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The Problem Physician: Strategies for Improving Care

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The Problem Physician: Strategies for Improving Care Javier A. Gonzalez del Rey, M.D., M. Ed. Cincinnati Children s Hospital Medical Center – PowerPoint PPT presentation

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Title: The Problem Physician: Strategies for Improving Care


1
The Problem Physician Strategies for Improving
Care
  • Javier A. Gonzalez del Rey, M.D., M. Ed.
  • Cincinnati Childrens Hospital Medical Center

2
Learning Objectives
  • A systematic approach to identifying causes of
    inadequate physician performance
  • Practical interventions to prevent or change
    specific behaviors which may interfere with
    optimal patient care
  • Practical skills to handle difficult
    conversations during the feedback process

3
Adopter Categorization Speed of Adoption
Innovators
Late Majority
Early Majority
Early Adopters
Tradition-alists
2
13
35
35
15
4
Some scary information
  • Every year approximately 0.5 MDs are disciplined
    in the USA
  • 3 5 of MDs present a problem of disruptive
    behavior
  • 10 of MDs will demonstrate significant
    deficiencies in knowledge or skills as some point
    in their career
  • 10 of MDs restrict their practices for medical
    illness

5
Underlying Causes
  • Mental Behavioral
  • Substance abuse
  • Physical Illness
  • Age related and disease related cognitive
    impairment
  • Failure to maintain or acquire knowledge and
    skills
  • Anxiety or Depression
  • Overwork
  • Family problems
  • Dysfunctional working environment
  • Personality

6
Unfortunately
  • at least one third of all physicians will
    experience, at some time in their career, a
    period during which they have a condition that
    impairs their ability to practice medicine
    safely

Ann Inern Med 2006144107-115
7
Professional Competence
  • The habitual and judicious use of communication,
    knowledge, technical skills, clinical reasoning,
    emotions, values and reflection in daily practice
    for the benefit of the individual and community
    being served

JAMA 2002287226-35
8
Professional Competence
  • The habitual and judicious use of communication,
    knowledge, technical skills, clinical reasoning,
    emotions, values and reflection in daily practice
    for the benefit of the individual and community
    being served

JAMA 2002287226-35
9
What is a Problem Learner?
  • A problem learner is a learner with academic
    performance which is significantly below
    performance potential because of a specific
    affective, cognitive, structural, or
    interpersonal difficulty.

10
What is a Problem Learner Physician?
  • A problem learner is a learner with academic
    performance which is significantly below
    performance potential because of a specific
    affective, cognitive, structural, or
    interpersonal difficulty.

11
Lets Review Some Similarities
Physicians or Learners?
12
First
13
Current Mix??
  • Traditionalists (born 1922-1943)/Silent
    Generation
  • (1925-1942) 63 million ( 1)
  • Baby Boomers (born 1943-1960)/The Boom
  • Generation (1943-1961) 77 million (30)
  • Xers (born 1960-1980)/Generation X (1962-1981)
  • 44 million (59)
  • Millenials (born 1980-2000 or 1978 and beyond)/
  • Generation Y (1982-1998) 70 million (10)

14
Traditionalists Born 1925-1945 Baby Boomers Born 1946-1964 Generation X Born 1965-1977 Millennials Born 1978 or after
Age Span 61 to 81 years old 42 to 60 years old 29 to 41 years old 28 or younger
Traits Conservative Discipline Respect for authority Loyal Patriotic Idealistic Break the rules Time stressed Politically correct Pragmatic Self-sufficient Skeptical Flexible Media/Info/Tech savvy Entrepreneurial Confident Well-educated Self-sufficient Tolerant Team builders Socially/politically conscious
Defining Events Great depression World War II Korean War New Deal Cold and Vietnam Wars Woodstock Civil Rights Space Travel Collapse of communism Missing kids on milk cartons Computers in school Energy crisis Clinton/Lewinsky School shootings Terrorism on U.S. soil Corporate scandals
Work Is Inevitable Exciting adventure Difficult challenge Make a difference
Work Ethic Loyal/dedicated Driven Balanced Eager but anxious
Employment Goals Retirement for some Second career Work/life balance Unrealistic
Education A dream Birthright Way to get to an end A given
Technology LP record 8-track cassettes CD iPod/MP3, computers_at_home
Communication Face to face Telephone Cellular phone IM/Text messaging
TV Peyton Place Dallas Melrose Place The OC
Sports Joe DiMaggio Joe Namath Michael Jordan Lebron James
Time at Work is defined Punch clock Visibility Why does it matter if I get it done? Is it 5 PM? I have a life.
15
Second
16
Pedagogy
  • Teacher-centered learning where the teacher
    assumes full responsibility for the learning
    process by determining the content, timing, and
    method of instruction.

