2. Martha E. Brown, MD PRN Associate Medical Director And UF Associate Professor of Psychiatry Addiction Medicine Division William Swiggart, MS, LPC/MHSP Associate in Medicine Co-Director Vanderbilt Center for Professional Health www.mc.vanderbilt.edu/cph

3. We judge ourselves by our motives others judge us by our behavior. AA saying

4.   Give learners an overview of disruptive/distressed behavior  Provide resources and examples of interventions. Goals

5.   Describe the Joint Commission requirements  List examples of disruptive behavior  Estimate the impact of disruptive behavior  Explore the etiology of disruptive behavior  Discuss the components of a comprehensive evaluation  Apply specific educational approaches  Identify some appropriate resources Disruptive/Distressed Physician Behavior Objectives

6.  Disruptive and Distressed Physicians

7. 2004 AAMC Council of Deans “Physicians are often poorly socialized and enter medical school with inadequate social skills for practice.” “There is a growing body of literature documenting that residency programs do not prepare resident physicians adequately for the practice of medicine.”

8.   Defined disruptive behavior as a Sentinel Event  Recognition that disruptive behavior can:  Foster medical errors  Contribute to poor patient satisfaction  Contribute to preventable adverse outcomes  Increase the cost of care (including malpractice)  Lead to turnover/loss of qualified medical staff Joint Commission, Issue 40 July 9, 2008

9.  Defined by The Joint Commission as: “Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patient’s illness.” Sentinel Events

10.  Goal of including Disruptive Behavior as a Sentinel Event:  Reform health care settings to address the problem  There is a 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 Joint Commission

11.   Hospitals establish a formal Code of Conduct  Leadership creates a process for reporting, evaluating and managing disruptive behavior Joint Commission Requirements

12.   Educate all team members about professionalism  Hold all team members accountable for modeling desirable behaviors  Enforce the code consistently and equitably  Non-confrontational intervention strategies  Progressive discipline Joint Commission Recommendations

13.  Disruptive behavior includes, but is not limited to, words or actions that:  Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution)  Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating)  Threaten personal or group safety, such as aggressive or violent physical actions  Behavior or behaviors that undermine a culture of safety  Violate Vanderbilt University and/or VUMC policies, including those related to conflicts of interest and compliance Definition of Disruptive Behavior Vanderbilt University and Medical Center Policy #HR-027, 2010

14.   An occasional “out of character” reaction of an individual  Lack of perfectionism. No one is perfect  Constructive criticism in good faith with the aim of improving patient care or education  Expressions of concern about a patient’s care and safety  Expressions of dissatisfaction with policies through appropriate grievance channels or other non-personal means Disruptive Behavior Is Not Vanderbilt University and Medical Center Policy #HR-027, 2010

15.  Policies will not work if disruptive behavior goes unreported and unaddressed. 14

16. Aggressive Anger Outbursts Profane/Disrespectful Language Throwing Objects Demeaning Behavior Jokes Physical Aggression Sexual Comments or Harassment Racial/Ethnic Passive Aggressive Derogatory comments about institution, hospital, group, etc. Refusing to do tasks Passive Chronically late Alcohol and other drugs Not responding to call Inappropriate or inadequate chart notes Spectrum of Disruptive Behaviors

17. Case Presentation (1) Dr. A is a 40 year old anesthesiologist referred for evaluation following several angry outbursts in his hospital’s OR. The most egregious (and final) outburst involved his threatening to shoot one of his OR staff. Although he reportedly immediately told staff that he wasn’t serious about the threat, a complaint was filed because he was commonly known to have an extensive gun collection at his home, and this staff member lived in the same neighborhood.

18. Case presentation (2) Dr. B reported that he was chronically fatigued and had been working at nearly twice his normal workload in the three months prior to his assessment. In addition, he reported several incidents involving his anger while in undergraduate school, medical school and residency. He reported no use of medications, and no prior treatment for anger management, except for referral to a psychiatrist over the course of a semester while in school.

