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1 Methods of Assessment Myths of Invincibility Origins of Disruption and Distress in Physicians John R. Whipple, MD; Scott Stacy, PsyD; Peter Graham, PhD; Monica Söderberg, LSCSW Myths & Stories Fitness to practice assessments for disruptive and distressed physicians consist of a multi-disciplinary evaluation that includes review of collateral information from the referral source, face to face interviews with the physician, computer generated personality and symptom questionnaires, urine drug screens and in some cases, therapeutic polygraph interviews. At Acumen Assessments, the Rorschach Inkblot Method (RIM) and Shedler- Westen Assessment Procedure (SWAP-200) are used with other standardized psychological tests to obtain a comprehensive profile of the clinicians current state of mental functioning. This multiple dimensional approach to diagnostic conceptualization of a doctor’s difficulties allows for targeted intervention that promotes sustainable change. Myth of the Savior II: “I’d rather be right than liked!” Presenting Complaints: Oppositional Defiance, Hyper-critical of others and Undermining administrative efforts, Controlling Motivational Themes: Self-righteous, morality bolsters self-esteem Developmental Etiology: Over-identification with Idealized Parental Figures (Acute Distress) Axis I: Dysthymia, primary, early onset My Story--Introduction As a son of a plastic surgeon, I grew up idealizing the life of a physician. From a young man's perspective, I admired the autonomy my father and his colleagues seemed to have to conduct their careers as they wished. They seemed to tackle life or death decisions with grace, humor and dignity. Popular media perpetuated this myth as “Marcus Welby, MD” showed doctors seriously debating ethical and medical dilemmas with equanimity and always a happy ending to every episode. Even “M.A.S.H” characterized doctors in a positive light as they performed “meatball surgery” and superseded the authority of the US military to address the traumas of war. I have gone from wanting to emulate the heroes of my childhood to appreciating the unique challenges of a life in medicine. Beginning with the rigors of medical school at the University of Virginia, I began to realize that being a doctor was not as easy as it looked. During my third year rotations, I also came to realize that there was more to healing than procedures or prescriptions. I was struck with the traumatic adjustments patients and doctors go through as they fight through episodes of illness. Their stories and the interpersonal conflicts inspired my decision to become a psychiatrist. I entered residency training at the Karl Menninger School of Psychiatry in 1987 and became a staff psychiatrist at Menninger in 1990. It was at Menninger that I was first confronted with the struggles of other doctors, who presented for outpatient assessments due to boundary violations, psychiatric complaints or chemical dependency problems. This early introduction to doctors in distress eventually lead to my current position as medical director at Acumen Institute in Lawrence, KS. Along the way, I have also worked as the medical director of an inpatient psychiatric facility and a community mental health clinic. These forays into administrative leadership positions provided me with a unique view of health care delivery and the institutional challenges that an organization faces as it interfaces with strong-willed physicians. As a psychiatrist who assesses and treats impaired, emotionally distressed and disruptive physicians, I want to share my insights into the doctors’ struggles as their human vulnerabilities confront the ‘myths of invincibility’. These medical myths, furthermore, continue to inform the expectations of doctors even as their roles change in modern medicine. While they are still expected to be at the beck and call of their patients or institutions, doctors, in many cases, are also placed into double bind situations of ‘felt helplessness’ that jeopardize both the physician's professional integrity as well as their personal health. This conflict, both internal and external, leads to the high rates of suicide, divorce, substance abuse, and disruptive conduct documented in the physician wellness literature. In this presentation, developmental and present day risk factors that contribute to physician burn out and impairment will be discussed. Motivational themes, intentions and personal myths will be shared as gleamed from the case histories of representative physicians in distress seen through the work at Acumen Assessments and Acumen Institute (n=608). By sharing the stories of real doctors who are struggling as well as the intra-psychic factors that drive them, this presentation may help inform executive decisions that allow for sustainable well-being in all the parties involved. Finally, my story would not be possible without the collaboration and companionship of my brilliant partners: Scott Stacy, PsyD; Peter Graham, PhD and Monica Söderberg, LSCSW. This poster represents a sampling of our work together. Myth of the Savior I: “I must protect the innocent!” Presenting Complaints: Hostility, Anger Dyscontrol, Disorganization of time, neglect of administrative tasks Motivational Themes: Identification with the Victim Developmental Etiology: Unresolved Childhood Trauma (Acute Distress) Axis I: PTSD, Major Depressive Disorder. Figure 1: Personality Disorder (Axis II) T-Scores The Different Faces of Distress N=608 Physicians Impaired: Disturbance of Conduct due to physical, mental or Substance abuse disorder. Disruptive: Disturbance of Conduct noticed by others that impacts clinical relationships. Distressed: Subjectively experienced disturbance in well being or function. The Origins of the complaint impacts intervention The Intensity of Distress impacts level of care!! Figure 2: Factor T-Scores (Shedler & Westen [2004b] factor scores) Characterologically based negativity and hyper-vigilant anxiety predominates as these doctors anticipate attack, exploitation or abandonment. These doctors’ are preoccupied with persecutory