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Unprofessional and Distressed Resident Physician Behaviors Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration.

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Presentation on theme: "Unprofessional and Distressed Resident Physician Behaviors Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration."— Presentation transcript:

1 Unprofessional and Distressed Resident Physician Behaviors Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Vanderbilt University School of Medicine Marshall University Joan C. Edwards School of Medicine August 28, 2012

2 Introduction Distressed physicians can have disruptive behavior Est. prevalence of disruptive behavior in U.S. MDs is 5% (International similar) Focus of attention: disruptive behavior can have destructive impact on: –institutions, staff, and pt care Samenow, Swiggart, and Spickard. A CME Course Aimed at Addressing Disruptive Physician Behavior Physician Executive Jan/Feb, 2008:pg 32-40

3 Introduction Five different state medical societies data demonstrate disruptive behaviors comprise up to 30% of complaints received. * (independent of substance abuse and other forms of impairment) Samenow, Swiggart, and Spickard. A CME Course Aimed at Addressing Disruptive Physician Behavior Physician Executive Jan/Feb, 2008:pg 32-40

4 Introduction Disruptive behavior leads to problems with communication which leads to adverse events 1 –Communication breakdown factored in OR errors 50% of the time 2 –Communication mishaps were associated with 30% of adverse events in OB/GYN 3 –Communication failures contributed to 91% of adverse events involving residents 4 1) Dayton et al, J Qual & Patient Saf 2007; 33:34-44; 2) Gewande et al, Surgery 2003; 133: ) White et al, Obstet Gynecol 2005; 105(5 Pt1): ; 4) Lingard et al, Qual Saf Health Care 2004; 13:

5 Introduction Case Your team standing at the nurses station blowing off steam after a rough morning. The upper level resident used a particularly graphic and insulting metaphor to describe one morbidly obese and challenging patient. Everyone laughed at the description. The nurse gives a look of disdain and the residents flips her the bird after she turns her head. You are uncomfortable with the residents level of professional conduct. 1.Is this blowing off stress or distressed behavior? Why? 2.What do YOU do? 3.What systems exist to help with complaints and interventions? 4.What does the resident need? 5.How does any system promote or dissuade such behavior?

6 Goals The purpose of this session is to discuss unprofessional and distressed behaviors of resident physicians and discuss and share resources and tools for identifying and assisting residents in need.

7 Objectives Participants of the session will: 1.Discuss the behaviors and consequences of unprofessional and distressed resident physicians. 2.Discuss and share methods for identifying and addressing unprofessional and distressed behaviors during residency. 3.Practice 1 method of communication when approaching residents with unprofessional conduct. 4.Determine if changes are needed to their policy for identifying, addressing and managing unprofessional conduct by resident physicians.

8 Agenda 1.Introduction 2.Unprofessional and distressed behaviors 3.Methods and tools for identification and intervention 4.Review & practice DRAN and Cup of Coffee Conversations 5.Program/policy assessments 6.Summary

9 Ground Rules Lecture discussion workshop Interactive Flexible Share experiences Time limited

10 Stressed or Disruptive Is this blowing off stress or disruptive behavior?

11 Stress Reactions Permission to be human!!!

12 Flooding 1.Neurological and biochemical event 2.Triggers 3.Sudden onset: Like an oncoming truck 4.Inability to self-soothe or self-regulate 5.Tend to keep away or isolate

13 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,

14 Flooding Things to do when you flood: –Step away from the situation: if possible go into the restroom –Self-sooth: Breathe, relax –Practice mindfulness techniques Things to do after you flooded: –Reflection – triggers, symptoms, event –Seek coaching & mentoring

15 Disruptive Behavior Behavior or behaviors that undermine a culture of safety. 1 Disruptive behavior is a sentinel event 2 1)The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD , elements of performance (EP) 4 and 5, Spring 2012; 2)Joint Commission, Issue 40 July 9, 2008

16 Aggressive Passive Aggressive Figure 1 Inappropriate anger, threats Yelling, publicly degrading team members Intimidating staff, patients, colleagues, etc. Pushing, throwing objects Swearing Outburst of anger & physical abuse Hostile notes, s Derogatory comments about institution, hospital, group, etc. Inappropriate joking Sexual Harassment Complaining, Blaming Chronically late Failure to return calls Inappropriate/inadequate charts Avoiding meetings & individuals Non-participation Ill-prepared, not prepared 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. Spectrum of Disruptive Behaviors

