“Creating a Culture of Professionalism”

1. “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

2. 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

3. 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.

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

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

6. Professional vs. Unprofessional

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

8. 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.

9. 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.

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

11. 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

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

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

14. Distressed/Disruptive Behaviors

15. 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

16. 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.

17. 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

18. 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

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

20. Boundary Violations

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

22. Boundary Violations • Etiologies: • Environment: • 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.

23. Misprescribing CPD

24. Six Categories of Misprescribing Physicians Brown, Swiggart, Dewey, & Ghulyan, “Searching for answers: proper prescribing of controlled prescription drugs.” J Psychoactive Drugs. 2012 Jan-Mar;44(1):79-85.

25. 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

26. Impairment

27. 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

28. 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

29. 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

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

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

33. Clinician

34. 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.

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

36. 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.

37. Clinician Health & Wellness 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 • 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.

38. Clinician Health & Wellness 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. • Academic faculty: • Worked longer hours • Took less vacation • 10% with mild depression • 27% with elevated anxiety • No sig difference clinical vs. academic

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

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

41. Stress & Productivity Reduced Cognition Productive Stress “Impairment” ??? No Prolonged Stress Declining Function 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.

42. 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

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

44. 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

45. 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

46. 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

47. Work Environment

48. 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.

49. 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

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