Promoting Professionalism: The Importance of Effectively Managing Disruptive Behaviour

1. Promoting Professionalism: The Importance of Effectively Managing Disruptive Behaviour • Derek Puddester MD MEd FRCPC • Director, Faculty Wellness Program • uOttawa

3. At the end of this 90 minute workshop, participants will be able to : • Define disruptive behaviour and summarize its causes, manifestations, and impacts • Describe a staged approach to preventing and intervening in cases of disruptive behaviour • Apply key strategies and solutions to a series of cases provided by the facilitator and those raised by participants

4. Acknowledgments • Parts of this workshop have been developed in collaboration or partnership with others, including Dr. Dorothy Shaw (UBC), Dr. Joy Albuquque (OMA PHP), Dr. Paul Farnan (BC PHP), and Dr. Michael Kaufman (OMA PHP)

5. What is reasonable behaviour? (Pfifferling) • Communicates with others clearly & directly, displaying respect for others • Supports policies promoting cooperation and teamwork • Complies with established practice standards • Addresses concerns about clinical judgments with associates directly & privately • Addresses dissatisfaction with policies through the appropriate grievance channels • Uses conflict resolution skills in managing disagreements

6. Definitions of DB and Background • Disruptive behaviour = Problematic communication and behaviour that ultimately affects patient care (e.g. inappropriate anger, inappropriate action, inappropriate response) • (St. George) repeated episodes of sexual harassment; racial or ethnic or sexist slurs; loud, rude comments; intimidation or abusive or offensive language; persistent lateness; throwing instruments; sarcasm or cynicism; threats of violence; vengeful litigation; demands for special treatment; refusal to treat • (CPSS) verbal or nonverbal behaviour which may demonstrate disrespect to others in the workplace, affect or have the potential to affect adversely the care provided to patients; reflect a misuse of a power imbalance between the parties

7. (North Carolina PHP) chronic pattern of contentious, threatening, intractable, litigious behaviour that deviates significantly from the cultural norm of the per group, creating an atmosphere that interferes with the efficient functioning of the health care staff and institution

8. What disruptive behaviour is NOT • Behaviour specific to a form of illness (e.g mania) • Behaviour specific to a form of impairment (e.g. alcohol abuse) • Feedback, criticism, or advocacy offered in good faith and in the spirit of improved patient care (e.g. letter to the editor, • Mandatory reporting or lodging an appropriate complaint • Testifying against a colleague or hospital • Doing unpopular or controversial acts

9. Literature trends • Well established literature, increasingly interprofessional • Most literature from US, Canada, Australia, New Zealand • Found in all health professions • No one broadly accepted definition or conceptual framework • Less tolerated, higher expectations for effective behaviour

10. Direct linkages between DB and patient safety, sustainability of health professionals, and quality of workplace health • Few studies on prevention and interventions, yet most studies comment on need for proactive and systematic approaches • Safety literature clearly emphasizes systematic approaches, with specific mention of undergraduate teaching • Policies, alone, do not have an impact on prevention of DB

11. Prevalence • Literature suggests trends are on the rise • 1%- 5% (Linney, 1997) • 6% of physicians have >25 complaints on same theme in 5 years (Hickson, 2002) • 3% – 5% (Leape, 2006) • 95% of members of the American College of Physician Executives report DB is an issue they confront regularly. 83% complaints on “disrespect”, 51% for “refusal to complete tasks or carry out duties”, 41% “yelling”, 37% for “insults”. 56% report complaints between physicians and physician assistants/nurses, and 63% felt physicians are treated more leniently than other professionals

12. Medical students and Residents • 94% of programs report the presence of ‘problem learners’ • 6.9% residents identified as disruptive (Yao, 2005) • 50% of medical students report experiencing abusive behaviour from colleagues or supervisors (Phelan, 1993) • Disruptive behaviour in undergraduate training is associated with later disruptive behaviour, patient errors, and college complaints/discipline (Papadakis, 2005)

13. Examples of Disruptive Behaviour (Pfifferling) • Fails to comply with practice standards • Is disrespectful or discourteous a majority of the time • Criticizes staff or learners in front of others • Shames others for negative outcomes • Communicates indirectly about others (colleagues, patients) • Ignores existing policies/standards and/or creates their own

