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William Swiggart, MS, LPC/MHSP Associate in Medicine Co-Director Vanderbilt Center for Professional Health www.mc.vanderbilt.edu/cph October 22, 2011.

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Presentation on theme: "William Swiggart, MS, LPC/MHSP Associate in Medicine Co-Director Vanderbilt Center for Professional Health www.mc.vanderbilt.edu/cph October 22, 2011."— Presentation transcript:

1 William Swiggart, MS, LPC/MHSP Associate in Medicine Co-Director Vanderbilt Center for Professional Health October 22, 2011

2 Continuing Medical Education Courses Maintaining Proper Boundaries © Prescribing Controlled Drugs © Program for Distressed Physicians ©

3 Provide learners with information about sexual boundaries and sexual misconduct in medicine, and expose them to a preventative educational program that addresses these issues.

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5 1. Instruct participants on the general definitions, rules and guidelines around professional conduct regarding professional boundaries and sexual misconduct in the medical profession; 2. make physicians aware of their own vulnerabilities, 3. help physicians understand how to prevent sexual boundary crossings, and 4. stimulate reflection on current and future professional practice behaviors.

6 List the levels of sexual misconduct. Define sexual harassment. Compare and contrast the types of sexual misconduct as defined by the Federation of State Medical Boards (FSMB). Identify three main risk behaviors for sexual misconduct based on various issues like self- wellness, stress, social behaviors, and medical cultures. Identify five behaviors on the slippery slope.

7 Identify three preventive measures to avoid sexual misconduct. Practice phrases to help define professional boundaries. Describe the professional obligations for reporting sexual misconduct. Develop an individual action plan to set proper boundaries in your office.

8 Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine Take a test

9 HazardousAffairs

10 DVD Observation 1 – Sexual Harassment 1. What behaviors did the doctor portray that resulted in the accusation of sexual harassment? 2. How did his behavior create a hostile work environment? 3. What action would you take if you were his superior/supervisor/department head?

11 DVD Observation 2 – Doctor-Patient 1. What type of misconduct occurred? 2. How did Dr. James set himself up for this sexual boundary crossing?

12 Late appointments with no chaperone Business transactions/dual relationships Excessive physician self-disclosure Some forms of language use Some forms of language use Personal gifts Personal gifts Special favors Special favors Flirting, jokes etc. Flirting, jokes etc. Grooming behavior Grooming behavior Casual workplace Casual workplace

13 DVD Observation 3 – Teacher-Student 1. Identify five slippery slope behaviors. 2. How does the power differential come into play in this scenario?

14 1.D - In most situations, dating a patient will be viewed as wrong. Even if the relationship is mutual and doing well. The power differential makes dating a patient wrong because the patient cannot give appropriate informed consent. The physician will be held accountable. 2.F - Dr K should NOT accept this invitation and should restate the general policy that doctors cannot date patients. Dr K is vulnerable and doesnt know the intentions of the patient asking. This could be a set up.

15 3.A - Correct answer is 2: Sexual impropriety and sexual violations. 4.B - This is an example of sexual impropriety. Impropriety is usually gestures, behaviors or expressions that are seductive, reflecting lack of respect for the patients privacy. Contrasting impropriety with violations – violations most often include physical contact or a behavior resulting from pressure to perform sexual acts for favors.

16 5.C - Grooming is a slippery slope behavior. It is when patients or others attempt to adjust your clothing, hair, jewelry, etc. 6. F - None of these options are true. Doctors, especially psychiatrist, are not supposed to engage in relationships with patients. There are other individuals who can show you the town. Patients can give you information and advice about your new town but allowing them to take you out and show you the town is not acceptable and puts you at risk of being investigated by your medical board.

17 7. D - Once you prescribe medications to your partner you entered the doctor-patient relationship. Thus you are now having a sexual relationship with your patient. While giving a small amount may be seen as reasonable if you were covering this patient over the weekend, the key point is you prescribed a controlled substance for a patient with whom you are engaged in a sexual relationship. 8. E - All of the above are examples of the power differential. In each example there is an obvious hierarchy.

