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“Unprofessional and Distressed Resident Physician Behaviors”

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1 “Unprofessional and Distressed Resident Physician Behaviors”
Marshall University School of Medicine - Workshop August 28, 2012 “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 Dewey, CM Vanderbilt University School of Medicine

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 events1 Communication breakdown factored in OR errors 50% of the time2 Communication mishaps were associated with 30% of adverse events in OB/GYN3 Communication failures contributed to 91% of adverse events involving residents4 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 Marshall University School of Medicine - Workshop
August 28, 2012 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 resident’s level of professional conduct. Is this blowing off stress or distressed behavior? Why? What do YOU do? What systems exist to help with complaints and interventions? What does the resident need? How does any system promote or dissuade such behavior? Dewey, CM Vanderbilt University School of Medicine

6 Marshall University School of Medicine - Workshop
August 28, 2012 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. Dewey, CM Vanderbilt University School of Medicine

7 Marshall University School of Medicine - Workshop
August 28, 2012 Objectives Participants of the session will: Discuss the behaviors and consequences of unprofessional and distressed resident physicians. Discuss and share methods for identifying and addressing unprofessional and distressed behaviors during residency. Practice 1 method of communication when approaching residents with unprofessional conduct. Determine if changes are needed to their policy for identifying, addressing and managing unprofessional conduct by resident physicians. Dewey, CM Vanderbilt University School of Medicine

8 Marshall University School of Medicine - Workshop
August 28, 2012 Agenda Introduction Unprofessional and distressed behaviors Methods and tools for identification and intervention Review & practice DRAN and Cup of Coffee Conversations Program/policy assessments Summary Dewey, CM Vanderbilt University School of Medicine

9 Marshall University School of Medicine - Workshop
August 28, 2012 Ground Rules Lecture discussion workshop Interactive Flexible Share experiences Time limited Dewey, CM Vanderbilt University School of Medicine

10 Stressed or Disruptive
Marshall University School of Medicine - Workshop August 28, 2012 Stressed or Disruptive Is this blowing off stress or disruptive behavior? Dewey, CM Vanderbilt University School of Medicine

11 Stress Reactions Permission to be human!!!

12 Flooding Neurological and biochemical event Triggers
Sudden onset: “Like an oncoming truck” Inability to self-soothe or self-regulate 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 you’re 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: Things to do after you flooded:
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 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 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. 16 16

17 Etiology of Distressed Behaviors
Individual Factors: Psychological Factors1: Substance use/abuse, FHx, 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 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 Isn’t.” 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 Marshall University School of Medicine - Workshop
August 28, 2012 Introduction Case What do YOU do? Warning Do Nothing Immediate Intervention Report Dewey, CM Vanderbilt University School of Medicine

21 Marshall University School of Medicine - Workshop
August 28, 2012 Barriers to Action Lack of authority Lack of protection Unclear process Risk of retribution/retaliation Letters of recommendation in future Concerns of own deficiencies Fear Loyalty Culture Lack of training 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 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, 2010. Dewey, CM Vanderbilt University School of Medicine

22 Assertive Communication
Marshall University School of Medicine - Workshop August 28, 2012 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. Dewey, CM Vanderbilt University School of Medicine

23 Marshall University School of Medicine - Workshop
August 28, 2012 Describe Describe the other person’s 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. Dewey, CM Vanderbilt University School of Medicine

24 Marshall University School of Medicine - Workshop
August 28, 2012 Reinforce Recognize the other person’s 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 Dewey, CM Vanderbilt University School of Medicine

25 Assert Directly and Specifically
Marshall University School of Medicine - Workshop August 28, 2012 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 person’s character Ask explicitly for change in the other person’s behavior Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine. Dewey, CM Vanderbilt University School of Medicine

26 Marshall University School of Medicine - Workshop
August 28, 2012 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. Dewey, CM Vanderbilt University School of Medicine

27 Marshall University School of Medicine - Workshop
August 28, 2012 Tips If flooding – make an escape! Listen Avoid judgment Be empathetic but don’t 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 Dewey, CM Vanderbilt University School of Medicine

28 Marshall University School of Medicine - Workshop
August 28, 2012 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, I’ll get right back to you. Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine. Dewey, CM Vanderbilt University School of Medicine

29 Marshall University School of Medicine - Workshop
August 28, 2012 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 other’s performance & provides feedback Dewey et al. “Teaching Professionalism” EDP Workshop, Vanderbilt University School of Medicine, April 2010. Dewey, CM Vanderbilt University School of Medicine

30 Marshall University School of Medicine - Workshop
August 28, 2012 Introduction Case What systems exist to help with complaints and interventions? Dewey, CM Vanderbilt University School of Medicine

31 Marshall University School of Medicine - Workshop
August 28, 2012 What do we do well? Dewey, CM Vanderbilt University School of Medicine

32 Marshall University School of Medicine - Workshop
August 28, 2012 Introduction Case What does the resident need? Dewey, CM Vanderbilt University School of Medicine

33 Marshall University School of Medicine - Workshop
August 28, 2012 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 Dewey, CM Vanderbilt University School of Medicine

34 Marshall University School of Medicine - Workshop
August 28, 2012 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 Dewey, CM Vanderbilt University School of Medicine

