“Unprofessional and Distressed Resident Physician Behaviors”

Charlene M. Dewey, M.D., M.Ed., FACPAssociate Professor of Medical Education and Administration

Associate Professor of MedicineVanderbilt University School of Medicine

Marshall University Joan C. Edwards School of MedicineAugust 28, 2012

Introduction

• Distressed physicians can have disruptive behavior

• Est. prevalence of disruptive behavior in U.S. MDs is 5% (International similar)

• Focus of attention: disruptive behavior can have destructive impact on:– institutions, staff, and pt care

Samenow, Swiggart, and Spickard. “A CME Course Aimed at Addressing Disruptive Physician Behavior” Physician Executive Jan/Feb, 2008:pg 32-40

Introduction

• Five different state medical societies data demonstrate disruptive behaviors comprise up to 30% of complaints received. *(independent of substance abuse and other forms of impairment)

Samenow, Swiggart, and Spickard. “A CME Course Aimed at Addressing Disruptive Physician Behavior” Physician Executive Jan/Feb, 2008:pg 32-40

Introduction

Disruptive behavior leads to problems with communication which leads to adverse events1

– Communication breakdown factored in OR errors 50% of the time2

– Communication mishaps were associated with 30% of adverse events in OB/GYN3

– Communication failures contributed to 91% of adverse events involving residents4

1) Dayton et al, J Qual & Patient Saf 2007; 33:34-44; 2) Gewande et al, Surgery 2003; 133: 614-621. 3) White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038; 4) Lingard et al, Qual Saf Health Care 2004; 13: 330-334

Introduction Case

Your team standing at the nurses’ station blowing off steam after a rough morning. The upper level resident used a particularly graphic and insulting metaphor to describe one morbidly obese and challenging patient. Everyone laughed at the description. The nurse gives a look of disdain and the residents flips her the bird after she turns her head. You are uncomfortable with the resident’s level of professional conduct.

1. Is this blowing off stress or distressed behavior? Why?

2. What do YOU do?

3. What systems exist to help with complaints and interventions?

4. What does the resident need?

5. How does any system promote or dissuade such behavior?

Goals

The purpose of this session is to discuss unprofessional and distressed behaviors of resident physicians and discuss and share resources and tools for identifying and assisting residents in need.

Objectives

Participants of the session will:1. Discuss the behaviors and consequences of

unprofessional and distressed resident physicians.

2. Discuss and share methods for identifying and addressing unprofessional and distressed behaviors during residency.

3. Practice 1 method of communication when approaching residents with unprofessional conduct.

4. Determine if changes are needed to their policy for identifying, addressing and managing unprofessional conduct by resident physicians.

Agenda

1. Introduction

2. Unprofessional and distressed behaviors

3. Methods and tools for identification and intervention

4. Review & practice DRAN and Cup of Coffee Conversations

5. Program/policy assessments

6. Summary

Ground Rules

• Lecture discussion workshop

• Interactive

• Flexible

• Share experiences

• Time limited

Stressed or Disruptive

Is this blowing off s

tress or d

isruptive behavior?

Stress Reactions

Permission to be human!!!

Flooding

1. Neurological and biochemical event2. Triggers3. Sudden onset: “Like an oncoming

truck”4. Inability to self-soothe or self-regulate5. Tend to keep away or isolate

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.

Flooding

• Things to do when you flood:– Step away from the situation: if possible go into

the restroom– Self-sooth: Breathe, relax– Practice mindfulness techniques

• Things to do after you flooded:– Reflection – triggers, symptoms, event– Seek coaching & mentoring

Disruptive Behavior

• “Behavior or behaviors that undermine a culture of safety.”1

• Disruptive behavior is a sentinel event2

1) The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD.03.01.01, elements of performance (EP) 4 and 5, Spring 2012; 2) Joint Commission, Issue 40 July 9, 2008

Aggressive Passive Passive

Aggressive

Figure 1

Inappropriate anger, threats

Yelling, publicly degrading team members

Intimidating staff, patients, colleagues, etc.

Pushing, throwing objects

Swearing

Outburst of anger &physical abuse

Hostile notes, emails

Derogatory comments about institution, hospital, group,

etc.

Inappropriate joking

SexualHarassment

Complaining,Blaming

Chronically late

Failure to return calls

Inappropriate/inadequate charts

Avoiding meetings & individuals

Non-participation

Ill-prepared, not prepared

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.