19.  “RN did not call MD about change in patient condition because he had a history of being abusive when called. Patient suffered because of this.” Rosenstein, A., O’Daniel, M. Impact and Implications of Disruptive Behavior in the Perioperative Arena. J Am Coll Surg. 2006;203:96-105.

20. But More Common… “___ came late to the meeting, then spent remaining time on a Blackberry… didn’t listen to the discussion” “___ doesn’t exactly say anything you could object to, but always rolls eyes and makes faces in meetings… not helpful…later mocks the discussion…disputes wisdom of decisions” And Increasingly Common “___ writes an online Blog with implied criticisms of some of our units” “___ (resident) puts feelings about patients on Facebook - unnamed, but potentially identifiable” 19

21.  Why bother dealing with disruptive behavior?

22.   Perceptions of inequality when members of the team compare their contributions to those of the disruptive member (Kulik & Ambrose, 1992)  Some team members will decrease their contributions, withdraw (Schroeder et al, 2003; Pearson & Porath, 2005) Failure to Address Disruptive Conduct Leads to: Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.

23.   Team members may adopt disruptive person’s negative mood/anger (Dimberg & Ohman, 1996)  Lessened trust among team members can lead to lessened task performance (always monitoring disruptive person)... effects quality and patient safety (Lewicki & Bunker, 1995; Wageman, 2000)  Financial costs and litigation Failure to Address Disruptive Conduct Leads To: Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.

24.   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 Failure to Address Disruptive Conduct Leads To: Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.

25. Failure to Address Disruptive Conduct Leads To:  disharmony and poor morale 1,  staff turnover 2,  incomplete and dysfunctional communication 1,  heightened financial risk and litigation 3,  reduced self-esteem among staff 1,  reduced public image of hospital 1,  financial cost 1,  unhealthy and dysfunctional work environment 1, and potentially poor quality of care 1,2,3 1. Piper, 2000 2. Rosenstein, 2002 3. Hickson, 2002

26.   Communication breakdown factored in OR errors 50% of the time 2  Communication mishaps were associated with 30% of adverse events in OBGYN 3  Communication failures contributed to 91% of adverse events involving residents 4 Gerald B. Hickson, MD James W. Pichert, PhD Center for Patient & Professional Advocacy Vanderbilt University School of Medicine Disruptive Behavior Leads to Communication Problems…Communication Problems Lead To Adverse Events 1 1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44. 3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038. 2. Gewande et al, Surgery 2003; 133: 614-621. 4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334

27.  Disruptive Behavior Creates  fear  confusion or uncertainty  vengeance vs. those who oppose/oppress them  hurt ego/pride  grief (denial, anger, bargaining)  apathy  burnout  unhealthy peer pressure  ignorance (expectations, behavioral standards, rules, protocols, chain of command, standards of care)  distrust of leaders  dropout: early retirement or relocation  errors  disruptive behavior begets disruptive behavior Vanderbilt University and Medical Center Policy #HR-027

28.  How does this happen??

29.   Lack of Emotional Intelligence  Lack of awareness  Lack of clear boundaries  Multiple triggers  Slippery slope behaviors  Overworked and isolated  Burnout  Multiple etiologies Evolution of distressed physicians risk factors

30. Etiologies Why Might a Medical Professional Behave in Ways that are Disruptive?

31. ©CPPA, 2008 Why Might a Medical Professional Behave in Ways that are Disruptive? 1. Substance abuse and psychiatric issues  Alcohol and Drugs  Psychiatric Disorders including Major Depressive, Bipolar, & Anxiety Disorders 2. Narcissism, perfectionism or other personality traits/disorders 3. Spillover of family/home problems

32. ©CPPA, 2008 Why Might a Medical Professional Behave in Ways that are Disruptive? (cont’d) 4. Poorly controlled anger/Snaps under heightened stress, perhaps due to: a. Poor clinical/administrative/systems support b. Poor mgmt skills, dept out of control c. Back biters create poor practice environments 5. Well, it seems to work pretty well and the system reinforces the behavior 6. No one addressed it earlier (why? See #5) 7. Family of origin issues—guilt and shame 8. Training or poor social skills entering into medicine 9. 10.

