michael kaufmann md director, physician health program; medical director, pwsp ontario medical...

Michael Kaufmann MD

Director, Physician Health Program; Medical Director, PWSP

Ontario Medical Association

“Ain’t Misbehavin’”Respectful Behaviour in the Medical

Workplace

Dedicated to Doctors. Committed to Patients.

“The age of the cowboy surgeon is over.”

Wayne and Mary Sotile

“The Resilient Physician”


Learning objectives:

1.Understand the nature and causes of disruptive behaviour

in doctors;

2. Learn about the many strategies available to manage

disruptive behaviour in physicians based upon a staged

approach in a systems paradigm;

3. Learn about the Physician Workplace Support Program of

the Ontario Medical Association.


PRIMUM NON NOCERE

NOT SO PRIMUM NON NOCERE


“Where is it written that I have to be

nice?”orthopedic surgeon


It is written:

• Medical Association Code of Ethics

• Institutional Codes of Conduct

• CanMeds Roles

• Occupational Health Law (harassment and violence)

• Regulatory Policies

• Other


Disruptive behaviour is defined by the College of Physicians and Surgeons of Ontario (CPSO) as:

“inappropriate conduct, whether in words or action,

which interferes with, or has the potential to interfere with, quality health care delivery.”

Single egregious act

Pattern of behavioural incidents


Examples:

Abusive and aggressive behaviour

• Intimidation, bullying, physically threatening, throwing

objects

• Blaming, shaming, belittling language

• Unnecessary sarcasm or cynicism

• Harassment and violence


Examples:

Passive-aggressive behaviour

• Late or no replies to pages

• Non-compliance with policies and procedures

• Non-attendance at committee meetings

• Rigid, inflexible or non-responses to requests for

cooperation

• Intentional delay or obstruction of hospital procedures


Examples:

Boundary crossings

• Sexual comments or innuendoes

• Sexual harassment – unwelcome flirtation

• Inappropriate touching

• Interference with management of other doctors’ patients


Examples:

Other

• Racial, cultural slurs

• Disparaging remarks about colleagues and administrators

(including hostile e-mails, notes in patient records)

• Refusing to see certain categories of patients

• Lack of respect for comfort of others


What Disruptive Behaviour isn’t:

• Healthy criticism offered respectfully and in good faith with

the intention of improving patient care or facilities

• Making a complaint to an outside agency when indicated

• Testifying against a colleague

• Good faith patient advocacy

• Problems with competence

Dedicated to Doctors. Committed to Patients.18

Disruptive behaviourPrevalence

• 1%- 5% (Linney, 1997)

• 3% – 5% (Leape, 2006)

• 6% of physicians have >25 complaints on same

theme in 5 years (Hickson, 2002)

Behaviour

Distressed Physician

colleagues

co-workers

Hospitalsystems

patients

Family


Causes

• Temperament and personality structure


Causes

• Temperament and personality structure

• “Doctor behaviour”


Traditional Medical Culture Encourages“Doctor Behaviour”

• Perfectionism

• Like to be ‘In-Control’

• Dedication to patients above all

• Problem solvers, solution focused

• Successful in achieving goals

• Resist Change

• Obsessive

• Emotionally reserved


Causes• Temperament and personality structure

• “Doctor behaviour”

• Marital and family tensions

• Mismanaged stress – “shoot the first thing that moves.”

• Burnout and other occupational tensions / workplace factors

• Psychiatric disorders• Mood and anxiety disorders such as bipolar type II and OCD• Adjustment disorders• Character problems and disorders

• Substance use disorders

• Physical health problems


The PHP Experience:

• Approx. 10% of calls to PHP due to conduct problems

specifically

• Many referred with other problem types display disruptive

behaviour

• 88% male

• One third Surgeons

• Ob-Gyn & Anesthetists approximately 10% each.


Good intentions, but…

Lack of insight

into how behavioral choices

affect relationships with others

(intention-impact)


Surgeon referring to the impact of his behaviour on others.

“It’s like a summer rain shower – short, sharp,

then over.”


“I reached into my toolkit and

pulled out the only tool I knew

how to use – a hammer.”

orthopedic surgeon


Effective tools

• Code of Conduct with functional, accepted procedural

guidelines.

• Leadership training – skills for having motivating and compassionate conversations.– Understanding how to fairly apply management principles.

• Awareness of available resources, when and how to use

them.

• Understanding a systems approach.


Role of the Institution

• Strong leadership is required

• How will workplace issues be addressed?

• Who will follow-up?

• How will others in the work environment

be included in a remediation plan?

• The workplace is a rehab partner


Staged Approach

Informal talk: “cup of coffee”

Stage one – Awareness

Stage two -- Action Plan (Authority)

Stage three – Formal Discipline

Apparent pattern

Single “unprofessional"

incidents (merit?)

“Hickson” Framework

Mandated Issues

"Informal" Cup of Coffee Intervention

Level 1 "Awareness" Intervention

Level 2 "Authority" Intervention

Level 3 "Disciplinary" Intervention

Pattern persists

No ∆

Vast majority of professionals-no issues

Hickson GB, Pichert JW, Webb LE, Gabbe SG,Acad Med, Nov, 2007

CPSO Framework:

Suspension/restriction/ regulatory action etc.

