Transcript The Problem Colleague

The Problem Colleague
Carol A. Burke MD, FACG
Cleveland Clinic, Cleveland OH
Objectives
• Define professional vs disruptive behavior
• Discuss scenarios that a “problem
colleague” may present to you
• Develop a strategic plan for approaching a
colleague about concerns
• Discuss impairment issues
• Plan an approach for accessing resources
needed for a colleague
Toolkit for success
What Defines Medical Professionalism ?
Professionalism is like pornography: easy
to recognize but difficult to define
Sir Luke Fildes, The Doctor, 1887
Defining Medical Professionalism
• Subordinate personal interests to those of others
• Adhere to high ethical and moral standards
• Respond to societal needs with behaviors
reflecting social contract with communities
served
• Evince core humanistic values, honesty and
integrity, caring and compassion, altruism and
empathy, respect for others, trustworthiness
Swick H. Acad Med 2000; 75
Defining Medical Professionalism
• Exercise accountability for self and colleagues
• Demonstrate continuing commitment to excellence
• Exhibit commitment to scholarship and advancing the
field
• Deal with high levels of complexity and uncertainty
• Reflect upon actions and decisions
Swick H. Acad Med 2000; 75
ABIM and Professionalism
• Since 1994, ABIM has required candidates
to demonstrate they have acquired the
values of professionalism
– ‘‘aspires to altruism, accountability,
excellence, duty, service, honor, integrity and
respect for others
AMA Principles of Medical Ethics
Physician must recognize responsibility to patients first and
foremost, as well as to society, to other health
professionals, and to self.
Principles adopted are standards of conduct defining essentials of
honorable physician behavior
II. A physician shall uphold the standards of professionalism, be honest
in all professional interactions, and strive to report physicians
deficient in character or competence, or engaging in fraud or
deception, to appropriate entities
IV. A physician shall respect the rights of patients, colleagues,
and other health professionals, and shall safeguard patient
confidences and privacy within the constraints of the law.
AMA Code of Ethics
What are Disruptive Behaviors?
Disruptive Behaviors
• Profane, disrespectful or demeaning language or
behaviors
• Sexual harassment
• Intimidation
• Uncooperative attitudes
• Failure to follow practice guidelines or practice standards
• Verbal or physical outbursts of threats
• Criticizing hospital staff in front of patients or other staff
• Negative comments about another providers care
• Boundary violations: staff or patients
• Unethical or dishonest behavior
Leap L., Ann Intern Med. 2006;144:107-115.
Joint Commission Regulations on
Disruptive Behaviors
• 2008, JC required hospitals to have a code of conduct and
process for managing disruptive and inappropriate behaviors
• “overt actions such as verbal outbursts and physical threats, as well
as passive activities such as refusing to perform assigned tasks or
quietly exhibiting uncooperative attitudes during routine activities”
• “intimidating and disruptive behaviors are often manifested by health
care professionals in positions of power. Such behaviors include
reluctance or refusal to answer questions, return phone calls or
pages, condescending language or voice intonation and impatience
with questions.”
http://www.jointcommission.org/SentinelEvents. Iss. 40, Behaviors that undermine a culture of safety. 2008
The Disruptive Physician
Engages in consistent pattern of unprofessional,
uncooperative or contentious behavior which
creates a hostile and demoralizing work
environment, contributes to poor patient outcomes
and compromises the delivery of safe and quality
care
Characteristics of Disruptive Physicians
•
•
•
•
•
•
•
•
•
•
•
Don’t think of themselves as disruptive
High achievers
Expect high standards, of self and others
See themselves as patient advocates
Well liked by their patients
Passionate about their work
Appear confident
Believe in what is right
Often neglect their own health and wellness
Feel distressed, frustrated, disillusioned
All or nothing thinking
Modified from Jeffrey Kolson
Characteristics of Disruptive Physicians
•
•
•
•
•
•
•
•
•
Legitimate concerns communicated ineffectively
Feel under appreciated or unrecognized
Poor team players, preferring to act alone
Communicate emotionally, poor control over anger
Easily offended, fragile ego
Distrust and suspicious of motivation of others
Lack respect or empathy of others
Rarely apologizes for behavior, blames others
Passive aggressive
Modified from Jeffrey Kolson
Cite Factors Leading to
Disruptive Behavior
Factors associated with
Disruptive Behaviors
• Illness, age, disease-related cognitive
impairment
• Failure to maintain or acquire knowledge and
skills
• Overwork, lack of sleep, family strife
Factors associated with
Disruptive Behaviors
• Rapidly changing work environment
• Lack of control, Inadequate systems support
• Supervisor pressure, productivity demands, cost
containment requirements, malpractice litigation
• Poor practice management skills
• Challenges with poorly performing colleagues or
providers chronic criticisms creating difficult
practice environments
Institutional Factors
• Disruptive behavior sometimes reaction to
legitimate problems with system
– Lack of clear or enforced code of conduct
– Code of silence
– Fear of confrontation, retribution, lawsuit,
physical safety
– Fear of damaging physicians career
Factors associated with
Disruptive Behavior
• Mental problems, substance abuse or dependence
– Associated with MD suicide
• Workplace often last affected by DB due to above
– Non professional MD relationships already “impaired”