fantasies, tend to distort others’ intentions and project self-critical elements onto others. As such, verbal attacks occur on others for perceived neglect when, in fact, the doctors fall short of their professional obligations. These physicians feel victimized and while they identify with those persecuted by others, they are not aware of their tendency to persecute in response. They disavow identification with the aggressor but hostility permeates interpersonal functioning. Past traumatic experiences and their basic lack of trust in others to provide nurturing validation informs anaclitic and melancholic depressive tendencies. Schizoid withdrawal to avoid further intrusion by perceived dangerous interactions maintains their psychological status quo and prevents positive reparative experiences from occurring. Alternatively, histrionic or hysterical dynamics are pervasive as the physicians seek out external containment even as they push others away. Implications: Administrators and clinicians will do well to note that these physicians are inclined to minimize feelings of helplessness and resulting anxiety because it is hard for them to admit that they need others help. Whenever resentment or feelings of being mistreated are identified by the physician, feelings of helplessness and unresolved dependency needs fuel their rage. Their unresolved longings for assistance needs to be highlighted throughout treatment/coaching. In the absence of nurturing support/validation, the agitated, dysthymic state of mind and suspiciousness about others’ intentions is maintained by a conditioned response. Figure 1: Personality Disorder (Axis II) T-Scores Figure 2: Factor T-Scores (Shedler & Westen [2004b] factor scores) Typically, these physicians feel as if the department or institution does not have enough quality resources, and that physicians are expected to do too much with too little. They feel decisions are made contrary to their opinions as if they are not heard. Psychological testing suggests a poverty of warmth, joy or internalized feelings of nurturance. In this absence, interpersonal slights and demands subsequently are not balanced by self-soothing affects that carry the moment or discharge burden. Thought process tends to be overly complex, muddled and bound up in rather obsessive attention to insignificant or obscure details. This type of thinking lends itself to privately elaborating self-determined priorities that exclude the needs of others. In fact, they alienate others since they do not understand why others do not see the problems like they do—e.g. the right way. Implications: These physicians tend to make things more complicated than necessary and in the process, lose sight of the interpersonal context of fostering positive collaboration. These doctors struggle with their inefficiency and project these shortcoming onto clinical teams. In this way, the “system” is defective instead of their mental alertness, cognitive processing and narrow perspective. Setting limits on the scope of professional activities may be needed to decrease their tendency get involved in everything. These physicians want an external “action plan” that eliminates their deficiency. Administrators and clinicians need to acknowledge imperfection in medical delivery systems and help them accept it. Dismissing the imperfections fuels their self righteousness. Fairness is also paramount to gaining their respect. As such, consequences for mistakes have to be consistent. They must understand that their role is to work within the system; not fix it. The Myth of Invincibility: “If I don’t do it no one will!” Present Complaints: Arrogance, condescending, impulsively angry, Clinical “bully” Motivational Themes: Grandiosity and compulsive activity hides emotional vulnerabilities Developmental Etiology: Driven to success, victims of bullying and over-idealization of larger than life mentors (Acute Distress) Axis I: Bipolar Spectrum, ADHD Figure 1: Personality Disorder (Axis II) T-Scores Figure 2: Factor T-Scores (Shedler & Westen [2004b] factor scores) These physicians justify their risks or their conduct because they feel as if they work with patient populations that have few alternatives or that they are the best at what they do. Their grandiosity can escalate, under duress, into frank hypomania. On psychological testing, these physicians clearly elevate into pathological levels of narcissism. They cannot understand why others’ see them as disruptive to care, since they feel that their medical mission is far more important than ‘petty’ complaints about them. The self vs. others’ experience-perception is related to tendencies to disavow negative emotional experience through compulsive, self-assertive action. They pursue their agenda with a determined, head down, “full speed ahead” demeanor that ignores the sensitivities or concerns of others. Impulsive or reactive episodes of anger occur if others’ interfere or question their approach to practice. Their compulsive, domineering style keeps them unaware of their own emotional needs as well as those of others. Implications: These physicians need clear, set limits to their professional activities, which may cause a double bind for the institution, since they tend to be high producers. Limiting “add-ons” to their schedule–make them choose which procedure is most critical- - or elective procedures the day after call may help. Do not extend the clinical day for their urgency. Appealing to their narcissism and mirroring their value is key but their disruptive conduct must be condemned. These doctors can be effective leaders, which may be a carrot to use, but they must model professional conduct prior to promotions. 1.Shedler, J & Westen,D. (2004b) Refining DSM-IV Personality Disorder diagnosis: Integrating Science & Practice, Amer. J. of Psychiatry 149, 358-362. 2.Stacy, S., Graham, P., Athey, G. (2008). The Use of the Rorschach in Professional Fitness to Practice Evaluations. In Gacono, C., Evans, B., & Kaser-Boyd, N. (Eds.), The Handbook of Forensic Rorschach Psychology. Mahwah, NJ: Lawrence Erlbaum Associates.

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