1. “Creating a Culture of Professionalism”
Charlene M. Dewey, M.D., M.Ed., FACP
Associate Professor of Medical Education and Administration
Associate Professor of Medicine
Center for Professional Health
Vanderbilt University School of Medicine
Marshall University Joan C. Edwards School of Medicine
August 28, 2012

2. Professionalism AMA Code of Ethics 1847 ACP Ethics Manual 2005
A Physician Charter: ABIM, ACP, European Federation of Internal Medicine 2007
Stern’s professionalism model
Institutional codes of conduct and policies

3. Stern’s Professionalism Model
“Professionalism is demonstrated though a foundation of clinical competence, communication skills and ethical and legal understanding, upon which is built the aspiration to wise application of the principles of professionalism: excellence, humanism, accountability, and altruism.”
Stern: Figure 2-1 A Definition of Professionalism pg 19; “Measuring Medical Professionalism” Oxford Press 2006.

4. Professional Health & Wellness
Professionalism
Clinical Competence (Knowledge of Medicine)
Communication Skill
Ethical and Legal Understanding
Excellence
Humanism
Accountability
Altruism
Professionalism
Professional Health & Wellness
Professional Culture
Dewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006

5. “Personal & Institutional Vitality”
Two Systems Interact
“Personal & Institutional Vitality”
The External System
Functional
& Nurturing
Dysfunctional
The Internal System
Good Skills
& Well
Poor Skills
&/or Not Well
Clinician
Work Environment
“The Perfect Storm”

6. Professional vs. Unprofessional

7. Professional vs. Unprofessional
“We judge ourselves by our motives whereas others judge us by our behavior.”
~AA saying

8. Goals
The purpose of the session is to provide information and discussion around professionalism and lapses in professionalism and how the overall culture is influenced by both individual behaviors and institutional norms.

9. Objectives
Upon completion of the session, participants will be able to:
List and discuss four types of professionalism lapses.
Analyze the roles of the individual and the institution as they shape the overall culture of professionalism.
Accept that both individuals and the institution are responsible for promoting a culture of professionalism.

10. Agenda Four examples of professionalism lapses
Individual & institutional roles
Stress & burnout
Influencing professional cultures
Resources
Summary

11. Center for Professional Health
Faculty and Physician Wellness Committee
3 CME accredited professional development programs
Distressed Physician
Maintaining Proper Boundaries
Proper Prescribing CPD
~15 years in training/remeding physicians
Demographics:
Mandated > voluntary
IM, FP - but all specialties
Males > females
Rural, solo practices > academic health center

12. Professional Lapses 661,400 physicians/surgeons in US in 2008
>32,000 sanctions btw (~5-10%)
955 criminal
Many uncategorized
Many events not reported
Physician Survey 2007:
96% agreed physicians should report impaired or incompetent colleagues
45% who encountered such colleagues did not report events
Campbell, et al. “Professionalism in Medicine: Results of a National Survey of Physicians” Ann In Med, 2007

13. Professionalism Lapses
Four major professionalism lapses:
Distressed/disruptive behaviors
Boundary violations
Improper prescribing
Impairment

14. Distressed/Disruptive Behaviors

15. Marshall University School of Medicine - Workshop
August 28, 2012
Disruptive Behavior
“Behavior or behaviors that undermine a culture of safety.”1
Disruptive behavior is a sentinel event2
The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD , elements of performance (EP) 4 and 5, Spring 2012;
Joint Commission, Issue 40 July 9, 2008
Dewey, CM Vanderbilt University School of Medicine

16. Spectrum of Disruptive Behaviors
Aggressive
Passive
Passive
Aggressive
Inappropriate anger,
threats
Yelling, publicly degrading
team members
Intimidating staff,
patients, colleagues, etc.
Pushing, throwing objects
Swearing
Outburst of anger &
physical abuse
Chronically late
Failure to return calls
Inappropriate/
inadequate chart notes
Avoiding meetings & individuals
Non-participation
Ill-prepared, not prepared
Hostile notes, s
Derogatory comments about institution, hospital, group, etc.
Inappropriate joking
Sexual
Harassment
Complaining,
Blaming
Swiggart, Dewey, Hickson, Finlayson. “A Plan for Identification, Treatment, and remediation of Disruptive Behaviors in Physicians.” Frontier's of Health Services management, 2009; 25(4):3-11. 16 16

17. Distressed/Disruptive Behaviors
Etiologies-Individuals:
Psychological Factors1:
Substance use/abuse, trauma history, religious fundamentalism, familial high achievement
MH issues2:
Personality disorders, narcissism, depression, bipolar, OCD, etc.
Genetic/developmental issues:
Asperger’s, non-verbal learning differences, etc.
Family systems
Stress/physiologic reactions
Burnout3
Reduced wellness
1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002