18 9. A - In every situation, the physician will always be held responsible for crossing a sexual boundary and committing an act of sexual impropriety or violation. 10. A - Sexual violations usually involve a form of physical contact. Kissing, intercourse, touching of sexualized body parts, encouraging masturbation or exchanging medical care, drugs, etc. for sexual favors is a sexual violation.

19 11. C - This question is appropriate for anyone in an academic teaching facility where medical students are involved. The correct answer is C – sexual impropriety. The patient must give informed consent for medical students to witness or perform sensitive genitourinary exams. 12. B - Performing a genital exam without the use of gloves is considered a sexual impropriety.

20 13. C - In this item, clearly joking around and flirting is certainly risky unprofessional behavior. But if touch is involved – boundaries are being crossed. When individual team members feel unsafe or that their rights have been infringed upon due to repeated acts this becomes a hostile or offensive work environment and is sexual harassment.

21 14. C - This is sexual harassment. This is a very important point – even if the comment was targeted at another individual, meaning the recipient was not the intended target, it is still considered harassment if that person was offended. Thus keeping unprofessional specific comments to oneself is the best course of action or limit conversations to the intended party only.

22 15. A - You must formally discharge a patient; meaning written documentation. However, the power differential or the knowledge, emotions or influence you possess over this individual may be considered unethical as it still gives you power over that individual. In psychiatry – the once a pt always a patient may hold true as well. 16. E - The best option for this scenario is call to check on the pt, develop a plan and then educate the pt on the proper ways to contact their providers as well as reinforcing the general rules against using personal s.

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24 No: 584 Gender: Males 95% Females 5% Age range: Mean age: 49.5 yrs. Ethnic Origin: 78% Caucasian; 10% African Americans, 9% Asian and 4% Hispanic

25 Family Practice/GP 28% Internal Medicine 10% Med. Specialty 6% Surgery Specialty 9% General Surgery 4% OB/Gyn 7% Psychiatry 10% Other 26* * anesthesiology, neurology, emergency, dentist

26 Board of Medical Examiners Physician Health Program Treatment Center Self Referral

27 Complaints from patients, family members, nurses Affair with patient, office nurse/staff Flirting Cybersex

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29 Date someone you supervise such as office staff, i.e., nurse, secretary, a resident or intern.

30 If someone objects to your sexual jokes or flirting assume it is their problem. You can say anything you want to.

31 Prescribe scheduled drugs or operate on someone with whom you are sexually involved.

32 Use the hospital or office computer to view or download pornography.

33 Avoid even the appearance of professional boundaries in regards to dress, language and behavior in the office.

34 Make comments about your patients underclothing, e.g. how pretty or where did you buy that?

35 Tell stories about your own sexual life. This will certainly impress your patients and make them feel more at ease during the breast exam.

36 Be present when your patient is disrobing and offer to help with those hard to reach items. Dont use a chaperone in your office. They only make the patient uncomfortable.

37 Accept offers to meet after-hours from your patients even if it is just for coffee or a meal.

38 Flood your life with work, long hours, and ignore your personal needs. A lack of balance between professional and personal life are set- ups for problems.

39 Disregard your own emotional life and any past trauma you may have experienced which impacts you today. Stress, lack of balance between professional and personal life are set- ups for problems.

40 Ignore state, federal and professional guidelines regarding sexual harassment, sexual impropriety and sexual misconduct.

41 3% 10% 954,224 physicians currently in practice Swiggart, W., K. Starr, et al. (2002). Sexual boundaries and physicians: overview and educational approach to the problem. Sexual Addiction & Compulsivity 9:

42 Psychiatry once a patient always a patient Primary Care Surgeon Pediatrician patient surrogate Anesthesiology Rheumatology ????

43 The physician holds the balance of power over patients, staff and students. Mutual consent is not recognized as a defense for the physician. Patient and physician emotional vulnerabilities are at the core of boundary violations. Self care by the physician is critical to prevent hazardous romantic relationships.

44 Physicians lack training in the complexity of sexual boundary misconduct. An educational approach can resolve most of the problem. A pre-emptive approach is better than a post-violation intervention. The process is complaint generated.

