Transcript 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
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)
What To Do? (Protocol For All
Cases)
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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
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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
professionals
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 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
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
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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
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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)
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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
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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
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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
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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
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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:
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 Medical workup with labs, CT/MRI
 Psychiatric/substance abuse evaluation
 Neuropsychological testing
 Drug testing
 Collateral information
 Simulated patients and cases in the physician’s field
Step-wise Protocol For
Handling Disruption (Level 3)
 Recommendations
by evaluation team may
include
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PHP involvement
Outpatient treatment
Residential treatment
Long-term psychotherapy
360 evaluations
Direct or indirect supervision and monitoring of the
physician’s practice
 Inability to practice for an indefinite period of time
 Other recommendations as felt needed
Stories Of Success And Failure
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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
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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
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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
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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 communication
 Improved patient safety
 Increased quality of patient care
 Reduced litigation and malpractice claims
 Increased 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
 [email protected]
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