18. Distressed/Disruptive Behaviors
Etiologies-Institutional:
System reinforces behavior
Leadership ignores problems for productivity
Scapegoats
Individual pathology may over-shadow institutional pathology
Williams and Williams, 2004
Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007

19. Distressed/Disruptive Behaviors
Increase Liability and Risk
Poor Work Environment
Lost of Finances
& Reputation
Cycle
Horizontal Hostility
Poor
Communication
Reduced Pt
Safety
Staff Turnovers

20. Boundary Violations

21. Boundary Violations Sexual misconduct Sexual harassment Social media
Power differential
Sexual misconduct
Sexual impropriety
Sexual violations
Sexual harassment
Social media
Unprofessional, disinhibition, anonymity

22. Boundary Violations Etiologies: Environment: Individual: Patients:
Relaxed professional culture – “slippery slope”
Individual:
Stress & burnout
Lack of self-care
Lack of knowledge
Patients:
Predators & drugs
Dewey, Swiggart, Manley, & Spickard. “Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine” – CPH 2011.

23. Misprescribing CPD

24. Six Categories of Misprescribing Physicians
Dated:
Fails to keep current
Disabled:
Failed judgment due to impairment
Duped:
Fails to detect
Dishonest:
Personal or financial gain
Dismayed:
Rx as a quick fix due to time
Dysfunctional:
Fails to say no
Brown, Swiggart, Dewey, & Ghulyan, “Searching for answers: proper prescribing of controlled prescription drugs.” J Psychoactive Drugs Jan-Mar;44(1):79-85.

25. Misprescribing CPD Rules and guidelines:
DEA – “Practitioner's Manual”
SMB & FSMB
Drug seeking patients – “Confrontational phobia”
Prescribing for non-patient colleagues, friends, families
Self-prescribing
Dewey, Swiggart, Brown, Baron, & Ghulyan, “Proper Prescribing of CPDs: What Every Physician Needs to Know”,submitted 2012

26. Impairment

27. Impairment AMA: “…any physical, mental or behavioral disorder that
interferes with ability to engage safely in professional activities...”
Physical impairment
Cognitive impairment
Psychological impairment
Substance use disorders (licit and illicit drugs)
Mental health disorders (depression & suicide)
Affects: individual, family, patients, institution
AMA Polices Related to Physician Health, Accessed 8/13/2012

28. Impairment
“Every physician is responsible for protecting patients from an impaired physician and for assisting an impaired colleague.”
~ACP Ethics Manual
Ethics Manual, 5th Edition. American College of Physicians 190 N. Independence Mall West. Philadelphia, PA

29. Professionalism Lapses
Consequences:
Restriction or loss of DEA registration
Restricted or loss of medical license
Loss of job
Law suites and restriction of insurance coverage
Loss of relationships – personal and work
Loss of self

30. Unprofessional Conduct
Four major professionalism lapses:
Distressed/disruptive behaviors
Boundary violations
Improper prescribing
Impairment

32. Two Systems Interact The External System The Internal System
“Personal & Institutional Vitality”
The External System
Functional
& Nurturing
Dysfunctional
The Internal System
Good Skills
& Well
Poor Skills
&/or Not Well
Clinician
Work Environment
“The Perfect Storm”

33. Clinician

34. Clinician
“These are the duties of a physician: First... to heal his mind and to give help to himself before giving it to anyone else.”
~ Epitaph of an Athenian doctor, AD 2.
Boisaubin & Levine. Identifying and Assisting the Impaired Physician Am J Med Sci, 2001; 322(1):31-6.

35. Professional Health & Wellness Spectrum
High Functioning
High Productivity
Fair Functioning
Decreasing Productivity
Reduced Productivity
Relationships Suffer
Fair-Not Functioning
Fair-Not Productive
Institution & Family Loses
Burnout
Coping Mechanisms
Failing
Risk of MH issues and suicide
No Coping Mechanisms
Professionally Healthy
& Well
Stressed
Coping Mechanisms Strong
Physical
Mental
Emotional
Spiritual
Work &
Family
Relations
Dewey, CM and Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine, 2009. 35

36. Clinician Health & Wellness
Little education on topic
30-60% MD are distressed and at burnout
MS & residents
↑ Primary care (IM, FP, ER)
MDs suicide > other prof. & gen pop.
One physician per day; PhD – unclear
Grossly underestimated
Depression/bipolar & substance abuse = suicide risk
“Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, 2009 & Shannafelt, Arch In Med, 2012. 36

37. Clinician Health & Wellness
Gender differences:
Females > anxiety, depression, burnout
F>M MD suicides (>50% vs 40% higher risk)
Women chairs more stressed
Male physicians (regardless of race) live longer than other professionals
Reduced use of care by physician
Stigma & anonymity – slow to prioritize MH issues for physicians; licenses, etc.
Lin et al Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19): (Schindler et al 2006) and “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008 37

38. Clinician Health & Wellness
Academic faculty:
Worked longer hours
Took less vacation
10% with mild depression
27% with elevated anxiety
No sig difference clinical vs. academic
Lin et al Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):
Schindler et al. The Impact onof the changing Health Care Environment on the Health and Well-being of faculty at Four Medical Schools. Academ Med (1):27-34.