45 CoursesNAve AgeSex Distressed994911% F89% M Boundaries710505% F95% M Prescribing % F87% M Total1637 DistressedBoundariesPrescribing IM subspecialties*IM/FPIM/FM Psychiatry OB/GYNSurgery OB/GYNER *(interventionalists) Last Updated October 2011

46 Take a break

47 Vanderbilt Center for Professional Health Continuing Medical Education Courses Prescribing Controlled Drugs © Maintaining Proper Boundaries © Program for Distressed Physicians ©

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49 Give learners an overview of disruptive/distressed behavior and provide resources for interventions.

50 Joint Commission requirements Examples of disruptive behavior Impact of disruptive behavior Etiology of disruptive behavior Describe an educational approach Identify some appropriate resources

51 2004 AAMC Council of Deans Physicians are often poorly socialized and enter medical school with inadequate social skills for practice. There is a growing body of literature documenting that residency programs do not prepare resident physicians adequately for the practice of medicine.

52 Defined disruptive behavior as a Sentinel Event Recognition that disruptive behavior can: Foster medical errors Contribute to poor patient satisfaction Contribute to preventable adverse outcomes Increase the cost of care (including malpractice) Lead to turnover/loss of qualified medical staff

53 Defined by The Joint Commission as: Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patients illness.

54 Goal of including Disruptive Behavior as a Sentinel Event: Reform health care settings to address the problem There is a history of tolerance and indifference Promote a culture of safety Improve the quality of patient care by improving the communication and collaboration of health care teams

55 Hospitals establish a formal Code of Conduct Leadership creates a process for reporting, evaluating and managing disruptive behavior

56 Educate all team members about professionalism Hold all team members accountable for modeling desirable behaviors Enforce the code consistently and equitably Non-confrontational intervention strategies Progressive discipline

57 Disruptive behavior includes, but is not limited to, words or actions that: Prevent or interfere w/an individuals or groups work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution); Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating); Threaten personal or group safety, such as aggressive or violent physical actions; Violate Vanderbilt University and/or VUMC policies, including those related to conflicts of interest and compliance. 57 Vanderbilt University and Medical Center Policy #HR-027, 2010

58 58

59 Aggressive Anger Outbursts Profane/Disrespectful Language Throwing Objects Demeaning Behavior Physical Aggression Sexual Comments or Harassment Racial/Ethnic Jokes Passive PassiveAggressive Derogatory comments about institution, hospital, group, etc. Refusing to do tasks Passive Chronically late Alcohol and other drugs Not responding to call Inappropriate or inadequate chart notes Spectrum of Disruptive Behaviors

60 Case Presentation (1) Dr. A is a 40 year old anesthesiologist referred for evaluation following several angry outbursts in his hospitals OR. The most egregious (and final) outburst involved his threatening to shoot one of his OR staff. Although he reportedly immediately told staff that he wasnt serious about the threat, a complaint was filed because he was commonly known to have an extensive gun collection at his home, and this staff member lived in the same neighborhood.

61 Case presentation (2) Dr. B reported that he was chronically fatigued and had been working at nearly twice his normal workload in the three months prior to his assessment. In addition, he reported several incidents involving his anger while in undergraduate school, medical school and residency. He reported no use of medications, and no prior treatment for anger management, except for referral to a psychiatrist over the course of a semester while in school.

62 RN did not call MD about change in patient condition because he had a history of being abusive when called. Patient suffered because of this. Rosenstein, A., ODaniel, M. Impact and Implications of Disruptive Behavior in the Perioperative Arena. J Am Coll Surg. 2006;203:

63 But More Common… ___ came late to the meeting, then spent remaining time on a Blackberry… didnt listen to the discussion ___ doesnt exactly say anything you could object to, but always rolls eyes and makes faces in meetings… not helpful…later mocks the discussion…disputes wisdom of decisions And Increasingly Common ___ writes an online Blog with implied criticisms of some of our units ___ (resident) puts feelings about patients on Facebook - unnamed, but potentially identifiable 63

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65 Perceptions of inequality when members of the team compare their contributions to those of the disruptive member (Kulik & Ambrose, 1992) Some team members will decrease their contributions, withdraw (Schroeder et al, 2003; Pearson & Porath, 2005) Felps, W et al How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27,