Spectrum of Disruptive Behaviors

Etiology of Distressed Behaviors

Individual Factors:• Psychological Factors1:

– Substance use/abuse, FHx, 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

Etiologies of Distressed Behaviors

Institutional Factors:– Scapegoats– System reinforces Behavior– 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

Risk Factors

• Personality types• Lack of self-awareness• Lack of emotional intelligence• Training/experience• Lack of training in coping skills and stress

management• Lack of training dealing with conflict• Your family system• Poor self-care

Introduction Case

What do YOU do?

Warning

Do Nothing Immediate Intervention Report

Lack of authorityLack of protectionUnclear process

Risk of retribution/retaliationLetters of recommendation in future

Concerns of own deficiencies

Barriers to Action

• Fear

• Loyalty

• Culture

• Lack of training

Hickson et al. “The why and how of dealing with special colleagues: discouraging disruptive behaviors.” Center for Patient and Professional Advocacy, Vanderbilt University School of Medicine, October 28-9, 2010.

Reluctance to “betray’Potential loss of recog/reputationImplications for patients loyaltiesLack of incentive to do right

Misuse of informationNeeds a scapegoatLack of…

Conflict management skillsAssertiveness training

Communication training

Assertive Communication

• When asking for something, use the acronym – DRAN

Describe

Reinforce

Assert

Negotiate

Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine.

Describe

• Describe the other person’s behavior objectively – use reflective “I”

• Use concrete terms

• Describe a specified time, place & frequency of action

• Describe the action/behavior, not the “motive”

• Be respectful but avoid minimizing

Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine.

Reinforce

• Recognize the other person’s past efforts• Remember: It takes eight positive comments to

compensate for one negative comment.

Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine. & John Gottman, Ph.D. The Relationship Cure. Crown Publishers, New York, 2001, 74-78

Assert Directly and Specifically

• 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

Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine.

Negotiate

• Work toward a compromise that is reasonable

• 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

Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine.

Tips

• If flooding – make an escape!• Listen• Avoid judgment• Be empathetic but don’t join the pity party• Beware the 7 traps:

• Pulling rank • Expectation of thanks• Adopting their role • Fail to deliver the message• Control contest • Fail to recognize self-issues• Giving to much advice

• End positively

Specific Phrases

• I am coming to you as a colleague.• You are a valued member of the team.• I hear and saw the event…• You may be right.• I know this may be frustrating.• I want to address some concerns I have.• Give me a minute, I’ll get right back to you.

Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine.

Practice DRAN

• Role plays• Use the introduction case• Each person takes turn practicing

DRAN; then switch• You are practicing – mistakes are

ok.• Person listening assess other’s

performance & provides feedback

Dewey et al. “Teaching Professionalism” EDP Workshop, Vanderbilt University School of Medicine, April 2010.

Introduction Case

What systems exist to help with complaints and interventions?

What do we do well?

Introduction Case

What does the resident need?

ACGME

ACGME Competency-Professionalism: Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

• demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development

• demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

• demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

Interventions

• Education– Clear policy

– Rules/regulations

– Ethics/professionalism

– Self-care

• Training & coaching• Assessments (burnout, MH, SU, FFD, BVI, FOO, etc.)

• Monitoring (B29-BMT, pt surveys, intent to change)

• Experiences – witness doing right (role models)

• Emotional intelligence• Referrals

Interventions

• Internal vs. external referrals– EAP– Fitness for duty assessments (MH, SU)

– State physician health program– Out of state programs (education, training, treatment)

Emotional Intelligence

• Self-awareness

• Self-regulation

• Motivation

• Empathy

• Social skills

Goleman, D. “What makes a leader?” HBR 1998:82-91

Self-Awareness

• “First, people need self-awareness to reflect on their behaviors, including their emotional displays, so as to judge them against group norms.”

• “…encourages people to reflect on their actions and understand the extent to which those actions match both personal values and beliefs as well as group standards.”

• How do you teach self-awareness?

Heatherton, TF. “Neuroscience of Self and Self-Regulation.” Annu Rev Psychol 2011:62:363-90.

Self-Regulation

• “The process by which people change thoughts, feelings, or actions in order to satisfy personal and society goals and standards.”

• “Self-regulation involves both the initiation and maintenance of behavioral change in addition to inhibiting undesired behaviors or responding to situational demands.”

• How do you teach self-regulation?

Heatherton, TF. “Neuroscience of Self and Self-Regulation.” Annu Rev Psychol 2011:62:363-90.

