Transcript Slide 1

2007 Annual Conference
DISRUPTIVE
PROFESSIONALS
Raymond M. Pomm, M.D.
Professionals Resource Network
WHAT IT IS NOT...
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
SUBSTANCE
RELATED
DISORDERS
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PSYCHOTIC
DISORDERS
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
MAJOR
DEPRESSION
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
BIPOLAR I / II
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
WHAT IT IS...
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
A Continuum
Hi Disruptive
Dangerous
Disruptive
Difficult
Different
Lo Disruptive
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Disruptive Professionals are
ultimately...
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
TEAM
BUSTERS!
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
The Underlying Issues...
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Predisposing
Character


Stress
Hospital
Culture

 
Poor
Role Models
Poor
Coping
Skills
Disruptive
Incidents
Council on Licensure, Enforcement and Regulation
2007 Annual Conference

Atlanta, Georgia
PERSONALITY
DISORDERS
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
NARCISSISTIC
PERSONALITY
DISORDER
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
THIS IS NO ORDINARY
PERSON YOU’RE DEALING
WITH!
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
WHAT TO DO...
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
There is no law that says one
cannot be Disruptive
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
The: -Hospital
-Group
-Corporation
-Leadership
holds the hammer
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
The steps to validate and
protect the hammer:
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
The intent of this policy and procedure is to
assist the referral source in utilizing the
services of PRN in the management of the
disruptive practitioner. The goal of these
steps is to determine whether rehabilitation is
a viable medical option. Before PRN will
accept the referral of a disruptive practitioner,
the following protocol must be followed:
Slide 1 of 8
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
1) The referral source must document all disruptive
behaviors, ramifications of said behaviors and any
action taken due to the behaviors.
2) Confidential, one-on-one discussion of the behaviors
in question between a “friendly” colleague
(representative of the referral source) and the
disruptive practitioner. The practitioner will be
informed, prior to the discussion, that the
confidentiality may be rescinded if the behaviors
continue.
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Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
3) Non-confidential, formal meeting with the admin level
representative of the referral source, supervisor (if
applicable) and the disruptive practitioner to discuss
documented disruptive behaviors that need to be
corrected, resulting in a warning that outlines
consequences, if not corrected.
** An optional step can be inserted at this point if the referring
source has an associated Impaired Practitioner Committee.
This committee can be authorized to refer to PRN (step #4 b-e)
or a recommendation will be made to the disciplinary body for
suspension/termination (step 4a) of the disruptive practitioner.
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Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
4) Meeting of disciplinary body of the referral source:
a) disciplinary body must be ready to
suspend/terminate the disruptive practitioner
if he/she is unwilling to proceed and comply
with the following steps;
b) if both parties are in agreement, the
disruptive practitioner must contact PRN in
order to avoid suspension/termination;
c) disruptive practitioner must sign release for
PRN to communicate with referral source;
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Slide4 of 8
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
d) phone call made by referral source to
PRN in presence of the disruptive
practitioner;
e) all of the documentation must be faxed to
PRN by referral source within five (5)
business days of the referral to PRN;
f) documentation must be of adequate detail
for PRN to take appropriate action;
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Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
5) Refer for evaluation, to be arranged by PRN, to
a DOH/PRN approved evaluator. The
evaluation must be comprehensive. The
evaluation must be completed within ten (10)
business days of the referral or PRN
will recommend the hospital follow through with
suspension/termination (unless delay is caused
by the evaluator and/or PRN).
Slide 6 of 8
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
6) If evaluation is not completed in timely fashion, PRN
will make decision whether information is sufficient
for referral to Department of Health to compel an
evaluation within a certain time frame.
7) If appropriate, contract with PRN under Behavioral
Management Contract to include:
a) therapeutic recommendations of the evaluator,
b) behavioral requirements and consequences
as agreed to by the referral source, evaluator
and disruptive practitioner,
Slide7 of 8
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
8) The disruptive practitioner must execute the
contract within ten (10) business days of its
receipt.
** PRN is available to the referral source to
discuss situation/issues/procedures at any
time during this process
Slide 8 of 8
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Let’s look at
Evaluation/Treatment/
Monitoring Process...
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Speaker Contact Information
Raymond M. Pomm, M.D.
Professionals Resource Network
P.O. Box 1020
Fernandina Beach, FL 32035
(800) 888 - 8776
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
2007 Annual Conference
Disruptive Professionals:
New Approaches to
Evaluation and Management
Larry Harmon, PhD
Physicians Development Program
Disruptive Behavior is …
… a pattern of conduct which
reduces or disrupts
the ability of the
healthcare (or other) team
to do it’s best work
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Who are the Disruptive Docs?
• MBAs
• “Good Doc … Bad Talk”
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Clinical Evaluation
• Clinical Interview
• Extensive Personal History
• Psychological & Cognitive Testing
• Criminal Background Checks
• Drug Testing
• “Workplace Behavior Assessment”
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Workplace Behavioral Assessment
360° P.U.L.S.E. Survey
P.hysicians + Professionals
U.niversal
L.eadership + Teamwork
S.kills
E.ducation Survey
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Workplace Behavioral Assessment
1. Each physician scores self on survey
2. Other physicians and healthcare
team members give physician
survey feedback
3. Feedback Report is prepared
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
3 Types of Assessments
1. Individual - Continued disruptive
pattern despite progressive warnings
2. Small Group or Section (2-10)
• Individual resists
• Protect identity of subject
3. Department or Hospital Program
Annual Leadership Feedback Reports
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Conducting an
Individual
Workplace Behavioral
Assessment
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Phase I:
Assessment
Step 1: Referral Letter
Step 2: Physician Orientation
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Step 3. Select “Feedback Groups”
Administration
Colleagues
Other
Depts.
Supervisors
Dr. Disruptive
Nurses+
Support Healthcare Staff
*Patient Pulse survey
Staff
Council on Licensure,
Enforcement and Regulation
Patients*
2007 Annual Conference
Atlanta, Georgia
Step 3. Select “Feedback Groups”
Administration
“Validator”Supervisors
Colleagues
Other
