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Options For Success: Addressing The Behavior

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When the physician who is taking a CME course on the issue, ... Many times the physician does not see themselves or their behavior as disruptive. – PowerPoint PPT presentation

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Title: Options For Success: Addressing The Behavior


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

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 doesnt 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 physicians
    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 physicians 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 impact and 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 mentors 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 individuals 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?sitecp
    h
  • http//www.fsphp.org
  • Marthabrown_at_ufl.edu

25
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