Presentation on theme: "“Creating a Culture of Professionalism”"— Presentation transcript:
1 “Creating a Culture of Professionalism” Charlene M. Dewey, M.D., M.Ed., FACPAssociate Professor of Medical Education and AdministrationAssociate Professor of MedicineCenter for Professional HealthVanderbilt University School of MedicineMarshall University Joan C. Edwards School of MedicineAugust 28, 2012
2 Professionalism AMA Code of Ethics 1847 ACP Ethics Manual 2005 A Physician Charter: ABIM, ACP, European Federation of Internal Medicine 2007Stern’s professionalism modelInstitutional 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 ProfessionalismClinical Competence (Knowledge of Medicine)Communication SkillEthical and Legal UnderstandingExcellenceHumanismAccountabilityAltruismProfessionalismProfessional Health & WellnessProfessional CultureDewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006
5 “Personal & Institutional Vitality” Two Systems Interact“Personal & Institutional Vitality”The External SystemFunctional& NurturingDysfunctionalThe Internal SystemGood Skills& WellPoor Skills&/or Not WellClinicianWork Environment“The Perfect Storm”
7 Professional vs. Unprofessional “We judge ourselves by our motives whereas others judge us by our behavior.”~AA saying
8 GoalsThe 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 ObjectivesUpon 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 rolesStress & burnoutInfluencing professional culturesResourcesSummary
11 Center for Professional Health Faculty and Physician Wellness Committee3 CME accredited professional development programsDistressed PhysicianMaintaining Proper BoundariesProper Prescribing CPD~15 years in training/remeding physiciansDemographics:Mandated > voluntaryIM, FP - but all specialtiesMales > femalesRural, solo practices > academic health center
12 Professional Lapses 661,400 physicians/surgeons in US in 2008 >32,000 sanctions btw (~5-10%)955 criminalMany uncategorizedMany events not reportedPhysician Survey 2007:96% agreed physicians should report impaired or incompetent colleagues45% who encountered such colleagues did not report eventsCampbell, 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 behaviorsBoundary violationsImproper prescribingImpairment
15 Marshall University School of Medicine - Workshop August 28, 2012Disruptive Behavior“Behavior or behaviors that undermine a culture of safety.”1Disruptive behavior is a sentinel event2The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD , elements of performance (EP) 4 and 5, Spring 2012;Joint Commission, Issue 40 July 9, 2008Dewey, CM Vanderbilt University School of Medicine
16 Spectrum of Disruptive Behaviors AggressivePassivePassiveAggressiveInappropriate anger,threatsYelling, publicly degradingteam membersIntimidating staff,patients, colleagues, etc.Pushing, throwing objectsSwearingOutburst of anger &physical abuseChronically lateFailure to return callsInappropriate/inadequate chart notesAvoiding meetings & individualsNon-participationIll-prepared, not preparedHostile notes, sDerogatory comments about institution, hospital, group, etc.Inappropriate jokingSexualHarassmentComplaining,BlamingSwiggart, Dewey, Hickson, Finlayson. “A Plan for Identification, Treatment, and remediation of Disruptive Behaviors in Physicians.” Frontier's of Health Services management, 2009; 25(4):3-11.1616
18 Distressed/Disruptive Behaviors Etiologies-Institutional:System reinforces behaviorLeadership ignores problems for productivityScapegoatsIndividual pathology may over-shadow institutional pathologyWilliams and Williams, 2004Sutton, 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 RiskPoor Work EnvironmentLost of Finances& ReputationCycleHorizontal HostilityPoorCommunicationReduced PtSafetyStaff Turnovers
21 Boundary Violations Sexual misconduct Sexual harassment Social media Power differentialSexual misconductSexual improprietySexual violationsSexual harassmentSocial mediaUnprofessional, disinhibition, anonymity
22 Boundary Violations Etiologies: Environment: Individual: Patients: Relaxed professional culture – “slippery slope”Individual:Stress & burnoutLack of self-careLack of knowledgePatients:Predators & drugsDewey, Swiggart, Manley, & Spickard. “Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine” – CPH 2011.