Depts.
Adds Any
Missing Names
(ChiefDr.
of Staff,Disruptive
CEO,
i.e., the “Boss”)
Nurses+
Support Healthcare Staff
*Patient Pulse survey
Staff
Council on Licensure,
Enforcement and Regulation
Patients*
2007 Annual Conference
Atlanta, Georgia
Step 4. “Self-Rating”
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2007 Annual Conference
Atlanta, Georgia
Motivating/Encouraging Dimensions
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2007 Annual Conference
Atlanta, Georgia
Disruptive/Discouraging Dimensions
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Step 5. Writes Cover Letter
TO: My Team Members and Colleagues
RE: Invitation for Honest Feedback
I am participating in a national Physicians
Leadership Development Program, and part of the
program is to obtain feedback to help me better
understand my workplace interpersonal
leadership style and people skills.
I have requested the Physicians Development
Program to distribute their physician people skills
survey, called the “P.U.L.S.E. Leadership Survey,”
to my team members, so I can get group
feedback.
Be honest…survey is anonymous…
Dirk Disruptive, MD
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Step 6: Send Surveys+Create Report
1. Mailed / Emailed to Raters
3. Feedback Report Prepared
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Dr. Disruptive requests your
honest and anonymous feedback
Dirk Disruptive, MD
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Treating us with common courtesy.
Explaining rather than yelling.
Saying please and thank you.
Talking down to us.
Yelling and screaming.
Scaring me. I call in sick when you’re here.
Being an excellent doctor.
Having great technical skills.
Taking good care of patients.
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
“Discourager” or “Disruptive”
Feedback Report
Physicians P.U.L.S.E. Program
P.hysicians U.niversal L.eadership S.kills E.ducation Program
LEADERSHIP FEEDBACK REPORT
Prepared for
Dr. Disruptive
January 1, 2007
This report includes feedback from 22 individuals,
including your self-rating if you completed one.
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Self-Rating
Physician
Peers
Self-Rating
Nursing Staff
Physician-Peers
Nursing
Staff
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Nursing
Staff
Physic
-ians
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Findings & Recommendations
•
•
•
•
•
No Disruptive •
Mild
•
Moderate
•
Serious
•
Severe Disrup-•
tive Behavior •
No Recommendation
Anger Mgmt. Videos
Anger Mgmt. Program
Weekly Group
Psychotherapy
Tele-Coaching (month)
• Survey Monitoring
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Phase II:
Distance
Education
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Teamwork-Leadership Training
 Using Emotional Intelligence
 Managing Anger at Work
 Resolving Conflicts
 Managing Difficult Staff
 Managing/Motivating Teams
 Managing Frustration
 Managing Time
 Emotional Self-discipline
 Managing Medical Mistakes
Constructively
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Phase III.
Follow-up
“Graduation” requires 4 consecutive
acceptable Feedback Reports
NO RED BEHAVIORS!
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Phase IV:
Group Program
or Treatment
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
3 Types of Assessments
1. Individual - Continued disruptive
pattern despite progressive warnings
2. Small Group or Section (2-10)
A. Individual resists
B. Protect identity of subject
3. Department or Hospital Program
A. Annual Leadership Feedback Reports
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Other Professionals
• Immigration and Naturalization
Service (INS)
–Law Enforcement
–Naturalization Services
• Telephone Marketers
• Hospital Executives
• Attorneys
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Research Findings
1. Do Disruptive Physicians – enrolled in
the P.U.L.S.E. Program and other
interventions …
A. REDUCE their Disruptive behaviors?
B. INCREASE Motivating Behaviors?
2. And, if they improve, does it last?
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
160 Disruptive Physicians
Participants
74 Active Physicians / 86 Physicians
1. COMPLETED PROGRAM BY Facility
or PDP STANDARDS 77.19%
completers
Completed by Facility Standards (61.40%)
Completed by Early PDP Standards (15.79%)
2. WITHDRAWAL -- NOT DUE TO DISRUPTIVE BEHAVIOR
10.52%
Facility withdrew Physician (5.26%)
Physician withdrew Self (5.26%)
PDP withdrew (00.00%)
3. EXPELLED -- FOR DISRUPTIVE BEHAVIOR
0.00%
By Facility (00.00%)
By PDP (00.00%)
4. OTHER (INSUFFICIENT INFORMATION)
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
12.28%
Atlanta, Georgia
Leadership Improvement in 282 Physicians
(Disruptive vs. Normal and Role-Model)
after P.U.L.S.E. Feedback from Raters
100
ROLE MODELS (N=68)
LEADERSHIP INDEX
80
NORMALS (N=97)
120.5%
Improvement
60
DISRUPTIVE (N=117)
572%
Improvement
40
20
0
MOST DISRUPTIVE 25%
(N=30)
Baseline #1** Follow-up #2* Follow-up #3*
Follow-up #4*
Follow-up #5*
(3.5 years)
-20
Council on Licensure,
and Regulation
**At baseline, all groups significantly
different at Enforcement
(p) <.01.
Dot t ed l i ne = P r oj ect ed val ues
2007
Annual
Conference
Baseline 1 vs. follow-up 2 for disruptive physicians: significantly different at (p)Atlanta,
< .01. Georgia
Top Improved Behaviors in Disruptives
1.
2.
3.
4.
5.
6.
Remains approachable even when stressed out
Treats team members with respect
Handles difficult team members effectively
Is open to suggestions
Responds to conflict by working out solutions
Adapts to changing policies, procedures, priorities
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Underlying
Principle
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
When you see Roadside Radar,
what’s the first thing you do?
“Feedback Creates Change!”
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Curious Questions?
Concerned Comments?
Interesting Ideas?
Larry Harmon, PhD
Director, Physicians Development Program
[email protected]
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
2007 Annual Conference
The Neurobiology of
Disruptive Behavior
Mick Oreskovich, MD
Medical Director and CEO
Washington Physicians Health Program
Our every thought
Every feeling
Every action
Is chemically mediated!
Disruptive behavior is a chemical
event in the brain!
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Transference
Countertransference
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
How To Deal With The FEAR This
Behavior Generates In Us?
• Acknowledge our counter transference: the set
of expectations, beliefs, and emotional
responses that we bring to this relationship!
• Educate ourselves about the causes of this
behavior!
• So that we can move toward seeing this
behavior phenomenologically, empathically,
and non-pejoratively
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Gene-brain-behavior relationships: Evidence that aggression is associated with brain MAO A activity in
healthy males. N Alia-Klein1, E. Shumay1, R. Goldstein1, A. Kriplani1, J. Logan1, F. Telang1, B. Williams2, I.
Craig2, GJ Wang1, F. Henn1, N. Volkow3 and J. Fowler1
1 Brookhaven Center for Translational Neuroimaging, BNL, Upton, New York; ; 2 Psychological Medicine,
Psychiatry, King's College, London, United Kingdom; ; 3 National Institute on Drug Abuse, NIH, Bethesda,
Maryland
J Nucl Med. 2007; 48 (Supplement 2):262P
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Inside the middle of the brain is the limbic system and
the amygdala:
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Amygdala:
1. How we associate things in the world
with emotional responses and process
emotional information.
2. Allows us to overrule instinctive
responses by connecting the cortex’s
memories of things to the emotions
they engender.
3. Allows us to respond to fear stimuli.
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
About DNA





