Resources for the DistressedResources for the DistressedPhysicianPhysician

The Program The Program for for

Distressed PhysiciansDistressed Physicians©©

www.mc.vanderbilt.edu/cph

The Program for Distressed The Program for Distressed PhysiciansPhysicians©©

www.mc.vanderbilt.edu/cph

William Swiggart, MS, LPC/MHSPWilliam Swiggart, MS, LPC/MHSPwilliam.swiggart@vanderbilt.eduwilliam.swiggart@vanderbilt.edu

Assistant in MedicineAssistant in MedicineCoCo-- DirectorDirector

Vanderbilt Center for Professional HealthVanderbilt Center for Professional Health

Vanderbilt CenterVanderbilt Centerforfor

Professional HealthProfessional HealthContinuing Medical Education CoursesContinuing Medical Education Courses

Prescribing Controlled Drugs©

Maintaining Proper Boundaries©

Program for Distressed Physicians©

www.mc.vanderbilt.edu/cph

DefinitionDefinition

“a style of interaction with physicians, hospital personnel, patients, family members, and others that interferes with patient care…”

American Medical Association

Reported PrevalenceReported PrevalenceState/CountryState/Country PrevalencePrevalence SourceSourceAlabamaAlabama 12%12% ReferralsReferralsIndianaIndiana 8%8%

1%1%ReferralsReferralsStatewideStatewide

KentuckyKentucky 20%20%0.4%0.4%

ReferralsReferralsStatewideStatewide

TennesseeTennessee 30%30% ReferralsReferralsWisconsinWisconsin 30%30% ReferralsReferralsAustraliaAustralia 36%36% ReferralsReferralsEnglandEngland 6%6% DisciplinaryDisciplinary

Multiple References Available

PhysicianHospital/Clinic

Well functioning hospital system

MD with good skills; team player; emotional intelligence; knows conflict resolution

Periodic anger outbursts; poor team player

Narcissistic traits; recurrent anger outbursts; generally frustrated; passive aggressive; nurses take brunt of anger

Partially functioning system

Totally inadequate hospital/clinic function

Spectrum of Hospital/Clinic FunctionSpectrum of Hospital/Clinic Function& &

Physician BehaviorPhysician Behavior

ConsequencesConsequencesdisharmony and poor morale1, staff turnover2, incomplete and dysfunctional communication1, heightened financial risk and litigation3, reduced self-esteem among staff1, reduced public image of hospital1, financial cost1, unhealthy and dysfunctional work environment1, andpotentially poor quality of care1,2,3

1. Piper, 20002. Rosenstein, 20023. Hickson, 2002

When When ““a little chata little chat”” doesn't workdoesn't work

Mr. Bangsiding felt (and wrongly so) that a littlechat would be enough to stop Bob’s disruptive behavior.

A Program for Distressed A Program for Distressed Physicians Physicians ©©

Physicians appropriate for referral:Physicians appropriate for referral:Physician is currently workingPhysician is currently workingWilling to fully participate Willing to fully participate Physician does not require residential Physician does not require residential treatmenttreatmentPhysician has some support for change Physician has some support for change i.e., the State Physician Health Program i.e., the State Physician Health Program or institutional or group practice supportor institutional or group practice support

Rule outRule out

Active substance abuse or dependenceActive substance abuse or dependenceMedical illnessesMedical illnessesSkill or competence issues, etc.Skill or competence issues, etc.Certain psychiatric disordersCertain psychiatric disorders

A Program for Distressed PhysiciansA Program for Distressed Physicians(Phase I)(Phase I)

Components:Components:Comprehensive EvaluationComprehensive EvaluationScreening with additional measuresScreening with additional measures

Trauma (Trauma Symptom InventoryTrauma (Trauma Symptom Inventory™™))Flooding (Gottman)Flooding (Gottman)

Workplace assessment Workplace assessment –– PULSE PULSE (Harmon)(Harmon)

Phone interviewPhone interviewCollateral interviewCollateral interview

FloodingFlooding1.1. After a conflict I want to keep away or After a conflict I want to keep away or

isolate for a while.isolate for a while.2.2. I can never seem to soothe myself after a I can never seem to soothe myself after a

conflict.conflict.3.3. When I get negative, stopping it is like When I get negative, stopping it is like

trying to stop an oncoming truck.trying to stop an oncoming truck.4.4. I can never tell when a blowup is going to I can never tell when a blowup is going to

happen.happen.

FloodingFlooding

The average flooding score was reduced The average flooding score was reduced by 50% from the preby 50% from the pre--course test. course test.

