SOME ADDIONAL THOUGHTS ON DISRUPTIVE AND IMPAIRED PROFESSIONALS

1. SOME ADDIONAL THOUGHTS ON DISRUPTIVE AND IMPAIRED PROFESSIONALS Betsy White Williams, Ph.D., M.P.H. Michael V. Williams, Ph.D. Prepared to support: Dealing with Disruptive or Impaired Practitioners an AHLA Teleconference January 28, 2010

2. Quick background • Betsy White Williams, Ph.D., M.P.H. • EDUCATION AND TRAINING: • Betsy White Williams received her bachelors’ degree in psychology from Wellesley College in Massachusetts in 1980 receiving honors as a Wellesley College Scholar and was elected to Sigma Xi Society. She received here Master of Public Health from the School of Public Health of Boston University in 1982. She received her Doctorate in Psychology in 1991 with specializations in Clinical Psychology and Aging from the University of Southern California where she received commendation for Distinction upon admission to Candidacy. She completed her internship training at the Veterans’ Administration Hospital in Washington, D.C. with a specialization in neuropsychology in 1988 and post-doctoral training at the University of California, San Diego in 1992. • ACADEMIC POSITION AND HISTORY • Dr. Williams is currently an Assistant Professor of Psychiatry and Behavioral Sciences at Rush University Medical School in Chicago. She also serves as Director of CME Outcome Measures and Research. Prior to joining the faculty at Rush University Dr. Williams served as the Program Director of the Physician Assessment and Clinical Education Program at the University of California San Diego. • CLINICAL POSITION AND HISTORY • Dr. Williams currently serves as the Clinical Director of the Professional Renewal Center in Lawrence, KS. Prior to this, she served as Program Director of the Impaired Professionals Program at Rush Behavioral Health in Chicago. In addition to having served as the Program Director of PACE, she served as a staff neuropsychologist at the University of California, San Diego. • RESEARCH AND PUBLICATIONS • Dr. Williams’ research currently focuses on the issues relating to the efficacy of continuing medical education and the special educational needs of under-performing physicians. Her current research includes: Effect of time post activity on physician compliance with email assessment of activity efficacy, a project funded in part by a SACME research grant. Her most recent article is: Disruptive Doctors: A conceptual approach1. • Williams, B. W. and M. V. Williams (2008). "The disruptive physician: A conceptual organization." Journal of Medical Licensure and Discipline 94(3): 12-20.

3. Quick background • Michael V. Williams, Ph.D. • Education and Training • Dr. Williams is a Principal at the Professional Renewal Center in Lawrence, KS. Dr. Williams received his PhD in developmental psychology from the University of Southern California. He completed his post-doctoral training at the Sepulveda Veterans Administration Medical Center in Los Angeles. Dr. Williams began his early career at Southern California Edison Company where he served as Manager of Market Research and Forecasting. In this capacity, his research focused on application of mathematical models of psychological theory to forecasting and market acceptance models. • Work History and Experience • Dr. Williams has consulted for more than 20 years in the area of organizational management and quality improvement. He was a principal at the consulting firms of Booz•Allen&Hamilton, Inc. as well as Planmetics, Inc. In this work he designed and implemented large-scale studies looking at attitudes and behavior as well as quality improvement systems in a number of industries including energy, beverage, and communications. Dr. Williams has presented his work at both national and international meetings on market research, intelligence systems, and integrating forecasting and strategy. He also led the market research element in support of Florida Power and Light Company’s successful application for the Deming Award. The Union of Japanese Scientists and Engineers give this award annually to the international firm that most successfully advances the quality principles developed by Dr. W. Edwards Deming. • Current Focus and Interests • For the past seven years he has brought his skill set to the area of health care systems. Dr. Williams has provided consulting services to hospitals and clinics on issues of workplace functioning, disruptive behavior, and medical quality systems. Dr. Williams has lectured nationally and internationally and, in addition to publications in other areas, has published in the health industry areas on the disruptive physician, quality systems, chemical dependency, and sexual misconduct

4. Four considerations when dealing with disruptive or impaired professionals • Key considerations: • Do they present as a result of an internal quality process or as a result of a complaint; • What is the index professional’s competence and what degree of gain is present in the actions; • Does the system exacerbate or sustain the behavior; and, • What arrangements are made for return to work.

5. Do they present as a result of an internal quality process or as a result of a complaint • Physician dyscompetence is a substantial problem1 of which impairment and disruptive behavior are two types. An individual who has an issue with impairment or disruption typically presents in one of two ways: • As a result of a complaint • Typically harm has already occurred – leading to the complaint; • It is possible a number of unreported incidents exist that may now surface; • The physician, standing accused of harm, is more actively defensive; • As a result of quality assurance/improvement system • Behavior may be addressed prior to an occurrence of harm; • Path for resolution can be delineated to minimize contentious litigation; • The physician, needing skills, may become a collaborator in resolution. • Williams, B. W. (2006). "The prevalence and special educational requirements of dyscompetent physicians." The Journal of Continuing Education in the Health Professions 26(3): 173-191.

6. Anger Management Aggressive Behavior Gaming Displaced Frustration Frequency of Behav i or Individual versus System What is the index professional’s competence and what degree of gain is present in the actions • Considering competence and purposefulness (gain) of behavior has a number of benefits: • Competence can provide insight into: • Path for resolution • Will training work; • Should health or psychological issues be considered; • Likelihood of litigation • Purposefulness can provide insight into: • System issues that are contributing to or sustaining; • Potential for addressing the root causes internally. From: Williams, B. W. and M. V. Williams (2008). "The disruptive physician: A conceptual organization." Journal of Medical Licensure and Discipline 94(3): 12-20.

7. Does the system exacerbate or sustain the behavior • The system interacts with the impaired or disruptive professional in several possible ways1. Effective management of organizational risk is related to understanding and managing the system – individual interaction: • Individual gain can accrue to disruptive behavior • A physician rages in OR prep until they get “their” scrub team; • The system may ignore or tolerate impairment • Unwillingness to confront is a well documented phenomenon • The system can minimally respond • Official responses to disruptive or bullying complaints may have to pass through several committees causing excessive delays between identification of the problem and response. • Williams, M. V., B. W. Williams, et al. (2004). "A systems approach to disruptive behavior in physicians: A case study." Journal of Medical Licensure and Discipline 90(4): 18-24.

8. What arrangements are made for return to work • Return to work presents a number of risks: • The professional has been identified as problematic; • Individuals on the team may have continuing issues; • The returning individual may be or feel “targeted”; • The manner in which the individual is managed may expose the institution to risk from both the team or the index professional. • A number of safeguards can be put in place: • Quality assurance monitoring; • An on-site mentor; and, • External support through a Physician Health Program or similar professional providers.

9. Further considerations • Keys to response: • Clear understanding of the individual’s problems through a multi-disciplinary assessment; • Clear understanding of the institution’s role through an effective root-cause analysis; • Structuring ongoing systematic monitoring of professional performance through a well designed quality assurance/improvement system. • We hope to have these steps described in detail in the future with all of the specifics available through the AHLA.

10. Contact: • Betsy White Williams, Ph.D., M.P.H. Clinical Director bwilliams@prckansas.org • Michael V. Williams, Ph.D. Principal mvwilliams@prckansas.org Professional Renewal Center 1201 Wakarusa, Suite 200E Lawrence, KS 66049 (785) 842-9772