Introduction Case

How does any system promote or dissuade such behavior?

Disruptive Behaviors

CycleHorizontal Hostility

PoorCommunication

Reduced PtSafety

Lost of Finances& Reputation

Staff Turnovers

Increase Liability and Risk

Poor Work Environment

Samenow, Swiggart, and Spickard. “A CME Course Aimed at Addressing Disruptive Physician Behavior” Physician Executive Jan/Feb, 2008:pg 32-40; Felps, W et al. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, 2006; 27:175-222.

Failure to Address

• Disruptive behavior leads to problems with communication which leads to adverse events1

– Communication breakdown factored in OR errors 50% of the time2

– Communication mishaps were associated with 30% of adverse events in OBGYN3

– Communication failures contributed to 91% of adverse events involving residents4

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

Failure to Address

• Team members may adopt disruptive person’s negative mood/anger (Dimberg & Ohman, 1996)

• Lessened trust leads to lessened task performance & effects quality and pt safety (Lewicki & Bunker,

1995; Wageman, 2000)

• 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

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.

Joint Commission

Goals:1. Reform health care settings to address the

problem (history of tolerance and indifference)

2. Promote a culture of safety

3. Improve the quality of patient care by improving the communication and collaboration of health care teams

Gundersen, DC. “The Disruptive Physician” Federation of State Physician Health Programs (FSPHP) Annual Meeting Chicago, IL 2010.

The Joint Commission

Requirements:1. EP 4: The hospital/organization has a code of

conduct that defines acceptable and disruptive and inappropriate behaviors.1

2. EP 5: Leadership create and implement a process for managing disruptive and inappropriate behaviors1

• Multiple levels of leadership• Professional/leader training• E.g., CPPA – PARS® at Vanderbilt2

1) The Joint Commission. “Behaviors that undermine a culture of safety.” Issue 40, July 9, 2008 and 2) Center for Patient and Professional Advocacy – Patient Advocacy Reporting System. http://www.mc.vanderbilt.edu/centers/cppa/

Apparent pattern

Single “unprofessional" incidents (merit?)

Disruptive Behavior Pyramid

Mandated Issues

"Informal" Cup of Coffee Intervention

Level 1 "Awareness" Intervention

Level 2 "Authority" Intervention

Level 3 "Disciplinary" Intervention

Pattern persists

No ∆

Vast majority of professionals - no issues

Hickson GB, Pichert JW, Webb LE, Gabbe SG,Acad Med, Nov, 2007

Center for Patient and professional Advocacy at Vanderbilt

Disruptive Behavior Pyramid

The Joint commission

11 Suggestions:1. Educate all team members

2. Hold all team members accountable

3. Develop and implement policies and procedures/processes

4. Develop an organizational process for addressing intimidating and disruptive behaviors

5. Provide skills-based training and coaching for all leaders/managers

6. Develop and implement a system for assessing staff perceptions

The Joint Commission. “Behaviors that undermine a culture of safety.” Issue 40, July 9, 2008

The Joint Commission

7. Develop and implement a reporting/ surveillance system (possibly anonymous) for detecting unprofessional behavior.

8. Support surveillance with tiered, non-confrontational interventional strategies

9. Conduct all interventions within the commitment to the health and well-being of all staff,

10. Encourage inter-professional dialogues

11. Document all attempts to address behaviors

The Joint Commission. “Behaviors that undermine a culture of safety.” Issue 40, July 9, 2008

Recap Intro Case

1. Is this blowing off stress or distressed behavior? Why?

2. What do YOU do?

3. What systems exist to help with complaints and interventions?

4. What does the resident need?

5. How does any system promote or dissuade such behavior?

Take Home Points

1. Disruptive and unprofessional behaviors have significant consequences for many individuals and the institution and thus should not be ignored.

2. Physicians demonstrate unprofessional and disruptive behaviors for many reasons.

3. Provide means for remediation through assessments, education, training, monitoring, self-improvement, role modeling, and referrals.

4. Policies and codes of conduct should be implemented and made clear for all those working within the institution.

Summary

1. Discussed behaviors and consequences of unprofessional and distressed resident physicians.

2. Discussed and shared methods for identifying and addressing unprofessional and distressed behaviors during residency.

3. Practiced 1 method of communication (DRAN) when approaching residents with unprofessional conduct.

4. Determined if changes are needed to the policy for identifying, addressing and managing unprofessional conduct by resident physicians.