33. “The Perfect Storm” PhysicianHospital/Clinic The external system The internal system Two Systems Interact Good skills Poor skills Functional & nurturing Dysfunctional

34. Systems "Every system is perfectly designed to get the results it gets.” BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

35.  Individual Factors  Predisposing Psychological Factors (1)  Alcohol and Drug Family History  Trauma History  Religious Fundamentalism  Familial High Achievement, lack of skills regarding conflict and negotiation and other family of origin patterns  Personality Traits (2)  Narcissism  Obsessive/Compulsive  Physician Burnout (3)  Clinical Skills Satisfactory or Above Average (4) Etiologies 1.Valliant, 1972 2. Gabbard, 1985 3. Spickard and Gabbe, 20024. Papadakis, 2004, 2005

36.  Institutional Factors (1)  Scapegoats  System Reinforces Behavior  Individual Pathology may over-shadow institutional pathology Etiologies Williams and Williams, 2004

37. Methods to Address Behavioral Problems Mr. Bangsiding felt (and wrongly so) that a little chat would be enough to stop Bob’s disruptive behavior.

38.   The role of a comprehensive evaluation  The importance of consequences  Educational programs  Feedback from colleagues, patients, staff, etc.  Monitoring and accountability  External resources Methods to Address Behavioral Problems

40.  Clinical Approaches To The Disruptive Professional

41.   Confirm facts  Immediately talk with the professional and discuss that what happened was not appropriate  Obtain assurances the behavior will not reoccur  Complete a record of the incident and conversation for the personnel file  Closely follow up and monitor their behavior  Do not be intimidated by threats of legal action What to do? (Protocol for all cases)

42.   First time incident of disruptive behavior that is relatively “mild” and not egregious (i.e., routinely failing to complete records in a timely manner affecting patient care, being chronically late, or not answering pages) might be handled by executive committee  CME course should be mandated in most cases (MD should allow committee to talk with CME staff)  Mentoring of professional  Behavior closely watched by executive committee Step-wise Protocol for Handling Disruption

43.   Originally developed at the Vanderbilt Center for Professional Health (now offered at Vanderbilt, University of Florida, and Professional Renewal Center)  Designed to address the specific needs of professionals  whose workplace conduct has become problematic, but not risen to the point of a formal referral  3 days with 1 day follow-ups at 1, 3, and 6 months CME Program for Distressed Physicians

44. Components :  Phone interview  Three-day CME course ( 47.5 AMA PRA Category 1 Credits ™)  Teach Specific tools/skills - e.g., grounding skills, Alter, communication strategies  Three follow-up sessions with the core group over the next six months; importance of group process

45.   Teach specific skills related to preventing disruptive behavior  Promote peer accountability and support  Identify risk factors and prevention strategies  Understand their own behavior and how it affects others  Discuss healthy boundaries and appropriate expression of emotions  Understand socialization of professionals learned in training that contributes to maladaptive patterns  This is NOT treatment, but rather education CME Course Goals

46.   Repeated behavior that disrupts healthcare system or if 1st incident particularly egregious (throwing objects, continual/demeaning language such as profanity/sexual comments) must be addressed more formally  Call your PHP to discuss whether formal assessment is warranted or if referral to CME might be sufficient i n lieu of a more formal report to the PHP at this time  Brief contract outlining expectations/requirements should be signed by professional (include written permission to talk with CME staff or PHP) Step-wise Protocol for Handling Disruption

47.   If behavior reaches a level that there is an immediate risk of harm to patients or staff, then a more formal procedure needs to happen  The professional should be directed to contact their PHP immediately  Strong consideration should be given to suspension of privileges until the PHP deems the professional safe to practice again  This type of behavior usually results in a comprehensive residential evaluation and treatment Step-wise Protocol for Handling Disruption

48.   Professional will be sent to a program that specializes in evaluating disruptive professionals  Multidisciplinary evaluation lasting 1-5 days  Medical workup  Psychiatric/substance abuse evaluation  Psychosocial information including genogram  Neuropsychological testing  Collateral information  Comprehensive report results with recommendations by evaluation team which may include  Outpatient treatment  Residential treatment  Long-term psychotherapy  360 evaluations Comprehensive Evaluation

50. Let’s practice

51. 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, 74-78.

