“Creating a Culture of Professionalism” Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Center for Professional.
Download ReportTranscript “Creating a Culture of Professionalism” Charlene M. Dewey, M.D., M.Ed., FACP Associate Professor of Medical Education and Administration Associate Professor of Medicine Center for Professional.
Slide 1
“Creating a Culture of
Professionalism”
Charlene M. Dewey, M.D., M.Ed., FACP
Associate Professor of Medical Education and Administration
Associate Professor of Medicine
Center for Professional Health
Vanderbilt University School of Medicine
Marshall University Joan C. Edwards School of Medicine
August 28, 2012
Slide 2
Professionalism
1. AMA Code of Ethics 1847
2. ACP Ethics Manual 2005
3. A Physician Charter: ABIM, ACP,
European Federation of Internal
Medicine 2007
4. Stern’s professionalism model
5. Institutional codes of conduct and
policies
Slide 3
Stern’s Professionalism Model
“Professionalism is demonstrated though a
foundation of clinical competence,
communication skills and ethical and legal
understanding, upon which is built the
aspiration to wise application of the principles
of professionalism: excellence, humanism,
accountability, and altruism.”
Stern: Figure 2-1 A Definition of Professionalism pg 19; “Measuring Medical Professionalism” Oxford Press 2006.
Slide 4
Professionalism
Altruism
Accountability
Humanism
Excellence
Professionalism
Ethical and Legal Understanding
Communication Skill
Clinical Competence (Knowledge of Medicine)
Professional Health & Wellness
Professional Culture
Dewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006
Slide 5
Two Systems Interact
The External System
“Personal & Institutional Vitality”
Functional
& Nurturing
The Internal System
Good Skills
& Well
Work Environment
Clinician
Poor Skills
&/or Not Well
Dysfunctional
“The Perfect Storm”
Slide 6
Professional vs. Unprofessional
Slide 7
Professional vs. Unprofessional
“We judge ourselves by our
motives whereas others judge
us by our behavior.”
~AA saying
Slide 8
Goals
• The purpose of the session is to provide
information and discussion around
professionalism and lapses in
professionalism and how the overall culture
is influenced by both individual behaviors
and institutional norms.
Slide 9
Objectives
Upon completion of the session, participants
will be able to:
1. List and discuss four types of professionalism
lapses.
2. Analyze the roles of the individual and the
institution as they shape the overall culture of
professionalism.
3. Accept that both individuals and the institution
are responsible for promoting a culture of
professionalism.
Slide 10
Agenda
1.
2.
3.
4.
5.
6.
Four examples of professionalism lapses
Individual & institutional roles
Stress & burnout
Influencing professional cultures
Resources
Summary
Slide 11
Center for Professional Health
• Faculty and Physician Wellness Committee
• 3 CME accredited professional development
programs
– Distressed Physician
– Maintaining Proper Boundaries
– Proper Prescribing CPD
• ~15 years in training/remeding physicians
• Demographics:
–
–
–
–
Mandated > voluntary
IM, FP - but all specialties
Males > females
Rural, solo practices > academic health center
http://www.mc.vanderbilt.edu/cph
Slide 12
Professional Lapses
•
•
•
•
•
•
661,400 physicians/surgeons in US in 2008
>32,000 sanctions btw 2004 - 2008 (~5-10%)
955 criminal
Many uncategorized
Many events not reported
Physician Survey 2007:
– 96% agreed physicians should report
impaired or incompetent colleagues
– 45% who encountered such colleagues
did not report events
Campbell, et al. “Professionalism in Medicine: Results of a National Survey of Physicians” Ann In Med, 2007
Slide 13
Professionalism Lapses
Four major professionalism lapses:
1.
2.
3.
4.
Distressed/disruptive behaviors
Boundary violations
Improper prescribing
Impairment
Slide 14
Distressed/Disruptive Behaviors
Slide 15
Disruptive Behavior
• “Behavior or behaviors that undermine a
culture of safety.”1
• Disruptive behavior is a sentinel event2
1) The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD.03.01.01, elements of performance (EP) 4 and 5, Spring 2012;
2) Joint Commission, Issue 40 July 9, 2008
Slide 16
Spectrum of Disruptive Behaviors
Aggressive
Inappropriate anger,
threats
Yelling, publicly degrading
team members
Intimidating staff,
patients, colleagues, etc.
Pushing, throwing objects
Swearing
Outburst of anger &
physical abuse
Passive
Passive
Aggressive
Hostile notes, emails
Derogatory comments about
institution, hospital, group,
etc.
