1. Clinical Approach to the Disruptive Physician: The Tennessee Experience Anderson Spickard Jr., MD Reid Finlayson, MD Ron Neufeld, LADC Roland Gray, MD Bill Swiggart, MS, LPC/MHSP Charles Samenow, MD, MPH

2. Introduction

3. Distressed Physician Team
Vanderbilt Center for Professional Health
Anderson Spickard, Jr MD -- Director
William Swiggart, MS, LPC/MHSP -- Training Director
Charles Samenow, MD, MPH -- Research Assistant
Ron Neufeld, LADC -- Clinical Assessment, Teaching
Tobi Fischel-Ingram, PhD -- Teaching, Curriculum
Jennifer Blackford, PhD -- Biostatistics
David Dodd, MD -- Teaching
Dianna Phillips -- Administrative
Jan Cao -- Administrative
Vanderbilt Comprehensive Assessment Program
Reid Finlayson, MD
Ron Neufeld, LCSW
Tennessee Medical Foundation
Roland Gray, MD
Vince Parish

4. Research Education, Prevention Advocacy, Outreach
Assessment and Treatment
Education, Prevention
Advocacy, Outreach

5. VANDERBILT COMPREHENSIVE ASSESSMENT PROGRAM …for Professionals
Reid Finlayson, MD
Ron Neufeld, LADC

6. V-CAP MISSION
Providing the highest quality behavioral health evaluation and treatment planning services to professionals in crisis due to addictions, mental health issues, sexual boundary related problems and burnout.

7. Assessment Components
Psychological Testing
MMPI – II; SCT; TAT; PAI; COPE Coping Scale; State-Trait Anger Expression Inventory; DSFI (sexual functioning); GARS (stress)
Psychiatric Evaluation and Addiction Screening
MAST; DAST; SAST; BVI; TSI; BDI; Mini-Mental Status Exam; Flooding self-test

8. Assessment Components, cont’d.
Psychosocial Assessment and Genogram
Nursing Assessment
Lab work and urine drug screen
Other components as needed, including H&P, AASI, Neuropsych workup
Collaborative information from family, peers, administrators, coworkers, etc. with written permission by client
Written report and review session with client and designated others

9. Reasons for Referral

10. Disruptive Referrals Axis I Diagnosis
Intermittent Explosive Disorder
Adjustment Disorder
Impulse Control Disorder
None (or rule out)
Substance Dependence (either active or in remission)

11. Disruptive Referrals Axis II Diagnosis
Personality Disorder, NOS
Narcissistic (and other) traits
Compulsive personality traits
Others

12. Problematic Physicians: A Comparison of Personality Profiles by Offense Type*
88 Physicians evaluated for “Fitness for Duty”
82 male (M age 46.8 / SD=9.5) 6 female (47.5 / 12.2)
80% married; 13% divorced; 7% single
89% White; 5% Black; 4% Hispanic; 1% Asian
A – Behavior Disruptive (anger, demeaning others)
B – Sexual Boundary Violations
C – Others (SUD, emotional instability, etc.)
All 3 groups similar demographics: age, race, marital status (all ps >.05)
* Canadian Journal of Psychiatry 2007 – in press

13. Problematic Physicians MMPI -2 PAI CATEGORIES
A - DISRUPTIVE N = 39
B – SEXUAL N = 25
C – OTHER N = 24
CATEGORY ANALYSIS
MMPI-2: Ds=distress, Ch=character, Nl=normal, nV=invalid
PAI: D=distress, I-interpersonal, AS=antisocial, N=normal

14. Problematic Physicians
A (Disruptive)
Valid profiles, open, high interpersonal dysfunction, admit and rationalize anger
B (Sexual) – FEWEST NORMAL PROFILES
- MOST CHARACTER PATHOLOGY
Impulsive, selfish, low empathy, irresponsible
Exaggerated positive light = Therapeutic Challenge
C (Other)

15. Tennessee Medical Foundation’s Physician Health Program
Roland Gray, MD
Medical Director

16. Statistics for 2002-2006 TOTAL 667 2002-2006 YTD Identifications:
Chemical
335
Behavioral
194
Psychiatric 58
Sexual Boundary 56
Over-prescribing 24
TOTAL
667

17. “Distressed Physician” CME Course
William Swiggart, MS, LPC/MHSP

18. Center for Professional Health
Continuing Medical Education Courses
Prescribing Controlled Drugs
Maintaining Proper Boundaries
Disruptive/Distressed Physician

19. A Program for Distressed Physicians
Physicians appropriate for referral:
Physician is currently working
Physician does not require residential treatment
Physician has some support for change i.e., the State Physician Health Program or institutional or group practice support
This slide outlines the referral criteria we use for physicians referred to the CME course.

20. Differential Diagnosis
Substance abuse or dependence
Medical illnesses
Stress (career choice, personal/family, skills issues,etc.)
Psychiatric disorders
These are the other issues in a physician’s life that we try and assess before referral. We have permission from the physician to call individuals who know the physician to compile a set of collateral information before they come to the CME course.

21. When “a little chat” doesn't work
Mr. Bangsiding felt (and wrongly so) that a little
chat would be enough to stop Bob’s disruptive behavior.

22. A Program for Distressed Physicians (Phase I)
Components:
Comprehensive Evaluation
Screening with additional measures
Trauma (Trauma Symptom Inventory™)
Flooding (Gottman)
Workplace assessment (PULSE)
Phone interview
Collateral interview
The next series of slides illustrate the CME program that we have developed to train distressed physicians. The TSI™ is a good, validated tool to uncover the symptoms of Post Traumatic Stress Disorder (PTSD). The Flooding instrument is a tool used to identify the presence of poor emotional control (angry outbursts, etc.) following a stressful situation. The Physicians-Practitioners Universal Leadership Skills Survey Enhancement (PULSE) is a workplace behavioral assessment that we use to evaluate the effects of our training on the physicians future behavior at the workplace.

