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2007 Annual Conference DISRUPTIVE PROFESSIONALS Raymond M. Pomm, M.D. Professionals Resource Network.

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Presentation on theme: "2007 Annual Conference DISRUPTIVE PROFESSIONALS Raymond M. Pomm, M.D. Professionals Resource Network."— Presentation transcript:

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2 2007 Annual Conference DISRUPTIVE PROFESSIONALS Raymond M. Pomm, M.D. Professionals Resource Network

3 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation WHAT IT IS NOT...

4 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation SUBSTANCE RELATED DISORDERS

5 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation PSYCHOTIC DISORDERS

6 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation MAJOR DEPRESSION

7 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation BIPOLAR I / II

8 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation WHAT IT IS...

9 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation A Continuum Dangerous Disruptive Difficult Different Lo Disruptive Hi Disruptive

10 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Disruptive Professionals are ultimately...

11 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation TEAM BUSTERS!

12 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation The Underlying Issues...

13 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Predisposing Character Poor Role Models Stress Poor Coping Skills Disruptive Incidents  Hospital Culture 

14 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation PERSONALITY DISORDERS

15 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation NARCISSISTIC PERSONALITY DISORDER

16 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation THIS IS NO ORDINARY PERSON YOU’RE DEALING WITH!

17 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation

18 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation

19 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation

20 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation

21 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation

22 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation

23 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation WHAT TO DO...

24 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation There is no law that says one cannot be Disruptive

25 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation The: -Hospital -Group -Corporation -Leadership holds the hammer

26 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation The steps to validate and protect the hammer:

27 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation The intent of this policy and procedure is to assist the referral source in utilizing the services of PRN in the management of the disruptive practitioner. The goal of these steps is to determine whether rehabilitation is a viable medical option. Before PRN will accept the referral of a disruptive practitioner, the following protocol must be followed: Slide 1 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

28 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 1) The referral source must document all disruptive behaviors, ramifications of said behaviors and any action taken due to the behaviors. 2) Confidential, one-on-one discussion of the behaviors in question between a “friendly” colleague (representative of the referral source) and the disruptive practitioner. The practitioner will be informed, prior to the discussion, that the confidentiality may be rescinded if the behaviors continue. Slide 2 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

29 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 3) Non-confidential, formal meeting with the admin level representative of the referral source, supervisor (if applicable) and the disruptive practitioner to discuss documented disruptive behaviors that need to be corrected, resulting in a warning that outlines consequences, if not corrected. ** An optional step can be inserted at this point if the referring source has an associated Impaired Practitioner Committee. This committee can be authorized to refer to PRN (step #4 b-e) or a recommendation will be made to the disciplinary body for suspension/termination (step 4a) of the disruptive practitioner. Slide 3 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

30 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 4) Meeting of disciplinary body of the referral source: a) disciplinary body must be ready to suspend/terminate the disruptive practitioner if he/she is unwilling to proceed and comply with the following steps; b) if both parties are in agreement, the disruptive practitioner must contact PRN in order to avoid suspension/termination; c) disruptive practitioner must sign release for PRN to communicate with referral source; Slide4 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

31 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation d) phone call made by referral source to PRN in presence of the disruptive practitioner; e) all of the documentation must be faxed to PRN by referral source within five (5) business days of the referral to PRN; f) documentation must be of adequate detail for PRN to take appropriate action; Slide 5of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

32 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 5) Refer for evaluation, to be arranged by PRN, to a DOH/PRN approved evaluator. The evaluation must be comprehensive. The evaluation must be completed within ten (10) business days of the referral or PRN will recommend the hospital follow through with suspension/termination (unless delay is caused by the evaluator and/or PRN). Slide 6 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

33 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 6) If evaluation is not completed in timely fashion, PRN will make decision whether information is sufficient for referral to Department of Health to compel an evaluation within a certain time frame. 7) If appropriate, contract with PRN under Behavioral Management Contract to include: a) therapeutic recommendations of the evaluator, b) behavioral requirements and consequences as agreed to by the referral source, evaluator and disruptive practitioner, Slide7 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

34 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 8) The disruptive practitioner must execute the contract within ten (10) business days of its receipt. ** PRN is available to the referral source to discuss situation/issues/procedures at any time during this process Slide 8 of 8 PRN DISRUPTIVE PRACTITIONER POLICY & PROCEDURE

35 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Let’s look at Evaluation/Treatment/ Monitoring Process...

