“Creating a Culture of Professionalism” Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Center for Professional Health Vanderbilt University School of Medicine Marshall University Joan C. Edwards School of Medicine August 28, 2012

Professionalism AMA Code of Ethics 1847 ACP Ethics Manual 2005 A Physician Charter: ABIM, ACP, European Federation of Internal Medicine 2007 Stern’s professionalism model Institutional codes of conduct and policies

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.

Professional Health & Wellness Professionalism Clinical Competence (Knowledge of Medicine) Communication Skill Ethical and Legal Understanding Excellence Humanism Accountability Altruism Professionalism Professional Health & Wellness Professional Culture Dewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006

“Personal & Institutional Vitality” Two Systems Interact “Personal & Institutional Vitality” The External System Functional & Nurturing Dysfunctional The Internal System Good Skills & Well Poor Skills &/or Not Well Clinician Work Environment “The Perfect Storm”

Professional vs. Unprofessional

Professional vs. Unprofessional “We judge ourselves by our motives whereas others judge us by our behavior.” ~AA saying

Goals The 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.

Objectives Upon 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.

Agenda Four examples of professionalism lapses Individual & institutional roles Stress & burnout Influencing professional cultures Resources Summary

Center for Professional Health Faculty and Physician Wellness Committee 3 CME accredited professional development programs Distressed Physician Maintaining Proper Boundaries Proper Prescribing CPD ~15 years in training/remeding physicians Demographics: Mandated > voluntary IM, FP - but all specialties Males > females Rural, solo practices > academic health center http://www.mc.vanderbilt.edu/cph

Professional Lapses 661,400 physicians/surgeons in US in 2008 >32,000 sanctions btw 2004 - 2008 (~5-10%) 955 criminal Many uncategorized Many events not reported Physician Survey 2007: 96% agreed physicians should report impaired or incompetent colleagues 45% who encountered such colleagues did not report events Campbell, et al. “Professionalism in Medicine: Results of a National Survey of Physicians” Ann In Med, 2007

Professionalism Lapses Four major professionalism lapses: Distressed/disruptive behaviors Boundary violations Improper prescribing Impairment

Distressed/Disruptive Behaviors

Marshall University School of Medicine - Workshop August 28, 2012 Disruptive Behavior “Behavior or behaviors that undermine a culture of safety.”1 Disruptive behavior is a sentinel event2 The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD.03.01.01, elements of performance (EP) 4 and 5, Spring 2012; Joint Commission, Issue 40 July 9, 2008 Dewey, CM - 2012 Vanderbilt University School of Medicine

Spectrum of Disruptive Behaviors Aggressive Passive Passive Aggressive Inappropriate anger, threats Yelling, publicly degrading team members Intimidating staff, patients, colleagues, etc. Pushing, throwing objects Swearing Outburst of anger & physical abuse Chronically late Failure to return calls Inappropriate/ inadequate chart notes Avoiding meetings & individuals Non-participation Ill-prepared, not prepared Hostile notes, emails Derogatory comments about institution, hospital, group, etc. Inappropriate joking Sexual Harassment Complaining, Blaming Swiggart, 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. 16 16

Distressed/Disruptive Behaviors Etiologies-Individuals: Psychological Factors1: Substance use/abuse, trauma history, religious fundamentalism, familial high achievement MH issues2: Personality disorders, narcissism, depression, bipolar, OCD, etc. Genetic/developmental issues: Asperger’s, non-verbal learning differences, etc. Family systems Stress/physiologic reactions Burnout3 Reduced wellness 1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002

Distressed/Disruptive Behaviors Etiologies-Institutional: System reinforces behavior Leadership ignores problems for productivity Scapegoats Individual pathology may over-shadow institutional pathology Williams and Williams, 2004 Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007

Distressed/Disruptive Behaviors Increase Liability and Risk Poor Work Environment Lost of Finances & Reputation Cycle Horizontal Hostility Poor Communication Reduced Pt Safety Staff Turnovers

Boundary Violations

Boundary Violations Sexual misconduct Sexual harassment Social media Power differential Sexual misconduct Sexual impropriety Sexual violations Sexual harassment Social media Unprofessional, disinhibition, anonymity

Boundary Violations Etiologies: Environment: Individual: Patients: Relaxed professional culture – “slippery slope” Individual: Stress & burnout Lack of self-care Lack of knowledge Patients: Predators & drugs Dewey, Swiggart, Manley, & Spickard. “Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine” – CPH 2011.

Misprescribing CPD

Six Categories of Misprescribing Physicians Dated: Fails to keep current Disabled: Failed judgment due to impairment Duped: Fails to detect Dishonest: Personal or financial gain Dismayed: Rx as a quick fix due to time Dysfunctional: Fails to say no Brown, Swiggart, Dewey, & Ghulyan, “Searching for answers: proper prescribing of controlled prescription drugs.” J Psychoactive Drugs. 2012 Jan-Mar;44(1):79-85.