Inappropriate joking
Sexual
Harassment
Chronically late
Failure to return calls
Inappropriate/
inadequate chart notes
Avoiding meetings & individuals
Non-participation
Ill-prepared, not prepared
Complaining,
Blaming
Swiggart, Dewey, Hickson, Finlayson. “A Plan for Identification, Treatment, and remediation of Disruptive Behaviors in Physicians.”
Frontier's of Health Services management, 2009; 25(4):3-11.
Slide 17
Distressed/Disruptive Behaviors
Etiologies-Individuals:
• Psychological Factors1:
– Substance use/abuse,
trauma history, religious
fundamentalism, familial
high achievement
• MH issues2:
– Personality disorders,
narcissism, depression,
bipolar, OCD, etc.
1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002
• Genetic/developmental
issues:
– Asperger’s, non-verbal
learning differences, etc.
• Family systems
• Stress/physiologic
reactions
• Burnout3
• Reduced wellness
Slide 18
Distressed/Disruptive Behaviors
Etiologies-Institutional:
– System reinforces behavior
– Leadership ignores problems for productivity
– Scapegoats
– Individual pathology may over-shadow
institutional pathology
Williams and Williams, 2004
Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007
Slide 19
Distressed/Disruptive Behaviors
Increase Liability and Risk
Poor Work
Environment
Lost of Finances
& Reputation
Reduced Pt
Safety
Cycle
Horizontal
Hostility
Poor
Communication
Staff
Turnovers
Slide 20
Boundary Violations
Slide 21
Boundary Violations
• Power differential
• Sexual misconduct
– Sexual impropriety
– Sexual violations
• Sexual harassment
• Social media
– Unprofessional, disinhibition, anonymity
Slide 22
Boundary Violations
• Etiologies:
– Environment:
• Relaxed professional culture – “slippery slope”
– Individual:
• Stress & burnout
• Lack of self-care
• Lack of knowledge
– Patients:
• Predators & drugs
Dewey, Swiggart, Manley, & Spickard. “Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine” – CPH 2011.
Slide 23
Misprescribing CPD
Slide 24
Six Categories of
Misprescribing Physicians
Dated: Fails to keep current
Disabled: Failed judgment due to impairment
Duped: Fails to detect
Dishonest: Personal or financial gain
Dismayed: Rx as a quick fix due to time
Dysfunctional: Fails to say no
Brown, Swiggart, Dewey, & Ghulyan, “Searching for answers: proper prescribing of controlled prescription drugs.” J Psychoactive
Drugs. 2012 Jan-Mar;44(1):79-85.
Slide 25
Misprescribing CPD
• Rules and guidelines:
– DEA – “Practitioner's Manual”
– SMB & FSMB
• Drug seeking patients – “Confrontational
phobia”
• Prescribing for non-patient colleagues,
friends, families
• Self-prescribing
Dewey, Swiggart, Brown, Baron, & Ghulyan, “Proper Prescribing of CPDs: What Every Physician Needs to Know”,submitted 2012
Slide 26
Impairment
Slide 27
Impairment
AMA: “…any physical, mental or behavioral disorder that
interferes with ability to engage safely in professional
activities...”
1. Physical impairment
2. Cognitive impairment
3. Psychological impairment
–
–
Substance use disorders (licit and illicit drugs)
Mental health disorders (depression & suicide)
Affects: individual, family, patients, institution
AMA Polices Related to Physician Health, 2011 http://www.ama-assn.org/resources/doc/physician-health/policies-physicainhealth.pdf - Accessed 8/13/2012
Slide 28
Impairment
“Every physician is responsible for protecting
patients from an impaired physician and for
assisting an impaired colleague.”
~ACP Ethics Manual
Ethics Manual, 5th Edition. American College of Physicians 190 N. Independence Mall West. Philadelphia, PA. 19106-1572
Slide 29
Professionalism Lapses
• Consequences:
– Restriction or loss of DEA registration
– Restricted or loss of medical license
– Loss of job
– Law suites and restriction of insurance coverage
– Loss of relationships – personal and work
– Loss of self
Slide 30
Unprofessional Conduct
Four major professionalism lapses:
1.
2.
3.
4.