• Addiction reported in > 50% MDs admitted to psych hospitals
– Higher frequency of ETOHism in female MDs than
women in general population
Leap L., Ann Intern Med. 2006;144:107-115
Factors associated with
Disruptive Behavior
• MDs who suicide more critical of others/selves and
blame self for illness
• Some evidence MDs uncomfortable seeking help,
instead resort to alcohol or drugs and isolation
• Once help sought, appears not taken seriously by
colleagues
• Among suicidal physicians who sought help, > 50% who
committed suicide diagnosed with psychiatric conditions
but not hospitalized before death
Leap L., Ann Intern Med. 2006;144:107-115
Physician Suicide Rates
Men
1.41
Women
2.27
Schernhammer ES, Am J Psychiatry 2004; 161:12
Impact of Disruptive Behavior
•
•
•
•
•
Poor adherence to practice guidelines
Loss of patients
Low staff morale and turnover
Decreased staff and patient satisfaction
Medical errors, adverse outcomes, malpractice claims
– Association between patient complaints and MDs risk
management profiles
• Consistently doctor-patient, doctor-doctor, and staffdoctor communication is disruptor of team function and
driver of risk management activity
Communication
• Hierarchy, or power distance, frequently inhibits
people from speaking up
• Effective leaders flatten the hierarchy, create
familiarity and make it feel safe to speak up and
participate.
Leonard M, Qual Saf Health Care 2004;13(Suppl 1):i85–i90.
Positive impact of managing
disruptive behaviors
• Improved staff satisfaction and retention
• Enhanced reputation for the practice
• Creation of a culture of professionals who are
role models for trainees and one another
• Improved patient safety
• Reduced liability exposure and risk management
activity
• Greater productivity, civility and desirable work
environment
How Prevalent is Disruptive
Behavior?
Frequency and Impact of
Disruptive Behavior
4530 participants, 2846 nurses, 944 MDs, 40 administrators, 700 other
Rosenstein A, Joint Comm J Qual Patient Safety 2008;34
Prevalence of
Disruptive Behaviors
Team behaves professionally
Feel respected at work
Experienced DB
Staff
N = 40
Intern
N = 394
87.5%
80.4%
90%
71.5%
Less than interns
93%
Interns versus Staff
• Condescending behavior (OR, 5.46; P < .001)
• Exclusion from decision making (OR, 6.97; P < .001)
• Berating (OR, 4.84; P = .02)
• Inappropriate jokes, abusive language, and gender bias (NS)
• Interns: RN most frequent source of disruption (OR, 10.40; P < .001)
• Staff: Other MD most frequent source of disruptive behaviors
Mullan CP, J Grad Med Educ. 2013; 5(1):25-30
Approach to Disruptive Behavior
First Steps
• Develop code of conduct
defining acceptable, disruptive
and inappropriate behaviors
• Devise policies and procedures
for identification and
management of DB
Next Steps
• Educate team on behaviors
and code of conduct
• Hold members accountable for
modeling desirable behaviors
• Implement processes
appropriate for the
organization
• Provide training for leaders in
relationship-building,
collaborative practice, skills for
giving feedback on
unprofessional behavior, and
conflict resolution
Approach to Disruptive Behavior
• Develop, implement a reporting/surveillance system
• Use tiered, non-confrontational interventional strategies
• Conduct interventions in context of organizational
commitment to health and well-being of all staff, patient
safety and quality of care
• Ensure resources to support individuals whose behavior
is caused or influenced by physical or mental health
issues
• Document attempts to address disruptive behaviors
ACTION
Increasing
Severity of
Behavior
Unacceptable
behavior under any
circumstance or
repeated misconduct
Pattern persists or worsens
Repetition of same type of misbehavior:
A pattern of such develops
Single, non-violent or non serious incident
Dismissal
Authority intervention
Awareness intervention
One on one intervention
Modified from: Hickson GB. Acad Med 2007;82(11):1040-8
Management of Disruptive Behavior
•
•
•
•
•
•
•
•
Timely
Objective and factual
Organized
Role specific
Confidential
Respectful
In best interest of patient, MD and Institution
Measure it
Measuring Disruptive Behavior
Pichert J, Advances in Patient Safety: New Directions and
Alternative Approaches (Vol. 2: Culture and Redesign). Rockville
(MD): Agency for Healthcare Research and Quality (US); 2008
Aug
Collegial Approach
•
•
•
•
•
Preferred method, for as long as possible
Non confrontational, non punitive, respectful
Use with behaviors that don’t require reporting
Present objective observations/concerns
Affirm value to institution and acknowledge their
aspirations
• Provide feedback on impact of behavior
Collegial Approach
•
•
•
•
•
Point out need for change
Suggestions process/dealing with frustration
Offer voluntary referral for additional resources
Initiate documentation and continue monitoring
If problem persists, provide warning/consequences
Strategies
• Goal: Immediate intervention to diffuse tension
and de-escalate disruptive reactions
– “ I observed what occurred and …”
– “ I’m concerned about what is occurring…”
– “ I sense a significant amount of frustration on your
part…”
– “I saw some behaviors that concern me greatly…”
– “It seems like the situation has deteriorated…”
Strategies
•
•
•
•
Immediate feedback
Limit setting
Empowerment of the target as focus
Respectful communication is attempted with clear
expectations for appropriate behavior. Requires
assertiveness
– “I am going to ask you to refrain from using that language with
me…”
– “I cannot help you if you continue to yell at me…”
– “This behavior is unacceptable and unnecessary…”
– “STOP”
Strategies
• Explore root causes, underlying emotions,
needs
– Please tell me more about how things got to this
point…..