17 Etiology of Distressed Behaviors Individual Factors: Psychological Factors 1: –Substance use/abuse, FHx, trauma history, religious fundamentalism, familial high achievement MH issues 2 : –Personality disorders, narcissism, depression, bipolar, OCD, etc. Genetic/developmental issues: –Aspergers, non-verbal learning differences, etc. Family systems Stress/physiologic reactions Burnout 3 Reduced wellness 1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002

18 Etiologies of Distressed Behaviors Institutional Factors: –Scapegoats –System reinforces Behavior –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 Isnt. Business Plus, New York, 2007

19 Risk Factors Personality types Lack of self-awareness Lack of emotional intelligence Training/experience Lack of training in coping skills and stress management Lack of training dealing with conflict Your family system Poor self-care

20 Introduction Case What do YOU do? Warning Do NothingImmediate InterventionReport

21 Lack of authority Lack of protection Unclear process Risk of retribution/retaliation Letters of recommendation in future Concerns of own deficiencies Barriers to Action Fear Loyalty Culture Lack of training Hickson et al. The why and how of dealing with special colleagues: discouraging disruptive behaviors. Center for Patient and Professional Advocacy, Vanderbilt University School of Medicine, October 28-9, Reluctance to betray Potential loss of recog/reputation Implications for patients loyalties Lack of incentive to do right Misuse of information Needs a scapegoat Lack of… Conflict management skills Assertiveness training Communication training

22 Assertive Communication When asking for something, use the acronym – DRAN Describe Reinforce Assert Negotiate Swiggart et al. Program for Distressed Physicians, Center for Professional Health, Vanderbilt University School of Medicine.

23 Describe Describe the other persons behavior objectively – use reflective I Use concrete terms Describe a specified time, place & frequency of action Describe the action/behavior, not the motive Be respectful but avoid minimizing Swiggart et al. Program for Distressed Physicians, Center for Professional Health, Vanderbilt University School of Medicine.

24 Reinforce Recognize the other persons past efforts Remember: It takes eight positive comments to compensate for one negative comment. Swiggart et al. Program for Distressed Physicians, Center for Professional Health, Vanderbilt University School of Medicine. & John Gottman, Ph.D. The Relationship Cure. Crown Publishers, New York, 2001, 74-78

25 Assert Directly and Specifically 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 Swiggart et al. Program for Distressed Physicians, Center for Professional Health, Vanderbilt University School of Medicine.

26 Negotiate Work toward a compromise that is reasonable 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 Swiggart et al. Program for Distressed Physicians, Center for Professional Health, Vanderbilt University School of Medicine.

27 Tips If flooding – make an escape! Listen Avoid judgment Be empathetic but dont join the pity party Beware the 7 traps: Pulling rank Expectation of thanks Adopting their role Fail to deliver the message Control contest Fail to recognize self-issues Giving to much advice End positively

28 Specific Phrases I am coming to you as a colleague. You are a valued member of the team. I hear and saw the event… You may be right. I know this may be frustrating. I want to address some concerns I have. Give me a minute, Ill get right back to you. Swiggart et al. Program for Distressed Physicians, Center for Professional Health, Vanderbilt University School of Medicine.

29 Practice DRAN Role plays Use the introduction case Each person takes turn practicing DRAN; then switch You are practicing – mistakes are ok. Person listening assess others performance & provides feedback Dewey et al. Teaching Professionalism EDP Workshop, Vanderbilt University School of Medicine, April 2010.

30 Introduction Case What systems exist to help with complaints and interventions?

31 What do we do well?

32 Introduction Case What does the resident need?

33 ACGME ACGME Competency-Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to: demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices demonstrate sensitivity and responsiveness to patients culture, age, gender, and disabilities

34 Interventions Education –Clear policy –Rules/regulations –Ethics/professionalism –Self-care Training & coaching Assessments (burnout, MH, SU, FFD, BVI, FOO, etc.) Monitoring (B29-BMT, pt surveys, intent to change) Experiences – witness doing right (role models) Emotional intelligence Referrals

35 Interventions Internal vs. external referrals –EAP –Fitness for duty assessments (MH, SU) –State physician health program –Out of state programs (education, training, treatment)

36 Emotional Intelligence Self-awareness Self-regulation Motivation Empathy Social skills Goleman, D. What makes a leader? HBR 1998:82-91