Distressed/disruptive behaviors
Boundary violations
Improper prescribing
Impairment
Slide 31
Slide 32
Two Systems Interact
The External System
“Personal & Institutional Vitality”
Functional
& Nurturing
The Internal System
Good Skills
& Well
Work Environment
Clinician
Poor Skills
&/or Not Well
Dysfunctional
“The Perfect Storm”
Slide 33
Clinician
Slide 34
Clinician
“These are the duties of a physician: First... to
heal his mind and to give help to himself
before giving it to anyone else.”
~ Epitaph of an Athenian doctor, AD 2.
Boisaubin & Levine. Identifying and Assisting the Impaired Physician Am J Med Sci, 2001; 322(1):31-6.
Slide 35
Professional Health & Wellness
Spectrum
Work &
Family
Relations
High Functioning
High Productivity
Fair Functioning
Decreasing Productivity
Fair Functioning
Reduced Productivity
Relationships Suffer
Fair-Not Functioning
Fair-Not Productive
Institution & Family Loses
Physical
Mental
Emotional
Spiritual
Professionally Healthy
& Well
Stressed
Burnout
Coping Mechanisms
Strong
Coping Mechanisms
Failing
Risk of MH issues and
suicide
No Coping Mechanisms
Dewey, CM and Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine, 2009.
Slide 36
Clinician Health & Wellness
•
•
•
•
•
Little education on topic
30-60% MD are distressed and at burnout
MS & residents
↑ Primary care (IM, FP, ER)
MDs suicide > other prof. & gen pop.
– One physician per day; PhD – unclear
– Grossly underestimated
– Depression/bipolar & substance abuse = suicide risk
“Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, 2009 &
Shannafelt, Arch In Med, 2012.
Slide 37
Clinician Health & Wellness
• Gender differences:
•
•
•
•
Females > anxiety, depression, burnout
F>M MD suicides (>50% vs 40% higher risk)
Women chairs more stressed
Male physicians (regardless of race) live longer than other
professionals
• Reduced use of care by physician
• Stigma & anonymity – slow to prioritize MH issues
for physicians; licenses, etc.
http://www.aamc.org/members/gwims/statistics/stats09/start.htm
Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82.
(Schindler et al 2006) and “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008
Slide 38
Clinician Health & Wellness
• Academic faculty:
– Worked longer hours
– Took less vacation
• 10% with mild depression
• 27% with elevated anxiety
– No sig difference clinical vs. academic
Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82.
Schindler et al. The Impact onof the changing Health Care Environment on the Health and Well-being of faculty at Four Medical Schools.
Academ Med 2006 81(1):27-34.
Slide 39
Clinician Health & Wellness
•
•
•
•
•
•
•
•
Self-care
Stress & burnout
Emotional intelligence
Family systems
Training experiences – hidden curriculum
Coping skills
Conflict management
Personality types
Slide 40
Self-Care
Seven key areas:
1.
2.
3.
4.
5.
6.
7.
Sleep
Balanced meals
Physical activity
Socialization/hobbies
Vacations/down times
Spiritual engagement
Having a personal physician
Mind
Body
Soul
Emotion
Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter
Scientific Meeting, Sept 17, 2010.
Slide 41
Stress & Productivity
Prolonged
Stress
Reduced
Cognition
“Impairment” ???
No
Prolonged
Stress
Situational Stress
Stressed
Burnout
Non-Functional
Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter
Scientific Meeting, Sept 17, 2010.
Slide 42
Burnout
“In the current climate, burnout thrives in the
workplace. Burnout is always more likely
when there is a major mismatch between the
nature of the job and the nature of the person
who does the job.”
~Christina Maslach
The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997
Slide 43
Six Sources of Burnout
1. Lack of control
2. Work overload
3. Insufficient reward
4. Unfairness
5. Breakdown of community
6. Value conflict
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.”
Slide 44
Risk Factors for Burnout
•
•
•
•
•
•
Single
Gender/sexual orientation
># of children at home
Family problems
Mid-late career
Previous mental health
issues (depression)
• Fatigue & sleep
deprivation
•
•
•
•
General dissatisfaction
Alcohol and drugs
Minority/international
Teaching & research
demands
• Potential litigation
1) Puddester D. West J Med 2001;174:5-7; 2) Myers MJ West J Med 2001;174:30-33; 3) Gautam M West J Med 2001;174:37-41
Slide 45
Symptoms of Burnout
1. Chronic exhaustion
2. Cynical and detached
3. Increasingly ineffective at work
4. Leads to:
•
•
•
•
isolation
avoidance
interpersonal conflicts
high turnover
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17
Slide 46
Physician Health and Wellness
To preserve the quality of their performance,
physicians have a responsibility to maintain
their health and wellness, construed broadly
as preventing or treating acute or chronic
diseases, including mental illness, disabilities,
and occupational stress.