– I hear you say you feel frustrated because….
– I see you have been unable to achieve what is
important to you …..
• Avoid validating ineffective behaviors
Strategies
• Acknowledge current behavior not effective
• “ It seems like despite your efforts, the situation
has gotten worse…”
• “In retrospect, would you do it again the same
way?”
• “It sounds like you recognize your approach
needs to change….”
• “I think it is clear things cannot continue this
way…”
Strategies
• Provide feedback, clarify procedures, offer
possible solutions. When possible let MD decide
next step toward change
– “I really appreciate your knowledge and expertise, at
the same time, I wonder how you might improve on
the way you communicate without getting so angry…”
– “I need you to consider how our procedure works….”
– “ It is evident to me that your goal to become a
physician leader requires development in certain
areas…”
– I would really like you to consider meeting privately
with the PHP to strengthen in these areas…”
Peer Messengers
• Peer messengers, recognized by leaders,
supported with ongoing training, high-quality
data, and evidence of positive outcomes, willing
to intervene with colleagues over extended time
Pitchert J, Jt Comm J Qual Patient Saf. 2013 Oct;39(10):435-46
Impact of Peer Messengers
• 178 peer messengers and 373 high risk MDs
• 97% high-risk MDs received feedback
• 64% "Responders”
– Risk scores improved > 15%
– Nonresponders scores worsened 17% or
remained unchanged 19% (p < 0.001).
Pitchert J, Jt Comm J Qual Patient Saf. 2013 Oct;39(10):435-46
Impact of Peer Messengers
• Responders Characteristics:
– Practicing medicine and surgery vs emergency
medicine
– Longer organizational tenures
– Lengthier first-time intervention meetings
– Years to achieve “responder” correlated with
communication-related complaints (r = .32, p < .001),
but all complaint categories equally likely to change
• CONCLUSIONS: Peer messengers reduce patient
complaints, are adaptable to address unnecessary
variation in other quality/safety metrics.
Pitchert J, Jt Comm J Qual Patient Saf. 2013 Oct;39(10):435-46
Formal Approach
• Necessary when conduct unresolved or
egregious
– Verbal or physical assault
– Adverse effect on patient safety, well being
•
•
•
•
Document facts in writing, confidential
Consult with legal, professional staff affairs
Meet MD with coordinated and clear objectives
Set agenda, focus on behavior
– Avoid root causes, shifting focus, displaced blame
Formal Approach
• Avoid mixed messages
• Review code of conduct
• Identify behavioral expectations and
consequences
• Affirm commitment to help the MD
• Review disciplinary steps
• Inform of referral to Professional Affairs
– Fitness for duty
• Document meeting, monitor, continue FU’s
Modified from Jeffrey Kolson
Strategies
• Immediate cessation behavior, non negotiable
• Formal description of problem provided and remediation
options reviewed, affirm confidentiality
– “We are investigating reports you have violated our code of
conduct…”
– “Continued actions of this nature will not be acceptable….”
– “This matter will require your full cooperation to resolve…”
– “We would like to offer you the opportunity to rectify this
situation…”
– “Failure to rectify will result in further disciplinary action…”
Treatment Modalities
•
•
•
•
•
Role Modeling, Coaching, 360 evaluation
Psycho-Education, Group Therapy
Psychologic Counseling, Psychiatric Treatment
Substance Abuse/Dependency Treatment
Education and training
– Phone etiquette or “charm school”
– Sensitivity or diversity training
– Stress and anger management
– Conflict management or assertiveness training
– Communication competence
Questions?
Summary
• Standards for appropriate behavior exist
• Disruptive Behavior is common, unacceptable
• Organizational commitment, education and
resources required
– Devise policies for recognition/management of DB
• Tiered approach to intervention
– Collegial approach first
• Explore root causes, provide support, set
consequences