Addressing DisruptivePhysician Behavior

Counseling PeersCounseling Peers

William Hopkinson, MDWilliam Hopkinson, MDOrthopaedic Program Director, Loyola University Medical CenterOrthopaedic Program Director, Loyola University Medical Center

AAOS Fall Meeting, October 19, 2012AAOS Fall Meeting, October 19, 2012

XXX Disclosure XXX

Any opinions expressed in this presentation are solely my own

Retired USA MC

Part-time VA

Full time academic faculty at private university

Member AAOS Committee on Professionalism

Judiciary Committee

No financial conflicts of interest

““SPECIAL BEHAVIORSPECIAL BEHAVIOR””

Disruptive = InappropriateDisruptive = Inappropriate

Interferes with function/flow of workplaceInterferes with function/flow of workplace

If unaddressed, usually escalates.If unaddressed, usually escalates.

Disruptive Behavior ExamplesDisruptive Behavior Examples

YellingYelling

Profanity/Verbal abuseProfanity/Verbal abuse

Threatening body gesturesThreatening body gestures

Failing to adhere to usual authority, such Failing to adhere to usual authority, such as:as:– Not providing IDNot providing ID– Not participating in Time OutNot participating in Time Out– Not returning calls/pagesNot returning calls/pages

More Serious BehaviorMore Serious Behavior

ThreateningThreatening– Physical actions just short of contactPhysical actions just short of contact– Oral/ written /implied threatsOral/ written /implied threatsLegally defined as assaultLegally defined as assault

ViolentViolent– Physical behavior or specific threats of physical Physical behavior or specific threats of physical

harmharm– Harmful or offensive contactHarmful or offensive contactLegally defined as batteryLegally defined as battery

Is there a rationale for DB?Is there a rationale for DB?

Surgical Stress/ Frustrations Surgical Stress/ Frustrations -Increased complexity/ more regulations-Increased complexity/ more regulations-High volumeHigh volume-Low marginLow margin

of errorof error

Reason for DBReason for DB

Substance abuse/psych issuesSubstance abuse/psych issues

Narcissism/perfectionismNarcissism/perfectionism

Personal issuesPersonal issues

Reasons for Tolerating DB

None……but– Majority of surgeons are non-confrontational– Respect/tolerance of “rainmakers”– Rationalizing behavior– “Not my …..” problem /patient/ resident/ issue– If I ignore, maybe the problem will go away– ETC

Perception is RealityPerception is RealityWhat they think

they are

What others see

Why deal with disruptive behavior?Why deal with disruptive behavior?EasyEasy

Directly linked to adverse eventsDirectly linked to adverse events

Professionalism issueProfessionalism issue

LawsuitsLawsuits

Poor moralePoor morale

How to deal with disruptive behavior?How to deal with disruptive behavior?The Hard PartThe Hard Part

Pyramid upside downPyramid upside down

My ExperienceMy Experience

Department Vice-ChairDepartment Vice-Chair

Residency Program DirectorResidency Program Director

Professional Standards and Peer Review Professional Standards and Peer Review Committee, LoyolaCommittee, Loyola

Loyola PARS ProgramLoyola PARS Program– Co-chair and mentorCo-chair and mentor

AAOS Committee on ProfessionalismAAOS Committee on Professionalism

My Experience in the trenchesMy Experience in the trenches

One-on-one- peer interactionsOne-on-one- peer interactions

Authority figureAuthority figure

Our local PARS activityOur local PARS activity

LUMC Professionalism CommitteeLUMC Professionalism Committee

AAOS COP and Judiciary CommitteeAAOS COP and Judiciary Committee

Cup of coffeeCup of coffeeconversationconversation

Why – behavior notedWhy – behavior noted

When – soonWhen – soon

Where – safe/quiet placeWhere – safe/quiet place

How – balance empathy and objectivityHow – balance empathy and objectivity

stay on messagestay on message

Expectations Self-correctionExpectations Self-correction

Cup of coffee conversationCup of coffee conversation

To be meaningful – stay on topicTo be meaningful – stay on topic

Avoid the following tendenciesAvoid the following tendencies– Control contestControl contest– ““Curbside therapy”Curbside therapy”– EnablingEnabling– ““Oh, by the way, now that we are here……”Oh, by the way, now that we are here……”

Can an authority figure do this?Can an authority figure do this?Can you do this to the boss?Can you do this to the boss?