66 Team members may adopt disruptive persons negative mood/anger (Dimberg & Ohman, 1996) Lessened trust among team members can lead to lessened task performance (always monitoring disruptive person)... effects quality and pt safety (Lewicki & Bunker, 1995; Wageman, 2000) Felps, W et al How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27,

67 High turnover Pearson et al, 2000 found that 50% of people who were targets of disruptive behavior thought about leaving their jobs Found that 12% of people actually quit These results indicate a negative effect on return on investment Felps, W et al How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27,

68 Failure to Address Disruptive Conduct Leads to: disharmony and poor morale 1, staff turnover 2, incomplete and dysfunctional communication 1, heightened financial risk and litigation 3, reduced self-esteem among staff 1, reduced public image of hospital 1, financial cost 1, unhealthy and dysfunctional work environment 1, and potentially poor quality of care 1,2,3 1. Piper, Rosenstein, Hickson, 2002

69 Communication breakdown factored in OR errors 50% of the time 2 Communication mishaps were associated with 30% of adverse events in OBGYN 3 Communication failures contributed to 91% of adverse events involving residents 4 Gerald B. Hickson, MD James W. Pichert, PhD Center for Patient & Professional Advocacy Vanderbilt University School of Medicine 1. Dayton et al, J Qual & Patient Saf 2007; 33: White et al, Obstet Gynecol 2005; 105(5 Pt1): Gewande et al, Surgery 2003; 133: Lingard et al, Qual Saf Health Care 2004; 13:

70 fear confusion or uncertainty vengeance vs. those who oppose/oppress them hurt ego/pride grief (denial, anger, bargaining) apathy burnout unhealthy peer pressure ignorance (expectations, behav. standards, rules, protocols, chain of command, standards of care) distrust of leaders dropout: early retirement or relocation errors disruptive behavior begets disruptive behavior Vanderbilt University and Medical Center Policy #HR-027

71 Etiologies Why Might a Medical Professional Behave in Ways that are Disruptive?

72 ©CPPA, 2008 Why Might a Medical Professional Behave in Ways that are Disruptive? 1. Substance abuse, psych issues 2. Narcissism, perfectionism 3. Spillover of family/home problems 4. Poorly controlled anger (2° emotion)/Snaps under heightened stress, perhaps due to: a. Poor clinical/administrative/systems support b. Poor mgmt skills, dept out of control c. Back biters create poor practice environments

73 ©CPPA, 2008 Why Might a Medical Professional Behave in Ways that are Disruptive? 5. Well, it seems to work pretty well 6. No one addressed it earlier (why? See #5) 7. Family of origin issuesguilt and shame 8. 9.

74 The Perfect Storm PhysicianHospital/Clinic The external system The internal system Two Systems Interact Good skills Poor skills Functional & nurturing Dysfunctional

75 Systems "Every system is perfectly designed to get the results it gets. BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

76 Individual Factors Predisposing Psychological Factors (1) Alcohol and Drug Family History Trauma History Religious Fundamentalism Familial High Achievement, lack of skills regarding conflict and negotiation and other family of origin patterns Personality Traits (2) Narcissism Obsessive/Compulsive Physician Burnout (3) Clinical Skills Satisfactory or Above Average (4) 1.Valliant, Gabbard, Spickard and Gabbe, Papadakis, 2004, 2005

77 Institutional Factors (1) Scapegoats System Reinforces Behavior Individual Pathology may over-shadow institutional pathology Williams and Williams, 2004

78 Methods to Address Behavioral Problems Mr. Bangsiding felt (and wrongly so) that a little chat would be enough to stop Bobs disruptive behavior.