35 Marshall University School of Medicine - Workshop
August 28, 2012 Interventions Internal vs. external referrals EAP Fitness for duty assessments (MH, SU) State physician health program Out of state programs (education, training, treatment) Dewey, CM Vanderbilt University School of Medicine

36 Emotional Intelligence
Self-awareness Self-regulation Motivation Empathy Social skills Ongoing inner conversation = self-regulation Self-awareness = know thyself Goleman, D. “What makes a leader?” HBR 1998:82-91

37 Marshall University School of Medicine - Workshop
August 28, 2012 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: Dewey, CM Vanderbilt University School of Medicine

38 Marshall University School of Medicine - Workshop
August 28, 2012 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: Dewey, CM Vanderbilt University School of Medicine

39 Marshall University School of Medicine - Workshop
August 28, 2012 Introduction Case How does any system promote or dissuade such behavior? Dewey, CM Vanderbilt University School of Medicine

40 Increase Liability and Risk
Disruptive Behaviors Increase Liability and Risk Poor Work Environment Lost of Finances & Reputation Cycle Horizontal Hostility Poor Communication Disharmony and poor morale Reduced self-esteem among staff Unhealthy and dysfunctional work environment Staff turnover Incomplete and dysfunctional communication Potentially poor quality of care Reduced public image of hospital Heightened financial risk and litigation Financial cost Reduced Pt Safety Staff Turnovers 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 Marshall University School of Medicine - Workshop
August 28, 2012 Failure to Address Disruptive behavior leads to problems with communication which leads to adverse events1 Communication breakdown factored in OR errors 50% of the time2 Communication mishaps were associated with 30% of adverse events in OBGYN3 Communication failures contributed to 91% of adverse events involving residents4 1. Dayton et al, J Qual & Patient Saf 2007; 33: White et al, Obstet Gynecol 2005; 105(5 Pt1): 2. Gewande et al, Surgery 2003; 133: Lingard et al, Qual Saf Health Care 2004; 13: Dewey, CM Vanderbilt University School of Medicine

42 Marshall University School of Medicine - Workshop
August 28, 2012 Failure to Address Team members may adopt disruptive person’s 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, Dewey, CM Vanderbilt University School of Medicine

43 Joint Commission Goals:
Reform health care settings to address the problem (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 Gundersen, DC. “The Disruptive Physician” Federation of State Physician Health Programs (FSPHP) Annual Meeting Chicago, IL 2010.

44 The Joint Commission Requirements:
EP 4: The hospital/organization has a code of conduct that defines acceptable and disruptive and inappropriate behaviors.1 EP 5: Leadership create and implement a process for managing disruptive and inappropriate behaviors1 Multiple levels of leadership Professional/leader training E.g., CPPA – PARS® at Vanderbilt2 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 Disruptive Behavior Pyramid
Level 3 "Disciplinary" Intervention Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007 No ∆ Pattern persists Level 2 "Authority" Intervention Apparent pattern Level 1 "Awareness" Intervention Single “unprofessional" incidents (merit?) "Informal" Cup of Coffee Intervention Mandated Issues Vast majority of professionals - no issues Center for Patient and professional Advocacy at Vanderbilt 45

46 Marshall University School of Medicine - Workshop
August 28, 2012 The Joint commission 11 Suggestions: Educate all team members Hold all team members accountable Develop and implement policies and procedures/processes Develop an organizational process for addressing intimidating and disruptive behaviors Provide skills-based training and coaching for all leaders/managers Develop and implement a system for assessing staff perceptions The Joint Commission. “Behaviors that undermine a culture of safety.” Issue 40, July 9, 2008 Dewey, CM Vanderbilt University School of Medicine

47 Marshall University School of Medicine - Workshop
August 28, 2012 The Joint Commission Develop and implement a reporting/ surveillance system (possibly anonymous) for detecting unprofessional behavior. Support surveillance with tiered, non-confrontational interventional strategies Conduct all interventions within the commitment to the health and well-being of all staff, Encourage inter-professional dialogues Document all attempts to address behaviors The Joint Commission. “Behaviors that undermine a culture of safety.” Issue 40, July 9, 2008 Dewey, CM Vanderbilt University School of Medicine

48 Marshall University School of Medicine - Workshop
August 28, 2012 Recap Intro Case Is this blowing off stress or distressed behavior? Why? What do YOU do? What systems exist to help with complaints and interventions? What does the resident need? How does any system promote or dissuade such behavior? Dewey, CM Vanderbilt University School of Medicine

49 Marshall University School of Medicine - Workshop
August 28, 2012 Take Home Points Disruptive and unprofessional behaviors have significant consequences for many individuals and the institution and thus should not be ignored. Physicians demonstrate unprofessional and disruptive behaviors for many reasons. Provide means for remediation through assessments, education, training, monitoring, self-improvement, role modeling, and referrals. Policies and codes of conduct should be implemented and made clear for all those working within the institution. Dewey, CM Vanderbilt University School of Medicine

50 Marshall University School of Medicine - Workshop
August 28, 2012 Summary Discussed behaviors and consequences of unprofessional and distressed resident physicians. Discussed and shared methods for identifying and addressing unprofessional and distressed behaviors during residency. Practiced 1 method of communication (DRAN) when approaching residents with unprofessional conduct. Determined if changes are needed to the policy for identifying, addressing and managing unprofessional conduct by resident physicians. Dewey, CM Vanderbilt University School of Medicine


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