, at *4.
56. Fibuch & Robertson, supra note 8.
57. Id.
11
clear and precise language and contain a well-defined due
process clause with an appeal process. In turn, each physician
should be asked to read and sign the document indicating an
understanding of the rules.58
A number of hospitals publish these rules under the
category of “professionalism,” and mandate that physicians
exhibit a minimum level of acceptable behavior towards co-
workers and patients. Any violation of the rules may act as
support for starting disciplinary action to address the
conduct.59
While differences in language and procedures among health car e

facilities is expected, common elements, include: Clearly
explained behaviors that are expected; The repercussions for
deviation from these behaviors should be explained in detail;
Penalties should be staggered according to the severity of the
incident; Those who commit repeat violations will be treated
more harshly; and Every incident must be reported and
documented.60
This plan of action helps foster a positive atmosphere within
the organization and members of the team are put on notice as
to what is expected of them in the workplace.61
Discipline against a disruptive physician, however, can
result in retaliation by the offender, especially if the doctor’s
hospital privileges are suspended.62 A key event in this regard
occurred in 1988 when the United States Supreme Court decided
Patrick v. Burget.63 This matter involved whether Oregon law
protected physicians against federal antitrust liability as the
result of their serving on a peer-review committee.64 The facts
reveal that the plaintiff declined an invitation by the defendants

to join their surgical practice.65 Instead, the plaintiff opened
his
own clinic but experienced problems in his dealings with the
defendants.66 The dispute escalated into a peer-review
proceeding to terminate the plaintiff’s hospital privileges at the
58. Id.
59. Santin & Kaups, supra note 17, at 3.
60. Id.
61. Fibuch & Robertson, supra note 8.
62. See Hein-Muniz v. Aiken Reg’l Med. Ctr., 905 F. Supp. 2d
729 (D.S.C.
2012).
63. Patrick v. Burget, 486 U.S. 94 (1988).
64. Id. at 95–96.
65. Id. at 96.
66. Id.

city’s only hospital on the ground that his care of patients was
below the hospital’s standards.67
The plaintiff filed a federal lawsuit claiming violations of the
Sherman Act by the defendant’s charges and by their
participating in the peer-review proceeding in order to reduce
competition from the plaintiff rather than to improve patient
care.68 The Supreme Court ruled that the state’s law failed to
shield the defendants from liability for their activities on the
hospital peer-review committee.69 This ruling prompted
Congress to enact the Health Care Quality Improvement Act of
1986.70 The legislature found that the threat of money damages
under Federal law unreasonably dissuaded doctors from serving
on professional peer review committees. Therefore, there is a
national overriding interest to protect physicians who serve in
this capacity.71
This statute offers immunity under Federal and State laws
to those on a peer review body who act in the reasonable belief
that their action was in the furtherance of quality health care,

and they act after a reasonable effort to obtain the facts even
though their actions adversely impact the clinical privileges or
professional society membership of a physician.72 This statute
sets forth the specific requirements and standards for immunity
and applies to disruptive physician cases.73 Only a good faith
review qualifies for immunity, so whether the standards are
followed by the peer review committee is very important to the
final disposition of most disruptive physician cases and is the
subject of much litigation.74
It must be noted, however, that the Act only grants
immunity to “professional review actions.”75 This is defined as
an action or recommendation by the professional review body
which is done during a review activity, that is premised on the
competence or professional actions of a doctor, and which may
67. Id. at 97.
68. Id. at 97–98.
69. Patrick, 486 U.S. at 105.

70. Health Care Quality Improvement Act of 1986, 42 U.S.C. §
11101
(2019).
71. Id.
72. Id.
73. Erwin, supra note 5, at 281–80.
74. Id. at 280.
75. Gosfield, supra note 52, at *1.
13
adversely affect the clinical privileges of the physician.76
VI. Court Action
Being labeled a disruptive physician, especially if sanctions
are imposed, can have serious professional implications
including the loss of one’s hospital privileges. In fact, it can
have
career ending repercussions. State and federal agencies can
also

discipline a physician who is labeled disruptive if the offending
conduct is determined to influence the quality of patient care or
if it implies moral, ethical, or unprofessional deficiencies.77
Unhappy patients can register a complaint with the health plan
or managed health care firm triggering an investigation that can
cause the loss of a physician’s affiliation with the plan or
hospital. Intimating and unprofessional conduct can also be
reported to the National Practitioner Data Bank, thereby
resulting in other investigations and charges against the
physician who seeks a hospital affiliation or credentialing.78
This data bank79 maintains a listing of actions taken by
authorized organizations regarding health care practitioners,
entities, providers, and suppliers who do not meet professional
standards. These adverse reports are permanently kept unless
modified or removed by the entity that submitted them.80 In
turn, the information can be used in rendering decisions dealing
with licensure, employment, contracting, membership or clinical
privileges, or when conducting investigations. Under the

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