79 The role of a comprehensive evaluation The importance of consequences Educational programs Feedback from colleagues, patients, staff, etc. Monitoring and accountability External resources

80 Comprehensive Evaluation APA guidelines for Fitness for Duty Evaluations Multidisciplinary: 1-5 days Medical Psychiatric evaluation Psychological testing Psychosocial including genogram Addiction screening Collateral information Comprehensive report with recommendations

81 What We Have Learned? Monitoring contracts need to be flexible 360 evaluations are imperative for monitoring and to see how the professional is progressing Not all can be helped or saved Intensive small group CME with monitoring works for many

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83 A Program for Distressed Physicians Components: Phone interview Three-day CME course (47.5 AMA PRA Category 1 Credits ) Teach Specific tools/skills - e.g., grounding skills, Alter, communication strategies Three follow-up sessions with the core group over the next six months; importance of group process

84 Flooding* This means you feel so stressed that you become emotionally and physically overwhelmed… Pounding heart, sweaty hands, and shallow breathing. When youre in this state of mind…you are not capable of hearing new information or accepting influence. *John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001,

85 GROUNDING Categories exercise Judge versus describe Mindfulness with all senses Breathe

86 John M. Gottman, All Rights Reserved (revised 11/17/03)

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88 Scoring: If you answered yes to more than eight statements, this is a strong sign that you are prone to feeling flooded during conflict. Because this state can be harmful to you, its important to let others know how you are feeling. The antidote to flooding is to practice soothing yourself. There are four secrets of soothing yourself: breathing, relaxation, heaviness, and warmth. The first secret is to get control of your breathing. When you are getting flooded, you will find yourself either holding your breath a lot or breathing shallowly. Change your breathing so it is even and you take deep regular breaths. Take your time inhaling and exhaling. The second secret is to find areas of tension in your body and first tense and then relax these muscle groups. First, examine your face, particularly your forehead and jaw, then your neck, shoulders, arms, and back. Let the tension flow out and start feeling heavy. The secret is to meditate, focusing your attention on one calming vision or idea. It can be a very specific place you go to that was once a very comforting place, like a forest or a beach. Imagine this place as vividly as you can as you calm yourself down. The fourth part is to imagine the body part becoming warm. Flooding - Scoring John M. Gottman, All Rights Reserved (revised 11/17/03)

89 Describe an incident you are concerned about. Who was there? Pick someone to play you. A powerful cathartic exercise viewing their behavior from multiple points of view. Example.

90 When asking for something, use the acronym – DRAN Describe Reinforce Assert Negotiate

91 Describe the other persons behavior objectively Use concrete terms Describe a specified time, place & frequency of action Describe the action, not the motive

92 Recognize the other persons past efforts

93 Express your feelings Express them calmly State feelings in a positive manner Direct yourself to the offending behavior, not the entire persons character Ask explicitly for change in the other persons behavior

94 Request a small change at first Take into account whether the person can meet you needs or goals Specify behaviors you are willing to change Make consequences explicit Reward positive changes

95 Disruptive behavior Social Systems If the physician is returned to the institution to practice, it is necessary to ensure that the behavior does not recur. There is a significant level of recidivism As high as 20% among severe offenders (Grant and Alfred 2007) Prior behavioral issues are a significant risk factor for later disruption (Papadakis, Arnold, et. al. 2008) BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

96 Disruptive behavior Social Systems A monitoring system that is under development measures these issues using a 360 survey. Early data show the survey to be well tolerated and demonstrates face validity. The survey was developed to facilitate integration with institutional systems. BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

97 It is not enough to have good motives; others respond to our behavior. Physicians are often not given essential feedback about their behavior. The Team Behavior Survey (TBS) is designed to provide feedback from those we work with. © Swiggart, Williams, and Williams

98 Communication Concern for patients and families Accessibility and timeliness Work environment Ethical behavior Interpersonal behavior & respect for others Focus on medical tasks Ability to work with other members of the medical team

99 Potential Resources for Healthy Coping Courses Coaches, counselors Comprehensive Evaluation 360° Evaluations Risk Managers Physician Wellness Treatment Centers Office of General Counsel State BME Professional Societies QI Officers EAP Others State Physician Health Program

100 What We Have Learned? 1. There is a need to develop standard, model policies for hospitals. 2. Information needs to be widely distributed to hospitals and medical practices that this is treatable, saves money, prevents malpractice suits, and that early intervention is best. 3. Medical student and resident training cultivates many of the disruptive behaviors as they learn from their mentors behavior.

101 Disruptive behavior is a patient safety issue. State PHPs can be an extremely valuable resource for both physicians and institutions. An objective, comprehensive assessment is invaluable. It is important to understand the systems issues related to an individuals behavior. Resources are available.

102 Please visit our website

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