52. John M. Gottman, All Rights Reserved (revised 11/17/03)

54. Scoring: If you answered “yes” to more than eight statements, this is a strong sign that you are prone to feeling flooded during conflict. Because this state can be harmful to you, it’s important to let others know how you are feeling. The antidote to flooding is to practice soothing yourself. There are four secrets of soothing yourself: breathing, relaxation, heaviness, and warmth. The first secret is to get control of your breathing. When you are getting flooded, you will find yourself either holding your breath a lot or breathing shallowly. Change your breathing so it is even and you take deep regular breaths. Take your time inhaling and exhaling. The second secret is to find areas of tension in your body and first tense and then relax these muscle groups. First, examine your face, particularly your forehead and jaw, then your neck, shoulders, arms, and back. Let the tension flow out and start feeling heavy. The secret is to meditate, focusing your attention on one calming vision or idea. It can be a very specific place you go to that was once a very comforting place, like a forest or a beach. Imagine this place as vividly as you can as you calm yourself down. The fourth part is to imagine the body part becoming warm. Flooding - Scoring John M. Gottman, All Rights Reserved (revised 11/17/03)

55.  GROUNDING  Categories exercise  Judge versus describe  Mindfulness with all senses  Breathe SKILLS TO USE WHEN FLOODING

56.   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. Role Play Exercise

57.  When asking for something, use the acronym DRAN D escribe R einforce A ssert N egotiate ASSERTIVE COMMUNICATION GUIDELINES

58.   Describe the other person’s behavior objectively  Use concrete terms  Describe a specified time, place & frequency of action  Describe the action, not the “motive” Describe

59.   Recognize the other person’s past efforts Reinforce

60.   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 Assert Directly & Specifically

61.   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 Negotiate: Work Towards A Compromise That is Reasonable

62.  The 8:1 Ratio Communication *John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.

63. Disruptive behavior Social Systems  If the physician is returned to the institution to practice, it is necessary to ensure that the behavior does not recur.  There is a significant level of recidivism  As high as 20% among “severe offenders” (Grant and Alfred 2007)  Prior behavioral issues are a significant risk factor for later disruption (Papadakis, Arnold, et. al. 2008) BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

64. Disruptive behavior Social Systems  A monitoring system that measures these issues using a 360 ◦ survey.  Early data show the survey to be valid.  The survey was developed to facilitate integration with institutional systems. BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

65.   It is not enough to have good motives; others respond to our behavior.  Physicians are often not given essential feedback about their behavior.  The Team Behavior Survey (B-29) is designed to provide feedback from those we work with. © Swiggart, Williams, and Williams B-29 Survey ©

66.   Communication  Concern for patients and families  Accessibility and timeliness  Work environment  Ethical behavior  Interpersonal behavior & respect for others  System-based practice  Ability to work with other members of the medical team The Survey is Based on the Core Competencies of the ACGME

67. Potential Resources for Healthy Coping  Courses  Coaches, counselors  Comprehensive Evaluation  360° Evaluations  Risk Managers  Physician Wellness  Treatment Centers  Office of General Counsel  State BME  Professional Societies  QI Officers  EAP  Others  State Physician Health Program

68.   There is a need to develop standard, model policies for hospitals and medical practices  Medical student and resident training cultivates many of the disruptive behaviors, as trainees learn from their mentor’s behavior  Many physicians and other professionals come to training “predisposed” to having problems  Information needs to be widely distributed to hospitals and medical practices that this is treatable, saves money, prevents malpractice suits, and that early intervention is best  Disruptive behavior is a patient safety issue and needs to be quickly addressed  Not all can be helped or saved What we have learned?

69.  Please visit our websites http://drmarthabrown.com http://www.mc.vanderbilt.edu University of Florida and Vanderbilt Center for Professional Health