36 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Speaker Contact Information Raymond M. Pomm, M.D. Professionals Resource Network P.O. Box 1020 Fernandina Beach, FL 32035 (800) 888 - 8776

37 2007 Annual Conference Disruptive Professionals: New Approaches to Evaluation and Management Larry Harmon, PhD Physicians Development Program

38 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Disruptive Behavior is … … a pattern of conduct which reduces or disrupts the ability of the healthcare (or other) team to do it’s best work

39 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Who are the Disruptive Docs? MBAs “Good Doc … Bad Talk”

40 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Clinical Evaluation Clinical Interview Extensive Personal History Psychological & Cognitive Testing Criminal Background Checks Drug Testing “Workplace Behavior Assessment”

41 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation P.hysicians + Professionals U.niversal L.eadership + Teamwork S.kills E.ducation Survey Workplace Behavioral Assessment 360 ° P.U.L.S.E. Survey

42 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Workplace Behavioral Assessment 1.Each physician scores self on survey 2.Other physicians and healthcare team members give physician survey feedback 3.Feedback Report is prepared

43 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 3 Types of Assessments 1.Individual - Continued disruptive pattern despite progressive warnings 2.Small Group or Section (2-10) Individual resists Protect identity of subject 3.Department or Hospital Program Annual Leadership Feedback Reports

44 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Conducting an Individual Workplace Behavioral Assessment

45 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Phase I: Assessment Step 1: Referral Letter Step 2: Physician Orientation

46 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Dr. Disruptive Administration Supervisors Other Depts. Colleagues Patients* *Patient Pulse survey Nurses+ Healthcare Staff Support Staff Step 3. Select “Feedback Groups”

47 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Dr. Disruptive Administration Supervisors Other Depts. Colleagues Patients* *Patient Pulse survey Nurses+ Healthcare Staff Step 3. Select “Feedback Groups” Support Staff “Validator” Adds Any Missing Names (Chief of Staff, CEO, i.e., the “Boss”)

48 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Step 4. “Self-Rating”

49 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Motivating/Encouraging Dimensions

50 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Disruptive/Discouraging Dimensions

51 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation TO: My Team Members and Colleagues RE: Invitation for Honest Feedback I am participating in a national Physicians Leadership Development Program, and part of the program is to obtain feedback to help me better understand my workplace interpersonal leadership style and people skills. I have requested the Physicians Development Program to distribute their physician people skills survey, called the “P.U.L.S.E. Leadership Survey,” to my team members, so I can get group feedback. Be honest…survey is anonymous… Dirk Disruptive, MD Step 5. Cover Letter Step 5. Writes Cover Letter

52 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 1. Mailed / Emailed to Raters Step 6: Send Surveys+Create Report 2. Raters Complete Surveys 3. Feedback Report Prepared

53 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Dr. Disruptive requests your honest and anonymous feedback Dirk Disruptive, MD

54 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Treating us with common courtesy. Explaining rather than yelling. Saying please and thank you. Talking down to us. Yelling and screaming. Scaring me. I call in sick when you’re here. Being an excellent doctor. Having great technical skills. Taking good care of patients.

55 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation “Discourager” or “Disruptive” Feedback Report LEADERSHIP FEEDBACK REPORT Physicians P.U.L.S.E. Program P.hysicians U.niversal L.eadership S.kills E.ducation Program Prepared for Dr. Disruptive This report includes feedback from 22 individuals, including your self-rating if you completed one. January 1, 2007

56 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Self-Rating Nursing Staff Physician Peers Self-Rating Nursing Staff Physician-Peers

57 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Nursing Staff Physic -ians

58 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Findings & Recommendations No Disruptive Mild Moderate Serious Severe Disrup- tive Behavior No Recommendation Anger Mgmt. Videos Anger Mgmt. Prog ram Weekly Group Psychotherapy Tele-Coaching (month) Survey Monitoring

59 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Phase II: Distance Education

60 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Teamwork-Leadership Training  Using Emotional Intelligence  Managing Anger at Work  Resolving Conflicts  Managing Difficult Staff  Managing/Motivating Teams  Managing Frustration  Managing Time  Emotional Self-discipline  Managing Medical Mistakes Constructively

61 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Phase III. Follow-up “Graduation” requires 4 consecutive acceptable Feedback Reports NO RED BEHAVIORS!

62 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Phase IV: Group Program or Treatment

63 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 3 Types of Assessments 1.Individual - Continued disruptive pattern despite progressive warnings 2.Small Group or Section (2-10) A.Individual resists B.Protect identity of subject 3.Department or Hospital Program A.Annual Leadership Feedback Reports

64 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Other Professionals Immigration and Naturalization Service (INS) –Law Enforcement –Naturalization Services Telephone Marketers Hospital Executives Attorneys

65 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Research Findings 1. Do Disruptive Physicians – enrolled in the P.U.L.S.E. Program and other interventions … A. REDUCE their Disruptive behaviors? B. INCREASE Motivating Behaviors? 2. And, if they improve, does it last?