14. Unreasonable Behavior • Swears or uses consistently unprofessional language • Uses behaviour that can be viewed as inappropriate (intimidation, harassment, sexist, racist), dangerous (threats, violence), and/or criminal (assault, slanderous) • Bullying • Threatens associates with retribution, litigation or violence

15. Other ways of classifying behaviour • Aggressive: anger, blaming, use of shame, intimidation, harassment, language, threats, violence • Passive: chronically late, slow/no response to pages/calls/emails, refuses to monitor email, not complete charts in a reasonable timeframe, lack of flexibility, refusal to collaborate, lack of collegial participation • Passive-Aggressive: disrespect, endless emails without focus or solution, unapproachable stance, confusing or mixed body language, inappropriate affect and/or speech, indirect insults or malignment

16. Possible Aetiologies • Axis I or Axis III • Emerging recognition of axis II • Emerging maladaptive traits (e.g. arrogance) • Unhealthy workplace • Personal stress • Life transition difficulties • Burnout

17. “Classic Profile” • Known as an expert in their field, may be viewed as difficult to replace (e.g. House) • Incredibly busy, often due to taking on all aspects of clinical care • See themselves as clinically superior and others as less competent (and often don’t disguise these opinions) • Enduring lack of insight • Isolated – single, no children, few friends, minimal activities, may use money to purchase social recognition (e.g. charity, donations) • Rarely seek assistance • Path of destruction in their wake – expect systems to adjust to their needs even if this hurts colleagues or larger systems

18. Which disciplines? (Neff, 2002) • 27% Surgery • 25% Family/General Practice • 17% Internal Medicine • 10% Psychiatry • 8% OBGYN • 6% Anesthesia • 10% ‘double boarded’

19. Known causes (Neff, 2002) • 78% had Axis I Disorder • Major depressive disorder 40 -50 % • Bipolar 6% • Dysthymia 17% • Sexual disorder 5% • OCD 2% • Alcohol dependence 13% (Abuse 6%) • Impulse control disorder 2% • ADHD 2% • 28% had Axis II Disorder (NOS, Narcissism, OCPD)

20. Impact of Disruptive Behaviour • (Pfifferling, 1999) undermines practice morale, heightens turnover, decreases productivity, increases risk, causes peer distress • (Youssi, 2002) destabilizes patient care; strains peer relationships, decreases nurse-physician communication, discomforts patients, stigmatizes profession • (Rosenstein, 2002) directly correlated to increased work stress and burnout of nurses, as well as have significant contribution to nursing turnover and exit • (Institute for Safe Medication Practice) pharmacists frequently experience disruptive behaviour that immediately impacts care

21. 7% of medication errors due to intimidation of nurses by physicians (Institute for Safe Medication Practices, 2004) • Students report intimidation, harassment, and abuse negatively influence their choices of postgraduate training, employment, and perception of the supervisory relationship (LeClerc, 1988)

22. FWP Perspective - Quotes • I just started here and have this disruptive doc…he’s been a problem for a long time but no one told me • I think I have a borderline doc and don’t know what to do • No one has sorted this guy out but I’ve had it and am going to • I’m meeting with this disruptive doc in an hour and wonder what I should do? • But… • Do you have a policy on behaviour? (no) • Have you adequate documentation? (no) • Have you tried any strategies with follow up and documentation? (no) • Have you consulted with legal counsel? (no)

23. Identification • Establish consensus on the local level on definitions, expectations, and standards • e.g. Standards of Ethical Practice and Professional Behaviour (uOttawa, 1993), Declaration of Professionalism (uOttawa, 2005), Hospital Codes of Conduct • Annual evaluations (e.g. 360), informal/formal complaints process • Pattern recognition may require consultation with local expert in behaviour

24. Response options to DB? (Rosenthal) • Nothing (wait until its someone else’s problem • ‘Terribly quiet chat’ • Protective Support • Diverting patient flow • Exporting the problem • The ‘Wise Men’ Committee • Contacting the regulatory body • Medic

25. Better approach – ‘Universal Precautions’ (Farnan) • Be proactive – conduct policies, annual evaluations, complaints processes, staff/faculty development, grand rounds • Be reactive – be consistent, timely, procedural, and fair • Be thoughtful – watch your assumptions (e.g Axis II) and challenge your stigma (e.g. Axis I) • Be mindful of your role – you are not the clinician!