PrePre--course average = 8.29course average = 8.29PostPost--course average = 4.06course average = 4.06

Range 0 Range 0 --2424

Components of the ProgramComponents of the Program(Phase II)(Phase II)

ThreeThree--day CME course up to 46.5 CMEday CME course up to 46.5 CMEDidactic lectures Didactic lectures -- e.g., shame reaction, e.g., shame reaction, family of origin connections family of origin connections GenogramGenogramTeach Specific tools/skills Teach Specific tools/skills -- e.g., grounding e.g., grounding skills, Alter sheet, communication strategiesskills, Alter sheet, communication strategiesRoleRole--playingplayingHomeworkHomework

MD

Dad Mom

GFGM GF

GM

HeroGolden childNo limits

Over involvedpermissiveAloof

distant

Role Play ExerciseRole Play Exercise

Describe an incident you are Describe an incident you are concerned about.concerned about.Who was there?Who was there?Pick someone to play you.Pick someone to play you.A powerful cathartic exercise A powerful cathartic exercise viewing their behavior from multiple viewing their behavior from multiple points of view.points of view.Example.Example.

Components of the VUMC ProgramComponents of the VUMC Program(Phase III)(Phase III)

Three followThree follow--up sessions with the core group up sessions with the core group over the nextover the next six months; importance of six months; importance of group processgroup process

Repeat workplace assessment (PULSE)Repeat workplace assessment (PULSE)

Workbook (Workbook (The Anger Book, The Anger Book, M McKay, P M McKay, P Rogers, 2000)Rogers, 2000)

Characteristics and Characteristics and Behavioral Change in the Behavioral Change in the

First 20 Disruptive First 20 Disruptive PhysiciansPhysicians

Charles P. Samenow, MD, MPHDepartment of Psychiatry

Vanderbilt University Medical Center

DemographicsDemographics

Total Physicians Studied = 20Total Physicians Studied = 20Mean Age: 44.6 (compare to CPH mean age 49)Mean Age: 44.6 (compare to CPH mean age 49)Age Range: 27 Age Range: 27 -- 6161Predominantly Male (90%) and Caucasian Predominantly Male (90%) and Caucasian (100%)(100%)60% Married, 30% Divorced (1/2 multiple)60% Married, 30% Divorced (1/2 multiple)States Represented: 11States Represented: 11

Specialty TypesSpecialty TypesEmergency MedicineEmergency Medicine 3 (5%)3 (5%)Family MedicineFamily Medicine 2 (10%)2 (10%)Internal Medicine Internal Medicine (Specialty)(Specialty)

6 (30%)6 (30%)

Ob/Ob/GynGyn 3 (15%)3 (15%)PathologyPathology 1 (5%)1 (5%)Pediatrics (General)Pediatrics (General) 1 (5%)1 (5%)Pediatrics (Specialty)Pediatrics (Specialty) 1 (5%)1 (5%)Surgery (General)Surgery (General) 2 (10%)2 (10%)Surgery (Specialty)Surgery (Specialty) 2 (10%)2 (10%)

Referral SourcesReferral Sources

Hospital (38%)Hospital (38%)PHP (26%)PHP (26%)Board of Licensure (15%)Board of Licensure (15%)Group practice (12%)Group practice (12%)Treatment Facility (6%)Treatment Facility (6%)Self (3%)Self (3%)

Who is affected?Who is affected?

Colleagues 100%Colleagues 100%Staff (Hospital and/or Practice) 77%Staff (Hospital and/or Practice) 77%Supervisors 63%Supervisors 63%Direct effects on patients are rareDirect effects on patients are rareFamilyFamily

Was it something I did?

Was it something I said?

Is it my fault?

I better not bother her now?

He’s about to explode.

Run for cover!

EtiologiesEtiologiesIndividual FactorsIndividual Factors

Predisposing Psychological FactorsPredisposing Psychological Factors11

Alcohol and Drug Family HistoryAlcohol and Drug Family HistoryTrauma HistoryTrauma HistoryReligious FundamentalismReligious FundamentalismFamilial High AchievementFamilial High Achievement

Personality TraitsPersonality Traits22

NarcissismNarcissismObsessive/CompulsiveObsessive/Compulsive

Physician BurnoutPhysician Burnout33

Clinical Skills Satisfactory or Above AverageClinical Skills Satisfactory or Above Average44

1. Valliant, 1972 2. Gabbard, 19853. Spickard and Gabbe, 2002 4. Papadakis, 2004, 2005

EtiologiesEtiologies

Institutional FactorsInstitutional Factors11

ScapegoatsScapegoatsSystem Reinforces BehaviorSystem Reinforces BehaviorIndividual Pathology may overIndividual Pathology may over--shadow shadow institutional pathologyinstitutional pathology

Williams and Williams, 2004

AggressiveAggressive

Anger outburst, verbal threats, swearing (90%)

Physical contact and throwing objects (20%)

Sexual Harassment (10%)

PassivePassiveAggressiveAggressive

Derogatory comments about institution, hospital, group, etc.