39. Clinician Health & Wellness
Self-care
Stress & burnout
Emotional intelligence
Family systems
Training experiences – hidden curriculum
Coping skills
Conflict management
Personality types

40. Self-Care Seven key areas: Sleep Balanced meals Physical activity
Socialization/hobbies
Vacations/down times
Spiritual engagement
Having a personal physician
Mind
Body
Soul
Emotion
Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010. 40

41. Stress & Productivity Prolonged Stress Productive Stress
Reduced Cognition
Prolonged Stress
Productive Stress
Declining Function
“Impairment” ???
No Prolonged Stress
Situational Stress
Stressed
Burnout
Non-Functional
Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010. 41

42. Burnout
“In the current climate, burnout thrives in the workplace. Burnout is always more likely when there is a major mismatch between the nature of the job and the nature of the person who does the job.”
~Christina Maslach
The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997 42

43. Six Sources of Burnout Lack of control Work overload
Insufficient reward
Unfairness
Breakdown of community
Value conflict
Maslach & Leiter, “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” 43

44. Risk Factors for Burnout
Single
Gender/sexual orientation
># of children at home
Family problems
Mid-late career
Previous mental health issues (depression)
Fatigue & sleep deprivation
General dissatisfaction
Alcohol and drugs
Minority/international
Teaching & research demands
Potential litigation
1) Puddester D. West J Med 2001;174:5-7; 2) Myers MJ West J Med 2001;174:30-33; 3) Gautam M West J Med 2001;174:37-41 44

45. Symptoms of Burnout Chronic exhaustion Cynical and detached
Increasingly ineffective at work
Leads to:
isolation
avoidance
interpersonal conflicts
high turnover
Maslach & Leiter, “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17 45

46. Physician Health and Wellness
To preserve the quality of their performance, physicians have a responsibility to maintain their health and wellness, construed broadly as preventing or treating acute or chronic diseases, including mental illness, disabilities, and occupational stress.
~ AMA H
AMA Polices Related to Physician Health, Accessed 8/13/2012

47. Work Environment

48. Work Environment Can work environment influence individual health?
Stress: physician, environment, patients
Environment was the only sig predictor of stress
Job stress predicts job satisfaction
Job sat is positive predictor of positive mental health
Perceived stress was a stronger predictor of both poorer reports of physical and mental health
Therefore, environment influenced health
Powerful model how practice environment can impact physician health
Williams et al. Physician, practice and patient characteristics related to primary care physician physical and mental health: Results of the physician’s work-life study. Health Services Research, 2002; 37(1):

49. Work Environment Institutional factors to address:
Inadequate systems & supports1
System reinforces behavior1
Need for a scapegoat1,3
Money/financial benefit1
Culture – more, faster, better, longer2
Failure to recognize costs to individuals, pts, institution3
1) Williams and Williams, 2004; 2) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It.” ) Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007

50. Promoting Professionalism
“If you keep doing the same thing you always did….you will keep getting the same results you always got!”

51. Promoting Professionalism
Leadership commitment
Supportive institutional policies
Program or model to guide graduated interventions
Surveillance tools to capture allegations
Processes for reviewing allegations
Interventions
Multi-level training
Resources to help:
Unprofessional colleagues
Victims (staff, patients, students, trainees, colleagues)
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007.

52. Promoting Professionalism
Medical education & training: focus is cognitive
Emotional & self-regulation activities for MS and residents
Residency programs need to assess, train/prepare residents for the challenges in medicine1 & provide remediation as needed
Faculty development - need training/coaching (emotional intelligence (EI), coping mech., conflict management, early identification, etc.) in order to teach & role model professional behaviors
AAMC Council of Deans 2004

53. Resources

54. Resources Physician Health Programs (PHP)
Federation of State Physician Health programs (FSPHP)
Some model institutional resources:
CPH, FPWC, EAP, VCAP & CPPA programs (Vanderbilt)
Faculty Health Committee & Ombuds Office (UT Houston)
Relationship Center Care Initiative (IUSM)
Others

55. Resources Training programs: PACE, Case western, etc.
Treatment programs
Private counseling services
Professional Coaching - Center for Women in Med: Debbie Smith (
Suicide prevention hotline: TALK
Substance use: (AA, NA, Evelyn Fry, etc.)
Community-based wellness programs: YMCA/YWCA, Massage envy, etc. 55

56. Summary Listed and discussed four types of professionalism lapses.
Analyzed the roles of the individual and the institution as they shape the overall culture of professionalism.
Accepted that both individuals and the institution are responsible for promoting a culture of professionalism. 56

57. Questions & Answers