26. When a complaint is raised • Use your institutions complaints policy to guide your behaviour • If there is no policy…develop one • Key principles: • Listen • Don’t take sides • Request a documented complaint • Give tips and suggestions regarding complaints (e.g. specific, neutral, I-statements, non-inflammatory, suggested action) • Commit to action, do so, report back • Document

27. Complexity of Investigating Complaints • Solid detective work – with all of the same challenges • Accuracy of statements • Memory and recall issues • Need to verify and have witnesses (and statements) • Need to have supporting documentation • Search for patterns vs unique anomalies • Effort of documentation and record keeping • Privacy legislation

28. Considering steps towards resolution • Is safety an issue? • Is patient care compromised? • Are you obligated to report to Chief of Staff? The College? • Is a formal break or leave required? • Are emergent health issues relevant and warranting intervention? • Or…is there time to consider other aspects of intervention?

29. Preparing to Respond • What is your role? • Do you need advice (e.g. Chair, Chief of Staff, Counsel, College, FWP, PHP)? • Are there mandatory reporting issues? • Do you have adequate documentation? • Could the situation be readily managed via a conflict resolution process (e.g. mediation, conciliation, facilitated resolution) rather than a disruptive behaviour process?

30. DB Process – Initial Meeting (Leader) • Know exactly what you want out of the agenda prior to starting the meeting • More informal, non-threatening • Neutral territory or their office • Acknowledge their worth and value • Review confidentiality, privacy, and documentation issues • Indicate the background and policies that guide the process • Advise them of the specific complaint(s) and the reported impact on others • Review the standards that are expected and the discrepancy noted

31. Move into joint problem solving • Seek their perspective – be an active listener • Offer assistance • State what they need to stop, start, and maintain • Monitor your boundaries (you are NOT their clinician) • Review and summarize • Book follow up • Close warmly and with appreciation • Send a follow up written summary of discussion and outcomes, keep notes for your file

32. Follow up meeting (improved behaviour) • Review original complaint, first meeting, commitments • Report that ‘you were spotted doing something right!’ • Encourage and praise • Restate expectations of Organization • Close matter, but note openness and willingness to help if required in future

33. Follow up meeting (ongoing problems) • Formal meeting, leader’s office, firm tone • Two leaders (Initial leader and their superior or collaborator) • Review original complaint, action plan, documentation • Report new data and updated behaviour using documentation • Key issue – insight, openness, willingness to change? • Note that behaviour must stop immediately • Review consequences • Develop action plan and monitoring plan • Book follow up meeting in 7 – 14 days

34. Third Meeting – “Intervention” • Consider bringing more people into the meeting • Invite them to bring a supportive person • Formal tone • Review all facts and documents again • Review action plan and how it is viewed to have failed • Consider if more warnings are required or if it is time to administer consequences

35. Consequences • Period of formal remediation and monitoring • Mandatory education • Mandatory assessment (IME) • Loss of privileges (clinical, teaching, research) • Report to College

36. Comprehensive Assessment • Seek advice early on a multidisciplinary assessment • Ask practical and useful questions • Be objective – out of institution resources (out of town) • Be careful – who is the referring physician? • Clarify who pays for the assessment, who gets the detailed results, and what specific information you are seeking (you do not get the whole chart!). • Develop a process to ensure the assessment is moving forward in a thorough and timely manner

37. Sample questions: • Is there a physical or mental health problem (including substance use)? • What is the level of insight and judgment? • What is the risk of SI/HI? • What is the risk to patient safety? • Is there evidence of a genuine willingness to engage, meaningfully, in assessment and treatment recommendations, if indicated? • What are the relevant intervention and treatment recommendations? • Is there a need for ongoing monitoring of behaviour? • Are there mandatory reporting issues?