17
Pedagogy
Information
18
Andragogy
  • Experience
  • Need to know
  • Self Concept
  • Readiness to learn
  • Orientation to learning
  • Motivation
  • Expectations
  • Pleasure in learning

19
Andragogy
20
Adult as Learners
  • Respect
  • Experience
  • Application
  • Practice

21
Adult as Learners or Physicians as
Adults ?
  • Respect
  • Experience
  • Application
  • Practice

22
Third
23
Grasha-Riechmann Student Learning Styles
  • Competitive
  • Collaborative
  • Avoidant
  • Participant
  • Dependent
  • Independent

24
Teaching Styles
  • The attitudes, values, and behaviors that
    teachers display
  • It would be rare to find a teacher who fits only
    one of the styles we all have a Teaching Style
    Profile which is a blend of different styles with
    one or two being a little more dominant
  • THERE IS NO CORRECT OR PREFERRED PROFILE
  • Flexibility with styles is a sign of a good
    teacher

25
Teaching Styles
Expert Teacher centered Formal
Authority Personal Model Facilitator Delegator
Learner centered
26
Teaching Styles Management Styles
  • The attitudes, values, and behaviors that
    teachers display
  • It would be rare to find a teacher who fits only
    one of the styles we all have a Teaching Style
    Profile which is a blend of different styles with
    one or two being a little more dominant
  • THERE IS NO CORRECT OR PREFERRED PROFILE
  • Flexibility with styles is a sign of a good
    teacher

27
Competitive Independent
vs.
Experts Formal Authorities!!
28
Fourth
29
Enhancement of Adult Learning (How to Change
Behaviors or Attitudes)
  • Informal in a non-threatening environment
  • Ability to exert some control over the process
  • Mental and physical participation
  • Time for assimilation and practice
  • Early application
  • Practical applications
  • Regular evaluation

30
Essential Criteria
  • Validity
  • Reliability
  • Practicality
  • Formats
  • Skills
  • Attitude
  • Behavior
  • Types

31
Pitfalls
  • Failure to evaluate
  • Not specific
  • Teacher Bias
  • Halo effect
  • Reluctance to fail
  • Third party

32
Formative Evaluation
  • Throughout educational experience
  • Learning opportunity for faculty / trainee
  • Specific evaluation about performance
  • Timely used during current educational experience

33
Summative Evaluation
  • Occur at the end of the educational experience
  • Based on prior feedback / formative evaluations
  • Broad assessment of competence to date
  • Information used for future educational experience

34
Annual Summative Evaluation
  • Occur at the end of the educational experience
  • Based on prior feedback / formative evaluations
  • Broad assessment of competence to date
  • Information used for future educational experience

35
Performance Evaluation
Complex
Return on Investment
Patient / Healthcare Outcomes
Performance / Behavior Change
Learning / Competence
Simple
Perceptions / Satisfaction
36
In order to critique or improve
  • You must see it
  • You must experience it
  • You must feel it
  • You must participate
  • You must get involved
  • You must embrace

37
Student Resident Fellow or Attending?
  • Interpersonal
  • Affective
  • Structural
  • Cognitive

38
So First
39
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40
Importance of Beside Teaching and Direct
Observation
  • Adult learning theory at best
  • Allows true assessment of competence
  • Best possible feedback
  • New insight in communication skills
  • Best reinforcement of desired behaviors
  • Best opportunity to remedy errors or undesirable
    habits

41
Importance of Beside Teaching and Direct
Observation
  • Adult learning theory at best
  • Allows true assessment of competence
  • Best possible feedback
  • New insight in communication skills
  • Best reinforcement of desired behaviors
  • Best opportunity to remedy errors or undesirable
    habits

42
So In Summary
  • Prevent
  • Plan
  • Observe
  • Discuss
  • Prepare
  • Contract
  • Follow up

43
  •  There is nothing more difficult to carry out,
    nor more doubtful of success, nor more dangerous
    to handle, that to institute a new order of
    things

Niccolo Machiavelli
Gracias!!
44
References
  • Leape LL, Fromson JA. Problem Doctors Is
    there a system solution? Ann Intern Med.
    2006144107-115.
  • Epstein RM, Hundert EM. Defining and
    assessing professional competence. JAMA.
    2002287226-35.

45
References
  • Neff KE. Understanding and managing physicians
    with disruptive behavior. In Ransom SB, Pinsky
    WW, Tropman JE, eds. Enhancing Physicians
    Performance Advanced Principles of Medical
    Management. Tampa, FL American College of
    Physicians Executives 20045-72.
  • Vaughn, L. M., Baker, R. C., DeWitt, T. G.
    (1998). The problem learner. Teaching
    Learning in Medicine, 10, 217-222.

46
References
  • Cognitive Psychology and Instruction
  • Roger H. Bruning
  • Gregory J. Schraw
  • Royce R. Ronning
  • Merrill, Columbus, OH, 3rd Edition 1999
  • Adult Learning
  • Peter Sutherland
  • Kogan Page, London UK 1998

47
References
  • How to Turn Learners Onwithout turning them off
  • Robert F. Mager
  • CEP, Third Edition, 1997
  • Attitudes and Persuasion Classic and
    Contemporary Approaches
  • Richard E. Petty
  • John T. Cacioppo
  • Westview Press, 1996
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