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Unusual Attitudes

The term “unusual attitude” conjures up very different images for pilots and surgeons, but in both worlds this can lead to catastrophic outcomes. Recognizing and developing safe countermeasures for unusual attitudes, whether it’s in the operating room or the cockpit, is as essential for pilots as those of us who practice The High Reliability Mindset in healthcare.

For pilots, the term refers to a position of the airplane in space that is outside of the normal flight envelope.  It doesn’t always mean the airplane is out of control, if you have been to an airshow and watched aerobatics performed you have attitudes 1seen lots of airplanes in unusual attitudes that are still under full control of the pilots.  Normally however, it connotes a time, such as a wing stall or full spin, when the airplane is in imminent danger of crashing.   From the first day of pilot training, students learn how to recognize and recover an airplane that has entered into an unusual attitude.   Returning an airplane to normal flight parameters from an unusual attitude can be surprisingly difficult when adding complexity of the airplane, flight conditions and visibility deterioration or speed increases.

A tragic consequence of an unusual attitude led to the crash of Air France flight 447 from Rio de Janeiro to Paris on June 1st 2009 killing all 228 people onboard the aircraft. The causes of this tragedy are complex and, as always, multifactorial but were well summarized by the French aviation organization, the Bureau d’Enquêtes et d’Analyses (BEA).  The aircraft entered stormy weather and in the dark, the flight crew ignored repeated stall alerts and kept trying to climb, instead of leveling off or descending to pick up speed and this worsened stall until it attitudes 2was unrecoverable. Airspeed became so slow that the plane simply ceased to fly with speeds as slow as 70 miles/hour (normal cruise is well over 500 mph) because the nose was pitched up at times almost 40 degrees (normal is 5 degrees).  The aircraft in this fatal attitude fell from the sky at over 11,000 feet per minute, from 38,000 feet in 3 minutes and hit the ocean surface. The aircraft broke up on impact and everyone on board died. The flight recorders revealed that crash was not due to mechanical failure or the bad weather, but because the flight crew had failed to recognize and recover from the unusual attitude.

For healthcare practitioners, unusual attitudes refer to another kind of out of control situation, aggressive and inappropriate behavior in the hospital.  In a 2008 Sentinel Event Alert, The Joint Commission describes disruptive and intimidating behavior as including “overt actions such as verbal outbursts and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities.”  The report elaborates on the specific behavior of physicians and team leaders and it goes on to say, “intimidating and disruptive behaviors are often manifested by health care professionals in positions of power. Such behaviors include reluctance or refusal to answer questions, return phone calls or pages, condescending language or voice intonation and impatience with questions.

The AMA further defines inappropriate behavior as “conduct that is unwarranted and is reasonably interpreted to be demeaning or offensive“. Persistent, repeated inappropriate behavior can become a form of harassment and thereby become disruptive.  They cite examples such as making belittling or berating statements, name calling, profanity, inappropriate written comments in the medical record, ignoring staff requests and even refusing to answer pages or calls. Disruptive behavior is given even more weight by the AMA and defined as “any abusive conduct, including sexual or other forms of harassment, or other forms of verbal or nonverbal conduct that harms or intimidates others.”  This includes actions such as threatening language, throwing objects and even touching another person.

Does this behavior lead to error and affect patient safety and outcomes?  It sure does and this is supported in the Joint Commission’s Sentinel Event Alert that states these “behaviors undermine a culture of safety”.  A report from the Annals of Internal Medicine in 2006 estimated that 3% to 5% of physicians had demonstrated behavior that interferes with patient care that could interfere with the process of delivering quality care.   Further patient harm can come when there is a reluctance to call or interact with certain doctors to clarify or question orders for fear of provoking a hostile response.  A review in the January 2005 Journal of Nursing Management cited a correlation between intimidating behavior and increased incidence of medical error.  Interestingly this article also shows an almost equal distribution of disruptive behavior on the part of both nurses and physicians so it is an issue of human behavior throughout the healthcare delivery system.  There is also a clear trend that offended patients, colleagues, or staff can increase the risk of medical liability lawsuits, whistleblower actions, and complaints to state regulatory agencies.

It is clear that these kinds of unusual attitudes are bad for everyone, not the least of whom are the patients and their families but also our colleagues and fellow staff.  How can we recognize and recover from these unusual attitudes?  For sure we need to be introspective and objective about our own behavior.  Let’s face it – surgery, the emergency department and many other places in the hospital where we deal with time critical matters in sick patients are just as high pressure an environment as the cockpit of a jumbo jet over the Atlantic Ocean.  We can all loose our temper in the heat of battle and it has happened to me and I have served on several review panels when the behavior involved other physicians.  The first thing I do is take a deep breath, calm myself down and then apologize immediately after the incident.  I admit I lost my cool and sincerely ask for the understanding and forgiveness of those who I might have offended.  Fortunately, as I have matured, this has happened very rarely but still does happen to all of us.

On a system level, the Joint Commission has developed a leadership standard requiring all hospitals to have a code of conduct as well as a process for managing disruptive and inappropriate behaviors.   If the incident is not defused right away it is the responsibility of the administration and department chair to investigate any inference that behavior has been labeled as disruptive.  These behaviors should be addressed squarely and professionally using some standard guidelines that include some or all of the following elements.  Obtain and review the code of conduct, policy, manual, handbook, and/or bylaws that covers the governing “disruptive physician” policy.  The department should obtain a copy of any involved patient records and demand that any accusation be confirmed, by the source, in writing.  A meeting of all parties who can discuss the incident in a calm and objective way is the next step.  Require that any resolution of the complaint – favorable or not – should be put in writing and inserted in any applicable medical staff, employment, and/or credentialing file.   If the result of this review is unfavorable then counseling or corrective action needs to match the seriousness and repetitive nature of the behavior and carefully reviewed.   This process needs to be open and fair to all parties and respected physician leaders in the hospital community should handle any appeal and/or challenge seriously and equitably.

As practitioners of The High Reliability Mindset we need to police our own behavior first and set an example of the highest order of professionalism and courtesy to everyone.  Gentle counseling to diffuse the tension in the heat of the event should be our first line of defense but if the behavior is repetitive then corrective action should be initiated.  We owe this to ourselves, to our coworkers, our patients and our profession.

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Posted in High Reliability Mindset, Patient Safety.


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