Refusing to do tasks (20%)

PassivePassive

Chronically late, not responding to call (15%)

Inappropriate/inadequate chart notes, not dictating (15%)

Categories of Reported Disruptive BehaviorsCategories of Reported Disruptive Behaviors

InterventionsInterventions

Confrontation by Hospital/Practice (49%)Confrontation by Hospital/Practice (49%)Psychiatric Assessment (16%)Psychiatric Assessment (16%)Disciplinary Action by Employer (13%)Disciplinary Action by Employer (13%)Referral to PHP (9%)Referral to PHP (9%)Board of Licensure Action (7%)Board of Licensure Action (7%)Termination (4%)Termination (4%)Other CME Course (1%)Other CME Course (1%)None (1%)None (1%)

Physician Mental HealthPhysician Mental Health

Previous Psychotherapy (59%)Previous Psychotherapy (59%)Previous Psychotropic Medications (29%)Previous Psychotropic Medications (29%)

Study DesignStudy DesignRetrospective, Cohort DesignRetrospective, Cohort DesignTotal Physicians: 20Total Physicians: 20Behavior Measured By PULSEBehavior Measured By PULSE

Motivating BehaviorsMotivating BehaviorsDisruptive BehaviorsDisruptive BehaviorsMotivating Impact on OthersMotivating Impact on OthersDisruptive Impact on OthersDisruptive Impact on OthersBoth Self and Both Self and ““OthersOthers”” (Colleagues, Staff, (Colleagues, Staff, Supervisors)Supervisors)

Study DesignStudy Design

PrePre--Course PULSE: 15Course PULSE: 1533--month Followmonth Follow--up PULSE: 26up PULSE: 2666--month Followmonth Follow--up PULSE: 14up PULSE: 14Average # of Average # of ““OthersOthers””: 23: 23

General TrendsGeneral TrendsAt 3 months, significant changes in all At 3 months, significant changes in all domainsdomains

Increased motivating behaviors and motivating Increased motivating behaviors and motivating impactimpactDecreased disruptive behaviors and disruptive Decreased disruptive behaviors and disruptive impactimpact

Changes in behavior reported by Changes in behavior reported by ““othersothers””more significant than changes reported by more significant than changes reported by self.self.

General Trends (Continued)General Trends (Continued)

Analysis of individual physicians Analysis of individual physicians demonstrates:demonstrates:

Improvement in 20 of the 22 physiciansImprovement in 20 of the 22 physiciansAlthough mean behaviors do not seem severe, most Although mean behaviors do not seem severe, most physicians demonstrated severe behavioral physicians demonstrated severe behavioral problems in one or more domains.problems in one or more domains.Reports of disruptive behavior was not consistent Reports of disruptive behavior was not consistent across setting or those who observed it.across setting or those who observed it.

General TrendsGeneral Trends

66--month data demonstrates potential for month data demonstrates potential for maintenance or improvement in maintenance or improvement in behavioral changebehavioral changeLimited by small sample sizeLimited by small sample size

Qualitative AnalysisQualitative AnalysisFourteen of the twenty participants (70%) provided written comments at the last (6-month) follow-up session.

93% responded they had a better understanding of how their behavior affected patient care and that the course helped them change their attitudes and behaviors.

93% identified at least one specific change in their behavior both professionally and in their personal lives that they attributed to skills learned in the course.

physicians ranked activities that focused on building communication skills and identifying triggers for emotional disregulation as the most “effective” and “helpful” components of the course (average score of 4.6 out of 5 on rating scales).

Lessons LearnedLessons LearnedPhysicians are referred by physician health Physicians are referred by physician health programs, hospital or practiceprograms, hospital or practiceFull psychiatric assessment not always necessaryFull psychiatric assessment not always necessaryGroup process addressed the loneliness of their Group process addressed the loneliness of their professionprofessionParticipants were younger than other coursesParticipants were younger than other coursesCollateral information was vitalCollateral information was vitalPhysicians with narcissistic traitsPhysicians with narcissistic traits

Lessons LearnedLessons Learned

A number of them already in outpatient therapy A number of them already in outpatient therapy or open to that recommendation by this team as or open to that recommendation by this team as another component to their another component to their ““recoveryrecovery””Some unhappy in their careerSome unhappy in their careerConsidered good physicians technicallyConsidered good physicians technicallyMore open than expectedMore open than expectedThey liked the experiential aspects of the They liked the experiential aspects of the program especially group interactionprogram especially group interaction

Lessons LearnedLessons LearnedPULSE indicates behavioral change for a subset PULSE indicates behavioral change for a subset of physicians is not only possible, but can be of physicians is not only possible, but can be maintained.maintained.Even when not statistically significant, large Even when not statistically significant, large effect sizes and physician testimonials point to effect sizes and physician testimonials point to a promising interventiona promising interventionFuture studies needed to identify which Future studies needed to identify which physicians are most likely to succeed and to physicians are most likely to succeed and to understand role that system plays in understand role that system plays in enabling/facilitating behaviors.enabling/facilitating behaviors.

A CME Course Aimed at Addressing Disruptive A CME Course Aimed at Addressing Disruptive Physician BehaviorPhysician Behavior to be published in to be published in The The Physician ExecutivePhysician Executive, 34(1), Jan/Feb 2008. , 34(1), Jan/Feb 2008.

The Center for Professional HealthThe Center for Professional Healthwww.mc.vanderbilt.edu/cphwww.mc.vanderbilt.edu/cph