66 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 1. COMPLETED PROGRAM BY Facility or PDP STANDARDS77.19% Completed by Facility Standards (61.40%) Completed by Early PDP Standards (15.79%) 2. WITHDRAWAL -- NOT DUE TO DISRUPTIVE BEHAVIOR10.52% Facility withdrew Physician (5.26%) Physician withdrew Self (5.26%) PDP withdrew (00.00%) 3. EXPELLED -- FOR DISRUPTIVE BEHAVIOR0.00% By Facility (00.00%) By PDP (00.00%) 4. OTHER (INSUFFICIENT INFORMATION)12.28% 160 Disruptive Physicians Participants 74 Active Physicians / 86 Physicians completers

67 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Leadership Improvement in 282 Physicians (Disruptive vs. Normal and Role-Model) after P.U.L.S.E. Feedback from Raters NORMALS (N=97) **At baseline, all groups significantly different at (p) <.01. Baseline 1 vs. follow-up 2 for disruptive physicians: significantly different at (p) <.01. 120.5% Improvement 572% Improvement ROLE MODELS (N=68) (3.5 years) LEADERSHIP INDEX MOST DISRUPTIVE 25% (N=30) DISRUPTIVE (N=117)

68 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Top Improved Behaviors in Disruptives 1.Remains approachable even when stressed out 2.Treats team members with respect 3.Handles difficult team members effectively 4.Is open to suggestions 5.Responds to conflict by working out solutions 6.Adapts to changing policies, procedures, priorities

69 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Underlying Principle

70 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation When you see Roadside Radar, what’s the first thing you do? “Feedback Creates Change!”

71 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Larry Harmon, PhD Director, Physicians Development Program Larry@PdpFlorida.com Curious Questions? Concerned Comments? Interesting Ideas?

72 2007 Annual Conference The Neurobiology of Disruptive Behavior Mick Oreskovich, MD Medical Director and CEO Washington Physicians Health Program

73 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Our every thought Every feeling Every action Is chemically mediated! Disruptive behavior is a chemical event in the brain!

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75 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Transference Countertransference

76 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation How To Deal With The FEAR This Behavior Generates In Us? Acknowledge our counter transference: the set of expectations, beliefs, and emotional responses that we bring to this relationship! Educate ourselves about the causes of this behavior! So that we can move toward seeing this behavior phenomenologically, empathically, and non-pejoratively

77 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Gene-brain-behavior relationships: Evidence that aggression is associated with brain MAO A activity in healthy males. N Alia-Klein1, E. Shumay1, R. Goldstein1, A. Kriplani1, J. Logan1, F. Telang1, B. Williams2, I. Craig2, GJ Wang1, F. Henn1, N. Volkow3 and J. Fowler1 1 Brookhaven Center for Translational Neuroimaging, BNL, Upton, New York; ; 2 Psychological Medicine, Psychiatry, King's College, London, United Kingdom; ; 3 National Institute on Drug Abuse, NIH, Bethesda, Maryland J Nucl Med. 2007; 48 (Supplement 2):262P

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80 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Inside the middle of the brain is the limbic system and the amygdala:

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83 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 1.How we associate things in the world with emotional responses and process emotional information. 2.Allows us to overrule instinctive responses by connecting the cortex’s memories of things to the emotions they engender. 3.Allows us to respond to fear stimuli. Amygdala:

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90 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation About DNA  Six feet in every cell  3.2 billion letters of coding  10 to the 3,480,000,000  More than 5,000 books just to print that #!  10,000 trillion cells…earth to moon and back, again and again

91 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Genetic markers with behavioral correlates Serotonin Transporter Gene (SLC6A4): Chromosome 17q11.2 DRD2 receptor: Chromosome 11q22-q23 Effects of alcohol, BZ, barbiturates Chromosome 4p (GABA-A, GABA-  1) Chromosome 15 (GABA-  3) Serotonin level Chromosome 11 (tyrosine hydroxylase)

92 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation 5-HTTLPR S allele driven amygdala hyper-reactivity to environmental cues Hariri et al., Science 2002

93 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation S allele driven amygdala hyper- reactivity Hariri et al., Science 2002

94 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Hamann, Nature Neuroscience 2005 5-HTTLPR also effects information processing related to temperament between the amygdala and the cortex

95 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation It appears that if we inherit the 5- HTTLPR S allele: A “look” or tone of voice Changes our production of serotonin in our midbrain Fear becomes anger in our amygdala We perceive imminent threat in our forebrain We respond with a maladaptive defensive coping mechanism…ie., raise our voice, swear, and threaten We become the “disruptive doc”

96 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation David T George, MD, Section of Clinical Studies, NIAAA

97 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Our every thought Every feeling Every action Is chemically mediated! Disruptive behavior is a chemical event in the brain!

98 Atlanta, Georgia 2007 Annual Conference Council on Licensure, Enforcement and Regulation Mick Oreskovich, MD moreskovich@wphp.org www.wphp.org


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