37 Self-Awareness First, people need self-awareness to reflect on their behaviors, including their emotional displays, so as to judge them against group norms. …encourages people to reflect on their actions and understand the extent to which those actions match both personal values and beliefs as well as group standards. How do you teach self-awareness? Heatherton, TF. Neuroscience of Self and Self-Regulation. Annu Rev Psychol 2011:62:

38 Self-Regulation The process by which people change thoughts, feelings, or actions in order to satisfy personal and society goals and standards. Self-regulation involves both the initiation and maintenance of behavioral change in addition to inhibiting undesired behaviors or responding to situational demands. How do you teach self-regulation? Heatherton, TF. Neuroscience of Self and Self-Regulation. Annu Rev Psychol 2011:62:

39 Introduction Case How does any system promote or dissuade such behavior?

40 Disruptive Behaviors Cycle Horizontal Hostility Poor Communication Reduced Pt Safety Lost of Finances & Reputation Staff Turnovers Increase Liability and Risk Poor Work Environment Samenow, Swiggart, and Spickard. A CME Course Aimed at Addressing Disruptive Physician Behavior Physician Executive Jan/Feb, 2008:pg 32-40; Felps, W et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, 2006; 27:

41 Failure to Address Disruptive behavior leads to problems with communication which leads to adverse events 1 –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 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:

42 Failure to Address Team members may adopt disruptive persons negative mood/anger (Dimberg & Ohman, 1996) Lessened trust leads to lessened task performance & effects quality and pt safety (Lewicki & Bunker, 1995; Wageman, 2000) 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,

43 Joint Commission Goals: 1.Reform health care settings to address the problem (history of tolerance and indifference) 2.Promote a culture of safety 3.Improve the quality of patient care by improving the communication and collaboration of health care teams Gundersen, DC. The Disruptive Physician Federation of State Physician Health Programs (FSPHP) Annual Meeting Chicago, IL 2010.

44 The Joint Commission Requirements: 1.EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors. 1 2.EP 5: Leadership create and implement a process for managing disruptive and inappropriate behaviors 1 Multiple levels of leadership Professional/leader training E.g., CPPA – PARS® at Vanderbilt 2 1) The Joint Commission. Behaviors that undermine a culture of safety. Issue 40, July 9, 2008 and 2) Center for Patient and Professional Advocacy – Patient Advocacy Reporting System.

45 Apparent pattern Single unprofessional" incidents (merit?) Disruptive Behavior Pyramid Mandated Issues "Informal" Cup of Coffee Intervention Level 1 "Awareness" Intervention Level 2 "Authority" Intervention Level 3 "Disciplinary" Intervention Pattern persists No Vast majority of professionals - no issues Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 Center for Patient and professional Advocacy at Vanderbilt Disruptive Behavior Pyramid

46 The Joint commission 11 Suggestions: 1.Educate all team members 2.Hold all team members accountable 3.Develop and implement policies and procedures/processes 4.Develop an organizational process for addressing intimidating and disruptive behaviors 5.Provide skills-based training and coaching for all leaders/managers 6.Develop and implement a system for assessing staff perceptions The Joint Commission. Behaviors that undermine a culture of safety. Issue 40, July 9, 2008

47 The Joint Commission 7.Develop and implement a reporting/ surveillance system (possibly anonymous) for detecting unprofessional behavior. 8.Support surveillance with tiered, non-confrontational interventional strategies 9.Conduct all interventions within the commitment to the health and well-being of all staff, 10.Encourage inter-professional dialogues 11.Document all attempts to address behaviors The Joint Commission. Behaviors that undermine a culture of safety. Issue 40, July 9, 2008

48 Recap Intro Case 1.Is this blowing off stress or distressed behavior? Why? 2.What do YOU do? 3.What systems exist to help with complaints and interventions? 4.What does the resident need? 5.How does any system promote or dissuade such behavior?

49 Take Home Points 1.Disruptive and unprofessional behaviors have significant consequences for many individuals and the institution and thus should not be ignored. 2.Physicians demonstrate unprofessional and disruptive behaviors for many reasons. 3.Provide means for remediation through assessments, education, training, monitoring, self-improvement, role modeling, and referrals. 4.Policies and codes of conduct should be implemented and made clear for all those working within the institution.

50 Summary 1.Discussed behaviors and consequences of unprofessional and distressed resident physicians. 2.Discussed and shared methods for identifying and addressing unprofessional and distressed behaviors during residency. 3.Practiced 1 method of communication (DRAN) when approaching residents with unprofessional conduct. 4.Determined if changes are needed to the policy for identifying, addressing and managing unprofessional conduct by resident physicians.


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