Behaviour controlled by monitoring etc.

Stage 3 response:1. Confirm facts of report;2. Notify physician and discuss;3. MAC or other highest, formal authority to be notified;4. Essential to obtain assessment of cause (if not done previously);5. Consider suspension of privileges, etc.;6. If practice still possible, supervision likely required; and7. Consider obligation to notify CPSO.

YESNO

Behaviour repeated?

Stage 2 response:1. Confirm facts of report;2. Notify physician and discuss;3. Advisable to obtain assessment of

cause;4. Obtain commitment to

change/remediation activities (preferably in contract form); and

5. Record in file.

YESNO

Behaviour repeated?

Stage 1 response:1. Confirm facts of report;2. Notify physician and discuss

appropriateness;3. Obtain commitment that behaviour will not be

repeated;4. Record in file; and5. Follow up or monitor behaviour.

Risk of harm to patients or staff

Particularly egregious behaviour

First incident – relatively mild disruptive behaviour

Behaviour Management Flow Chart – CPSO Paradigm


Look, I can’t promise I’ll change, but I can promise I’ll

pretend to change


Physician Workplace Support Program

Mary Yates, Director

Michael Kaufmann, Medical Director


PWSP Guiding Principles:

• Good doctors…behaviour change is possible

• Context matters…in order to help somebody change, we

need to understand them as individuals and the context in

which they live and work

• Iterative process; PWSP is evolving, we’re learning and

adapting as we go along

• Our intention is to provide customized solutions

• Financial self-sufficiency – cost recovery


•Physician Focus

•Doctors’ Health

•Confidentiality

Civil Doctors

Patient Safety

•Legislative Mandate

•Public Responsibility

PHP CPSOPWSP


Governance

• Ontario Medical Association – Board of Directors

• Advisory Committee– OMA– CPSO (regulatory body)– Ontario Hospital Association– Residents Association– Canadian Medical Protective Association– HIROC (Hospital protective association)


Spectrum of PWSP Services

Case management

• assessment, rehabilitation, long term follow up

Education

• Medical schools, community hospitals, rounds, brief seminars

• Intensive workshops, communication skills

Training / Coaching for Physician Leaders

• early intervention strategies

Organizational consulting

• workplace/team assessments, recommendations for creating respectful workplaces


PWSP Services: Case management

• for referred physicians

• 4 phases–Preliminary Intake Assessment; all referrals start here–Comprehensive Assessment–Rehabilitation and Monitoring–Long term follow up

• each phase is contracted for separately


We have two clients:

• The doctor

• The workplace


Clarify expectations of PWSP involvement and

invoicing

Review of documentation

Understand reason for referral

Interviews with referring and referred physicians

Physician factors

Workplace factors

Letter of recommendations

Preliminary Intake Assessment


Recommendations for “Next Steps”

Advice & referral Comprehensive

Assessment

PWSP follow up6-12 months

Other?


Comprehensive Assessment

360 Behaviour Assessment

IMEsPsychiatric AddictionCognitive

Family / MaritalRisk of violence

Physical

Recommendations for Behavioural Rehabilitation

any or all the following may be recommended:

Workplace Interviews


Rehabilitation Framework

Motivation

Support

Information

Skills developmentTreatment

Personal supportWorkplace support

Awareness of self & othersFeedback about how others “see me”Clarify expectations &

ConsequencesAccountability


Behavioural Rehabilitation:

• Behavioural change interventions:–Education, coaching, individual and group counselling, clinical

treatment / therapies as indicated

• Behavioural monitoring contract:– Baseline 360 with Feedback Report Review– Quarterly 360’s (8 over 2 years)– Coaching– Workplace monitoring and reports to PWSP– PWSP advocacy / progress reports

• Workplace Reintegration Meeting(s)

• Other workplace recommendations

www.physiciansdevelopmentprogram.com

“360” Behavioural Monitoring


4 Months Later


43

6 1

PWSP Cases; June 2010 to April 2013

residentsmedical students

practicing physicians


18

15

6

43

4

PWSP cases by specialty; June 2010 to April 2013

N=50

surgery

medicine

anesthesia

other

paediatrics

family medicine


0

5

10

15

20

25

30

35

33

14

4

PWSP activity; completed & in progress June 2010 to April 2013

comprehensive assessments

monitoring contracts

preliminary assessments


Paradigm change

Old New

The physician is a “jerk” The physician / hospital needs help

These physicians are bad These are usually good doctors

It’s all the doctor’s fault Context matters

Be cautious, delay action Act promptly and decisively

“Fix” the doctor Consider the entire system

The situation is incorrigible Use a rational, staged approachand good results are possible

[email protected]

416-340-2972

php.oma.org

michael kaufmann md director, physician health program; medical director, pwsp ontario medical...

Documents

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violence slide

nocere slide

competence slide

medical workplace slide

resilient physician

orthopedic surgeon slide

disruptive behaviour