Yes – Yes – with carewith care

– Non-judgmentalNon-judgmental– Empathy and objectivityEmpathy and objectivity– Focus on the behaviorFocus on the behavior

Perception is realityPerception is reality

Prepare for full range of Prepare for full range of responsesresponses

When a lot of coffee doesn’t When a lot of coffee doesn’t workwork

CreCre

Self-creating an improvement plan

Local Hospital Task Force

Generating a report

Review by Committee of Peers

Actions taken can range from– No action– Fines– Mandated activities – local/national programs– Dismissal

The Loyola PARS ProgramThe Loyola PARS Program

Using “unsolicited” patient complaints to Using “unsolicited” patient complaints to measure physician riskmeasure physician risk

At Loyola, 2 co-chairs and 20 mentorsAt Loyola, 2 co-chairs and 20 mentors

Program started in 2003Program started in 2003– Mentor selection and trainingMentor selection and training– Assigning mentorsAssigning mentors– Annual updateAnnual update

Conceptual Framework – ProfessionalismConceptual Framework – Professionalism Professionals commit to:Professionals commit to:

Technical and cognitive excellenceTechnical and cognitive excellence

Professionals also commit to:Professionals also commit to: Clear and effective communicationClear and effective communication Modeling respectModeling respect Being availableBeing available

Professionalism promotes teamworkProfessionalism promotes teamwork

Professionalism demands self-regulationProfessionalism demands self-regulation

PARS: Reducing Malpractice Risk, PARS: Reducing Malpractice Risk, Professionalism and Self-RegulationProfessionalism and Self-Regulation

Loyola PARS ExperienceLoyola PARS Experience

2003-20112003-2011 Phys. Interventions Phys. Interventions No.No.

2003-20072003-2007 First InterventionsFirst Interventions 28 2820082008 First Interventions First Interventions 9 920092009 First InterventionsFirst Interventions 7 720102010 First InterventionsFirst Interventions 7 720112011 Proposed First YearProposed First Year 6 6

(Excluding 1 Recidivist) (Excluding 1 Recidivist) TotalTotal 5757

Results to date - LUMCResults to date - LUMC

Total # high complaint physiciansTotal # high complaint physicians 57 57First follow-up in First follow-up in ’’1212 6 6Departed After Initial InterventionDeparted After Initial Intervention 4 4Total with follow-up resultsTotal with follow-up results 47 47Results for those with follow-up data:Results for those with follow-up data: Good – Intervention visits suspendedGood – Intervention visits suspended 21 21 (45%)(45%) Good – Anticipate suspension in Good – Anticipate suspension in ’’1212 9 (19%) 9 (19%) Some improvement -- Still need tracking 1Some improvement -- Still need tracking 1 (2%)(2%)

SubtotalSubtotal 31 31 (66%)(66%)Unimproved/worseUnimproved/worse 14 14 (30%)(30%)Departed UnimprovedDeparted Unimproved 2 2 (4%)(4%)Total follow-up results Total follow-up results 47 47

AAOS Standards of Professionalism

6 SOPs establishing “minimum standards of acceptable conduct for Orthopaedic surgeons”

Each SOP has an aspirational statement with one or more mandatory standards

AAOS SOPsAAOS SOPs

Covers a range of professional topicsCovers a range of professional topics

One AAOS member files a grievance One AAOS member files a grievance against anotheragainst another

All other administrative actions should All other administrative actions should have been completedhave been completed

SOP on Professional SOP on Professional RelationshipsRelationships

AspirationalAspirational– Good relationships among physicians, nurses, Good relationships among physicians, nurses,

and other health care professionals are and other health care professionals are essential for good patient careessential for good patient care

– The orthopaedic surgeon should promote the The orthopaedic surgeon should promote the development and utilization of an expert development and utilization of an expert health care team that will work together health care team that will work together harmoniously to provide optimal patient care.harmoniously to provide optimal patient care.

SOP on Professional SOP on Professional RelationshipsRelationships

Mandatory standards: Mandatory standards:

An Orthopaedic surgeon:An Orthopaedic surgeon:– Shall maintain fairness, respect, and Shall maintain fairness, respect, and

appropriate confidentiality…appropriate confidentiality…– Shall conduct themselves in a professional Shall conduct themselves in a professional

manner in interactions…manner in interactions…– Shall work collaboratively with others to Shall work collaboratively with others to

reduce medical errors, increase patient reduce medical errors, increase patient safety, and optimize outcomes …safety, and optimize outcomes …

Professional Compliance Professional Compliance ProgramProgram

Actions to date (April 2012)Actions to date (April 2012)

125 grievances submitted125 grievances submitted

47 COP Hearings47 COP Hearings

21 Appeals to Judiciary Committee21 Appeals to Judiciary Committee

ResultsResults– 18 No action18 No action– 2 Letters of concern2 Letters of concern

Grievances Filed by SOPGrievances Filed by SOP

Providing MS Services 3

Professional Relationships 9

Expert Witness Testimony 94

Expert Opinion 9

Research/academic responsibility

0

Advertising 9

Conflicts of interest 1

AAOS Professionalism ProgramAAOS Professionalism Program

30 Official Actions of AAOS BOD30 Official Actions of AAOS BOD

7 Censures7 Censures

23 Suspensions 23 Suspensions

Ranging from months to 3 yearsRanging from months to 3 years

0 Expulsions0 Expulsions

SummarySummary

Disruptive behavior is Disruptive behavior is disabling to health caredisabling to health care

An organized process can be An organized process can be effectiveeffective

It starts with one-on-oneIt starts with one-on-one

Elimination of DB requires an Elimination of DB requires an organizational commitment organizational commitment

We all need to be involvedWe all need to be involved