24 Six Categories of Misprescribing Physicians Dated:Fails to keep currentDisabled:Failed judgment due to impairmentDuped:Fails to detectDishonest:Personal or financial gainDismayed:Rx as a quick fix due to timeDysfunctional:Fails to say noBrown, 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 & FSMBDrug seeking patients – “Confrontational phobia”Prescribing for non-patient colleagues, friends, familiesSelf-prescribingDewey, Swiggart, Brown, Baron, & Ghulyan, “Proper Prescribing of CPDs: What Every Physician Needs to Know”,submitted 2012
27 Impairment AMA: “…any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities...”Physical impairmentCognitive impairmentPsychological impairmentSubstance use disorders (licit and illicit drugs)Mental health disorders (depression & suicide)Affects: individual, family, patients, institutionAMA 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 ManualEthics Manual, 5th Edition. American College of Physicians 190 N. Independence Mall West. Philadelphia, PA
29 Professionalism Lapses Consequences:Restriction or loss of DEA registrationRestricted or loss of medical licenseLoss of jobLaw suites and restriction of insurance coverageLoss of relationships – personal and workLoss of self
30 Unprofessional Conduct Four major professionalism lapses:Distressed/disruptive behaviorsBoundary violationsImproper prescribingImpairment
32 Two Systems Interact The External System The Internal System “Personal & Institutional Vitality”The External SystemFunctional& NurturingDysfunctionalThe Internal SystemGood Skills& WellPoor Skills&/or Not WellClinicianWork Environment“The Perfect Storm”
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 FunctioningHigh ProductivityFair FunctioningDecreasing ProductivityReduced ProductivityRelationships SufferFair-Not FunctioningFair-Not ProductiveInstitution & Family LosesBurnoutCoping MechanismsFailingRisk of MH issues and suicideNo Coping MechanismsProfessionally Healthy& WellStressedCoping Mechanisms StrongPhysicalMentalEmotionalSpiritualWork &FamilyRelationsDewey, CM and Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine, 2009.35
36 Clinician Health & Wellness Little education on topic30-60% MD are distressed and at burnoutMS & residents↑ Primary care (IM, FP, ER)MDs suicide > other prof. & gen pop.One physician per day; PhD – unclearGrossly underestimatedDepression/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, burnoutF>M MD suicides (>50% vs 40% higher risk)Women chairs more stressedMale physicians (regardless of race) live longer than other professionalsReduced use of care by physicianStigma & 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, 200837
38 Clinician Health & Wellness Academic faculty:Worked longer hoursTook less vacation10% with mild depression27% with elevated anxietyNo sig difference clinical vs. academicLin 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.
40 Self-Care Seven key areas: Sleep Balanced meals Physical activity Socialization/hobbiesVacations/down timesSpiritual engagementHaving a personal physicianMindBodySoulEmotionDewey, 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 CognitionProlonged StressProductive StressDeclining Function“Impairment” ???No Prolonged StressSituational StressStressedBurnoutNon-FunctionalDewey, 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 MaslachThe Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 199742
43 Six Sources of Burnout Lack of control Work overload Insufficient rewardUnfairnessBreakdown of communityValue conflictMaslach & Leiter, “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.”43
44 Risk Factors for Burnout SingleGender/sexual orientation># of children at homeFamily problemsMid-late careerPrevious mental health issues (depression)Fatigue & sleep deprivationGeneral dissatisfactionAlcohol and drugsMinority/internationalTeaching & research demandsPotential litigation1) 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;174:37-4144
45 Symptoms of Burnout Chronic exhaustion Cynical and detached Increasingly ineffective at workLeads to:isolationavoidanceinterpersonal conflictshigh turnoverMaslach & Leiter, “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 1745
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 HAMA Polices Related to Physician Health, Accessed 8/13/2012
48 Work Environment Can work environment influence individual health? Stress: physician, environment, patientsEnvironment was the only sig predictor of stressJob stress predicts job satisfactionJob sat is positive predictor of positive mental healthPerceived stress was a stronger predictor of both poorer reports of physical and mental healthTherefore, environment influenced healthPowerful model how practice environment can impact physician healthWilliams 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 & supports1System reinforces behavior1Need for a scapegoat1,3Money/financial benefit1Culture – more, faster, better, longer2Failure to recognize costs to individuals, pts, institution31) 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 commitmentSupportive institutional policiesProgram or model to guide graduated interventionsSurveillance tools to capture allegationsProcesses for reviewing allegationsInterventionsMulti-level trainingResources to help:Unprofessional colleaguesVictims (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 cognitiveEmotional & self-regulation activities for MS and residentsResidency programs need to assess, train/prepare residents for the challenges in medicine1 & provide remediation as neededFaculty development - need training/coaching (emotional intelligence (EI), coping mech., conflict management, early identification, etc.) in order to teach & role model professional behaviorsAAMC Council of Deans 2004
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 programsPrivate counseling servicesProfessional Coaching - Center for Women in Med: Debbie Smith (www.cwmedicine.org)Suicide prevention hotline: TALKSubstance 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