38. If referred to the FWP or the PHP • It is reasonable to request and expect written confirmation that the following occurred: • That a meeting took place • That the physician agreed to referral to appropriate resource for assessment (and those details, including when) • That you will be asked to contribute objective collateral history • That the physician participated meaningfully in the assessment • A report with all recommendations was sent to their Family Physician • Relevant recommendations will be shared with the workplace with details of an implementation strategy • A follow up meeting will be held to facilitate re-integration to work, or other work • Ongoing monitoring will be discussed

39. Assessment Strategies • Family physician – history, PE, investigations • Psychologist – personality and psychopathology measures, psycho-educational evaluations • Psychiatry – mental illnesses or substance abuse issues • Addiction Specialist • Behavioural contracting • Learning/workplace monitors (role, reporting, confidentiality) • Identified coordinator (custodian of health information, reporting, confidentiality) who takes lead and acts as bridge between learner and institution • Role of courses and treatment programs

40. Request a proper assessment or else… • Dr. Disruptive has a curbside consult • Depth and breadth of consult limited • “Dr. Disruptive is fit for work.” • Lack diagnostic opinion and data • Lack clear and specific recommendations • Lack an ability to ask for follow up and review of change

41. Roles for PHOs • Advocate for national guidelines on respect in the workplace • Partner with new generations of other professions (nursing) and set a new joint standard • Connect with on the ground efforts grounded in professionalism and physician health

42. Offer training sessions in disruptive behaviour targeted at residents • Offer training sessions in assertiveness training (peer and with supervisors) • Partner with university efforts on “Residents as Teachers” programs and focus on disruptive behaviour

43. Advocate for Codes of Conduct for all universities, teaching sites, and other training environments (with teeth - ? linked to contracts) • Embed training in DB in annual orientations • Recognize and award professional behaviour

44. Cases • 10 minutes per case • Scribe/Reporter - 2 key points each • Group format • What are the issues? • What is the process? • What is the best/worst outcome?

45. Dr. Allan • Dr. Allan is a PGY-1 in family medicine and is new to your University. He is currently on the medicine CTU and has a heavy call schedule. The pharmacy calls you in your capacity as program director to report a major concern. They allege Dr. Allan signed a prescription in the name of an inpatient using the name of a staff physician and has delivered the script to the hospital pharmacy for dispensing. He has identified himself as the patient, not as a physician.

46. Busted at Accreditation • Overheard during a college accreditation review meeting with residents: • Q. Are there any concerns about intimidation and/or harassment in your program? • A. “Yes – there is a member of staff who yells at us on the ward and at the nursing station, when reviewing our patient histories. He has some unusual expectations as to how histories are to be written out and presented and you feel like you are walking on egg shells in case you didn’t quite get it right. Then yesterday he yelled at me and called me stupid in front of a patient because he didn’t agree with my differential diagnosis. I wouldn’t normally have said anything, because he’s such a good teacher in our academic half day sessions, but he’s really upset most of our residents. I spoke to the site director, but because he’s senior, she brushed it off – after all she experienced it too.”

47. Allegations • You are the clerkship co-ordinator for OB/GYN. A junior clerk is brought to you by one of her colleagues with a concern about unwanted touching from her senior resident while on call. She reports that the resident touched her face twice, despite being verbally and physically discouraged. In addition, he is described as repeatedly knocking on her door at 0400 to “be friendly.” She paged her colleague (who was on call for paediatrics) to sit with her until morning as the call room doors do not lock. She has made a formal complaint. You are tasked with meeting with the resident, obtaining his version of events, and trying to understand the full story.

48. Joe, MSII • Joe is a student who has been chronically late for PBL sessions. Joe then proceeds to dominate the group discussion and expects to be updated on what happened before Joe arrived. The group has discussed the ground rules which included punctuality, respect and shared airtime but no-one has actually given Joe feedback that these behaviours apply to him. It seems that the group, including the tutor, find Joe to be intimidating. The tutor is coming to you for advice and guidance.

49. Dr. Jones • You are a new site education director for the department of pediatrics. In your first year you are struck at how many complaints you have received about Dr. Jones. During a clinical skills session on abdominal examination, Dr. Jones made derogatory comments just before the group met the patient – a young Chinese girl who spoke little English. “She’s probably Hep B positive, most of them are.” Dr. Jones went on to make comments that the medical students in the group found offensive in terms of their visible minority status and gender. “You won’t have any trouble getting ahead, it’s us white males that are disadvantaged.” “Of course, you won’t have trouble either, women are favoured these days, even though they are not as productive.” He provided excellent medical instruction along with other comments reflecting his dissatisfaction with the current state of the Canadian medical profession. The group was very uncomfortable speaking directly to Dr. Jones and this is not the first time you have heard this complaint.