23. Flooding After a conflict I want to keep away or isolate for a while.
I can never seem to soothe myself after a conflict.
When I get negative, stopping it is like trying to stop an oncoming truck.
I can never tell when a blowup is going to happen.

24. Flooding
The average flooding score was reduced by 50% from the pre-course test.
Pre-course average = 8.29
Post-course average = 4.06
Range 0-24

25. Components of the Program (Phase II)
Three-day CME course up to 46.5 CME
Didactic lectures - e.g., shame reaction, family of origin connections
Genogram
Teach Specific tools/skills – e.g., grounding skills, Alter sheet, communication strategies
Role-playing
Homework
These are the elements of the three day course.

26. Role Play Exercise Describe an incident you are concerned about.
Who was there?
Pick someone to play you.
A powerful cathartic exercise viewing their behavior from multiple points of view.
Example.

27. Components of the VUMC Program (Phase III)
Three follow-up sessions with the core group over the next six months; importance of group process
Repeat workplace assessment (PULSE)
Workbook (The Anger Book, M McKay, P Rogers, 2000)

28. Characteristics and Behavioral Change in the First 20 Disruptive Physicians
Charles P. Samenow, MD, MPH
Department of Psychiatry
Vanderbilt University Medical Center

29. Demographics Total Physicians Studied = 20
Mean Age: 44.6 (compare to CPH mean age 49)
Age Range:
Predominantly Male (90%) and Caucasian (100%)
60% Married, 30% Divorced (1/2 multiple)
States Represented: 11

30. Specialty Types Emergency Medicine 3 (5%) Family Medicine 2 (10%)
Internal Medicine (Specialty)
6 (30%)
Ob/Gyn
3 (15%)
Pathology
1 (5%)
Pediatrics (General)
Pediatrics (Specialty)
Surgery (General)
Surgery (Specialty)

31. Referral Sources Employer (35%) PHP (35%) Board of Licensure (15%)
Treatment Center (10%)
Self (5%)
Other (5%)

32. Categories of Reported Disruptive Behaviors
Aggressive
Passive
Passive
Aggressive
Anger outburst, verbal threats, swearing (90%)
Physical contact and throwing objects (20%)
Sexual Harassment (10%)
Chronically late, not responding to call (15%)
Inappropriate/inadequate chart notes, not dictating (15%)
Derogatory comments about institution, hospital, group, etc.
Refusing to do tasks (20%)

33. Interventions Confrontation by Practice (95%)
Required Assessment (35%)
Involvement of PHP (35%)
Formal Disciplinary Action (30%)
Board of Licensure Involvement (10%)
Termination (10%)

34. Physician Mental Health
Previous Psychotherapy (65%)
Previous Psychotropic Medications (25%)

35. Study Design Retrospective, Cohort Design Total Physicians: 20
Behavior Measured By PULSE
Motivating Behaviors
Disruptive Behaviors
Motivating Impact on Others
Disruptive Impact on Others
Both Self and “Others” (Colleagues, Staff, Supervisors)

36. Study Design Pre-Course PULSE: 15 3-month Follow-up PULSE: 14
Average # of “Others”: 20

37. General Trends At 3 months, significant changes in all domains
Increased motivating behaviors and motivating impact
Decreased disruptive behaviors and disruptive impact
Changes in behavior reported by “others” more significant than changes reported by self.

38. Mean Motivating Behaviors As Measured by Self and Others
Self p = “Others” p < .001

39. Mean Change in Disruptive Behaviors as Measured by Self and Others
Self p = “Others” p < .001

40. General Trends (Continued)
Analysis of individual physicians demonstrates:
Improvement in 12 of the 14 physicians
Although mean behaviors do not seem severe, most physicians demonstrated severe behavioral problems in one or more domains.
Reports of disruptive behavior was not consistent across setting or those who observed it.

41. Change in Motivating Behaviors for Individual Physicians as Measured by Others

42. Mean % Change in Disruptive Behaviors (by Severity) as Measured by Others

43. Overheads

44. Who is effected? Colleagues 100% Staff (Hospital and/or Practice) 77%
Supervisors 63%
Direct effects on patients are rare

45. General Trends
6-month data demonstrates potential for maintenance or improvement in behavioral change
Limited by small sample size

46. 6-Month Trends for Disruptive Behavior Change as Measured by Others

47. Limitations Most behaviorally severe physicians may not be included
Difficult to determine the role the CME course plays in causing behavioral change
Difficulty in measuring longitudinal change

48. Lessons Learned Program for Distressed Physicians
Anderson Spickard Jr., MD

49. Lessons Learned
Physicians are referred by physician health programs, hospital or practice
Full psychiatric assessment not always necessary
Group process addressed the loneliness of their profession
Participants were younger than other courses
Collateral information was vital
Physicians with narcissistic traits

50. Lessons Learned
A number of them already in outpatient therapy or open to that recommendation by this team as another component to their “recovery”
Some unhappy in their career
Considered good physicians technically
More open than expected
They liked the experiential aspects of the program especially group interaction

51. Lessons Learned
PULSE indicates behavioral change for a subset of physicians is not only possible, but can be maintained.
Even when not statistically significant, large effect sizes and physician testimonials point to a promising intervention
Future studies needed to identify which physicians are most likely to succeed and to understand role that system plays in enabling/facilitating behaviors.