Misprescribing CPD Rules and guidelines: DEA – “Practitioner's Manual” SMB & FSMB Drug seeking patients – “Confrontational phobia” Prescribing for non-patient colleagues, friends, families Self-prescribing Dewey, Swiggart, Brown, Baron, & Ghulyan, “Proper Prescribing of CPDs: What Every Physician Needs to Know”,submitted 2012

Impairment

Impairment AMA: “…any physical, mental or behavioral disorder that interferes with ability to engage safely in professional activities...” Physical impairment Cognitive impairment Psychological impairment Substance use disorders (licit and illicit drugs) Mental health disorders (depression & suicide) Affects: individual, family, patients, institution AMA Polices Related to Physician Health, 2011 http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf - Accessed 8/13/2012

Impairment “Every physician is responsible for protecting patients from an impaired physician and for assisting an impaired colleague.” ~ACP Ethics Manual Ethics Manual, 5th Edition. American College of Physicians 190 N. Independence Mall West. Philadelphia, PA. 19106-1572

Professionalism Lapses Consequences: Restriction or loss of DEA registration Restricted or loss of medical license Loss of job Law suites and restriction of insurance coverage Loss of relationships – personal and work Loss of self

Unprofessional Conduct Four major professionalism lapses: Distressed/disruptive behaviors Boundary violations Improper prescribing Impairment

Two Systems Interact The External System The Internal System “Personal & Institutional Vitality” The External System Functional & Nurturing Dysfunctional The Internal System Good Skills & Well Poor Skills &/or Not Well Clinician Work Environment “The Perfect Storm”

Clinician

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.

Professional Health & Wellness Spectrum High Functioning High Productivity Fair Functioning Decreasing Productivity Reduced Productivity Relationships Suffer Fair-Not Functioning Fair-Not Productive Institution & Family Loses Burnout Coping Mechanisms Failing Risk of MH issues and suicide No Coping Mechanisms Professionally Healthy & Well Stressed Coping Mechanisms Strong Physical Mental Emotional Spiritual Work & Family Relations Dewey, CM and Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine, 2009. 35

Clinician Health & Wellness Little education on topic 30-60% MD are distressed and at burnout MS & residents ↑ Primary care (IM, FP, ER) MDs suicide > other prof. & gen pop. One physician per day; PhD – unclear Grossly underestimated Depression/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

Clinician Health & Wellness Gender differences: Females > anxiety, depression, burnout F>M MD suicides (>50% vs 40% higher risk) Women chairs more stressed Male physicians (regardless of race) live longer than other professionals Reduced use of care by physician Stigma & anonymity – slow to prioritize MH issues for physicians; licenses, etc. http://www.aamc.org/members/gwims/statistics/stats09/start.htm Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82. (Schindler et al 2006) and “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008 37

Clinician Health & Wellness Academic faculty: Worked longer hours Took less vacation 10% with mild depression 27% with elevated anxiety No sig difference clinical vs. academic Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82. 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 2006 81(1):27-34.

Clinician Health & Wellness Self-care Stress & burnout Emotional intelligence Family systems Training experiences – hidden curriculum Coping skills Conflict management Personality types

Self-Care Seven key areas: Sleep Balanced meals Physical activity Socialization/hobbies Vacations/down times Spiritual engagement Having a personal physician Mind Body Soul Emotion Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010. 40

Stress & Productivity Prolonged Stress Productive Stress Reduced Cognition Prolonged Stress Productive Stress Declining Function “Impairment” ??? No Prolonged Stress Situational Stress Stressed Burnout Non-Functional Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010. 41

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 Maslach The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997 42

Six Sources of Burnout Lack of control Work overload Insufficient reward Unfairness Breakdown of community Value conflict Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” 43

Risk Factors for Burnout Single Gender/sexual orientation ># of children at home Family problems Mid-late career Previous mental health issues (depression) Fatigue & sleep deprivation General dissatisfaction Alcohol and drugs Minority/international Teaching & research demands Potential litigation 1) 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;174:37-41 44

Symptoms of Burnout Chronic exhaustion Cynical and detached Increasingly ineffective at work Leads to: isolation avoidance interpersonal conflicts high turnover Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17 45

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 H-140.886 AMA Polices Related to Physician Health, 2011 http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf - Accessed 8/13/2012

Work Environment

Work Environment Can work environment influence individual health? Stress: physician, environment, patients Environment was the only sig predictor of stress Job stress predicts job satisfaction Job sat is positive predictor of positive mental health Perceived stress was a stronger predictor of both poorer reports of physical and mental health Therefore, environment influenced health Powerful model how practice environment can impact physician health Williams 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):121-43.

Work Environment Institutional factors to address: Inadequate systems & supports1 System reinforces behavior1 Need for a scapegoat1,3 Money/financial benefit1 Culture – more, faster, better, longer2 Failure to recognize costs to individuals, pts, institution3 1) Williams and Williams, 2004; 2) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It.” 1997 3) Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007

Promoting Professionalism “If you keep doing the same thing you always did….you will keep getting the same results you always got!”

Promoting Professionalism Leadership commitment Supportive institutional policies Program or model to guide graduated interventions Surveillance tools to capture allegations Processes for reviewing allegations Interventions Multi-level training Resources to help: Unprofessional colleagues Victims (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.

Promoting Professionalism Medical education & training: focus is cognitive Emotional & self-regulation activities for MS and residents Residency programs need to assess, train/prepare residents for the challenges in medicine1 & provide remediation as needed Faculty development - need training/coaching (emotional intelligence (EI), coping mech., conflict management, early identification, etc.) in order to teach & role model professional behaviors AAMC Council of Deans 2004

Resources

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

Resources Training programs: PACE, Case western, etc. Treatment programs Private counseling services Professional Coaching - Center for Women in Med: Debbie Smith (www.cwmedicine.org) Suicide prevention hotline: 1-800-273-TALK Substance use: (AA, NA, Evelyn Fry, etc.) Community-based wellness programs: YMCA/YWCA, Massage envy, etc. 55

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

Questions & Answers