Six feet in every cell
3.2 billion letters of coding
10 to the 3,480,000,000
More than 5,000 books just to print that #!
10,000 trillion cells…earth to moon and back,
again and again
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Genetic markers with behavioral correlates
• Serotonin Transporter Gene (SLC6A4):
Chromosome 17q11.2
• DRD2 receptor:
Chromosome 11q22-q23
• Effects of alcohol, BZ, barbiturates
Chromosome 4p (GABA-A, GABA-1)
Chromosome 15 (GABA-3)
• Serotonin level
Chromosome 11 (tyrosine hydroxylase)
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
5-HTTLPR S allele driven amygdala
hyper-reactivity to environmental cues
Hariri et al., Science 2002
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
S allele driven amygdala hyperreactivity
Hariri et al., Science 2002
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
5-HTTLPR also effects information
processing related to temperament
between the amygdala and the cortex
Hamann, Nature Neuroscience 2005
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
It appears that if we inherit the 5HTTLPR S allele:
• A “look” or tone of voice
• Changes our production of serotonin in our
midbrain
• Fear becomes anger in our amygdala
• We perceive imminent threat in our forebrain
• We respond with a maladaptive defensive
coping mechanism…ie., raise our voice, swear,
and threaten
• We become the “disruptive doc”
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
David T George, MD, Section of Clinical Studies, NIAAA
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Our every thought
Every feeling
Every action
Is chemically mediated!
Disruptive behavior is a chemical
event in the brain!
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia
Mick Oreskovich, MD
[email protected]
www.wphp.org
Council on Licensure, Enforcement and Regulation
2007 Annual Conference
Atlanta, Georgia