Options For Success: Addressing The Behavior

1. Martha E. Brown, MD Professionals Resource Network (PRN) Assistant Medical Director And UF Associate Professor of Psychiatry Addiction Medicine Division Options For Success: Addressing The Behavior

2. This Is Treatable (But Sometimes Hard To Deal With Or Love That Doc) • When the physician who is taking a CME course on the issue, cusses you out and files complaints against you, your assistant, and the CME office because he doesn’t like the course • When they punch a hole in your wall • When they are arrested for hiring people to injure and kill those who have made them mad • When they sue the medical executive committee and it drags on for years (by the way, he lost)

3. Clinical Approaches To The Disruptive Professional

4. What To Do? (Protocol For All Cases) • Confirm facts • Immediately talk with the physician 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 • Many times the physician does not see themselves or their behavior as disruptive

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

6. Step-wise Protocol for Handling Disruption (Level 1) • 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 the executive committee or head of the practice • Talk with the physician (with a witness) and obtain assurances behavior will not reoccur • Mentoring and/or supervision of the physician may be helpful

7. Step-wise Protocol for Handling Disruption (Level 1) • Behavior should be closely watched by executive or a wellness committee and discussed monthly • Strong consideration should be given to using 360 surveys • CME course should be mandated in most cases (MD should allow committee to talk with CME staff)

8. CME Program for Distressed Physicians • Originally developed by Dr. Andy Spickard at the Vanderbilt Center for Professional Health (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 many times has not risen to the point of a formal referral or is an early intervention • 3 days with 1 day follow-ups at 1, 3, and 6 months • Maximum of 47.5 AMA Category I hours

9. CME Course Goals • 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 which was learned in training that contributes to maladaptive patterns

10. CME Only Works For Certain Cases • Physician needs to have some awareness they did something wrong • Physician needs to be willing to attend ALL 6 days of the CME • Physician is willing to try and learn some new skills • CME is beneficial (“finishing class”) for more egregious cases, but only after those physicians have been to treatment

11. Step-wise Protocol for Handling Disruption (Level 2) • 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 • Confirm the facts and document • Call your Physician Health Program (PHP) to discuss whether formal assessment is warranted or if referral to CME might be sufficient in lieu of a more formal report to the PHP at this time (this is a “last chance” option)

12. Step-wise Protocol for Handling Disruption (Level 2) • Brief contract outlining expectations and requirements should be signed by physician (need to include written permission to talk with CME staff or PHP) • 360 surveys definitely should be required • Reports from CME and/or PHP required to come back to executive committee or hospital

13. What To Expect When You Call the PHP • Most states have a PHP (listings can be found at http://www.fsphp.org but how they operate vary state to state • Many PHPs have the ongoing mission to protect the health, safety, and welfare of the public, while at the same time working to get help for and monitor physicians who have problems • PHPs have the ability to help with early identification, intervention, and appropriate referral of physicians who are affected with an impairment

14. What To Expect When You Call The PHP • Most PHPS cover many impairment types including those arising from physical conditions, mental/emotional problems, disruptive behavior, and chemical dependency/abuse • Treatment and monitoring can help physicians obtain the earliest and safest opportunity to reintegrate with the healthcare team while protecting both the confidentiality of the doctor and public safety

15. What To Expect When You Call The PHP • If the physician is willing to seek treatment and the behavior is not a “reportable” event, the physician can remain anonymous to the state Medical Board • Many PHPs will report a physician to the Medical Board if the physician is not cooperative, the behavior continues despite treatment, the behavior is extremely dangerous or egregious • The physician could have their license suspended, disciplined, or revoked if they do not follow treatment recommendations

16. Step-wise Protocol For Handling Disruption (Level 3) • 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 • Group or hospital should call the PHP to report the physician and make sure the referral is made • The physician should also be directed to contact the PHP immediately themselves • Strongly consider suspension of privileges until PHP deems they are safe to practice again • This type of behavior usually results in residential evaluation and treatment

17. Step-wise Protocol For Handling Disruption (Level 3) • Physician will be sent to a program that specializes in evaluating disruptive professionals • Evaluation lasts usually a week • Evaluation may include: • Medical workup with labs, CT/MRI • Psychiatric/substance abuse evaluation • Neuropsychological testing • Drug testing • Collateral information • Simulated patients and cases in the physician’s field

18. Step-wise Protocol For Handling Disruption (Level 3) • Recommendations by evaluation team may include • PHP involvement • Outpatient treatment • Residential treatment • Long-term psychotherapy • 360 evaluations • Direct or indirect supervision and monitoring of the physician’s practice • Inability to practice for an indefinite period of time • Other recommendations as felt needed

19. Stories Of Success And Failure • Physicians do have their license disciplined, suspended, or revoked particularly if they are not cooperative with the PHP or treatment • Unfortunately Medical Boards are less likely at times to discipline based on behavior if there is not demonstrated patient or staff harm • Disruptive physicians are often taking the legal avenue and fighting back (which is not surprising) • Often easier if the hospital and practices have clear guidelines and policies to identify problem behavior and which delineates consequences a physician will face (and physician has agreed to this at beginning of practice in that setting

20. Stories Of Success And Failure • The good news is that studies have begun to demonstrate that addressing the behavior when it first appears can result in positive, dramatic changes in the workplace • 20 physicians labeled as disruptive who went through the Vanderbilt Distressed Physician CME course and consented to be in a study had significant improvements in how others viewed their behavior • At 3 months, the physicians showed an increase in motivating behaviors and impactand a decrease in disruptive behaviors and impact • A 6 month follow-up revealed that 93% of the physicians felt they had a better understanding of how their behavior affected patient care and that the course helped them change their behavior and attitudes

21. Stories Of Success And Failure • Failure-The suing doctor with a personnel file 2 feet tall • Failure-The gun toting doctor who kept a gun in his glove compartment and a bigger one in his trunk • Success-The surgeon and the real estate studying anesthesiologist • Success-The GI surgeon who changed not only in his workplace, but also in his home environment, saving his marriage

22. What We Have Learned • 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 • Disruptive behavior is a patient safety issue and needs to be quickly addressed • An appropriate plan of addressing the behavior must be developed, documented, and implemented

23. What We Have Learned • It is important to understand the systems issues related to an individual’s behavior • Dealing with disruptive behavior in the workplace results in: • Better team communication • Improved patient safety • Increased quality of patient care • Reduced litigation and malpractice claims • Increased staff morale • Not all can be helped or saved

24. REFERENCES • www.drmarthabrown.com • http://www.mc.vanderbilt.edu/root/vumc.php?site=cph • http://www.fsphp.org • Marthabrown@ufl.edu