OPTIONS FOR SUCCESS: ADDRESSING THE

BEHAVIORMartha E. Brown, MD

Professionals Resource Network (PRN) Assistant Medical Director

And

UF Associate Professor of Psychiatry

Addiction Medicine Division

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 doesn’t 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)

Clinical Approaches To The Disruptive

Professional

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

We judge ourselves by our motives others judge us by our behavior.

AA saying

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

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)

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 professionalsWhose 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

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

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

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)

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

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

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

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

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

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/MRIPsychiatric/substance abuse evaluationNeuropsychological testingDrug testingCollateral informationSimulated patients and cases in the physician’s field

Step-wise Protocol For Handling Disruption (Level 3)

Recommendations by evaluation team may includePHP involvementOutpatient treatmentResidential treatmentLong-term psychotherapy360 evaluationsDirect or indirect supervision and monitoring of the

physician’s practiceInability to practice for an indefinite period of timeOther recommendations as felt needed

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

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

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

What We Have Learned Medical student and resident training

cultivates many of the disruptive behaviors, as trainees learn from their mentor’s 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

What We Have Learned

It is important to understand the systems issues related to an individual’s behavior

Dealing with disruptive behavior in the workplace results in:Better team communicationImproved patient safetyIncreased quality of patient careReduced litigation and malpractice claimsIncreased staff morale

Not all can be helped or saved

REFERENCES

www.drmarthabrown.com http://www.mc.vanderbilt.edu/root/

vumc.php?site=cph http://www.fsphp.org Marthabrown@ufl.edu