~ AMA H-140.886
AMA Polices Related to Physician Health, 2011 http://www.ama-assn.org/resources/doc/physician-health/policies-physicainhealth.pdf - Accessed 8/13/2012
Slide 47
Work Environment
Slide 48
Work Environment
• Can work environment influence individual
health?
–
–
–
–
–
Stress: physician, environment, patients
Environment was the only sig predictor of stress
Job stress predicts job satisfaction
Job sat is positive predictor of positive mental health
Perceived stress was a stronger predictor of both poorer
reports of physical and mental health
– Therefore, environment influenced health
– Powerful model how practice environment can impact
physician health
Williams et al. Physician, practice and patient characteristics related to primary care physician physical and mental health: Results of
the physician’s work-life study. Health Services Research, 2002; 37(1):121-43.
Slide 49
Work Environment
Institutional factors to address:
– Inadequate systems & supports1
– System reinforces behavior1
– Need for a scapegoat1,3
– Money/financial benefit1
– Culture – more, faster, better, longer2
– Failure to recognize costs to individuals, pts,
institution3
1) Williams and Williams, 2004; 2) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It.”
1997 3) Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007
Slide 50
Promoting Professionalism
“If you keep doing the
same thing you always
did….you will keep
getting the same results
you always got!”
Slide 51
Promoting Professionalism
• Leadership commitment
• Supportive institutional policies
• Program or model to guide graduated interventions
– Surveillance tools to capture allegations
– Processes for reviewing allegations
– Interventions
• Multi-level training
• Resources to help:
– Unprofessional colleagues
– Victims (staff, patients, students, trainees, colleagues)
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring
and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007.
Slide 52
Promoting Professionalism
• Medical education & training: focus is cognitive
– Emotional & self-regulation activities for MS and
residents
– Residency programs need to assess, train/prepare
residents for the challenges in medicine1 & provide
remediation as needed
– Faculty development - need training/coaching
(emotional intelligence (EI), coping mech., conflict management, early
identification, etc.) in
order to teach & role model
professional behaviors
AAMC Council of Deans 2004
Slide 53
Resources
Slide 54
Resources
• Physician Health Programs (PHP)
• Federation of State Physician Health programs
(FSPHP)
• Some model institutional resources:
– CPH, FPWC, EAP, VCAP & CPPA programs
(Vanderbilt)
– Faculty Health Committee & Ombuds Office (UT
Houston)
– Relationship Center Care Initiative (IUSM)
– Others
Slide 55
Resources
•
•
•
•
Training programs: PACE, Case western, etc.
Treatment programs
Private counseling services
Professional Coaching - Center for Women in Med:
Debbie Smith (www.cwmedicine.org)
• Suicide prevention hotline: 1-800-273-TALK
• Substance use: (AA, NA, Evelyn Fry, etc.)
• Community-based wellness programs:
YMCA/YWCA, Massage envy, etc.
Slide 56
Summary
1. Listed and discussed four types of
professionalism lapses.
2. Analyzed the roles of the individual and
the institution as they shape the overall
culture of professionalism.
3. Accepted that both individuals and the
institution are responsible for promoting
a culture of professionalism.
Slide 57
Questions & Answers
“Creating a Culture of
Professionalism”
Charlene M. Dewey, M.D., M.Ed., FACP
Associate Professor of Medical Education and Administration
Associate Professor of Medicine
Center for Professional Health
Vanderbilt University School of Medicine
Marshall University Joan C. Edwards School of Medicine
August 28, 2012
Slide 2
Professionalism
1. AMA Code of Ethics 1847
2. ACP Ethics Manual 2005
3. A Physician Charter: ABIM, ACP,
European Federation of Internal
Medicine 2007
4. Stern’s professionalism model
5. Institutional codes of conduct and
policies
Slide 3
Stern’s Professionalism Model
“Professionalism is demonstrated though a
foundation of clinical competence,
communication skills and ethical and legal
understanding, upon which is built the
aspiration to wise application of the principles
of professionalism: excellence, humanism,
accountability, and altruism.”
Stern: Figure 2-1 A Definition of Professionalism pg 19; “Measuring Medical Professionalism” Oxford Press 2006.
Slide 4
Professionalism
Altruism
Accountability
Humanism
Excellence
Professionalism
Ethical and Legal Understanding
Communication Skill
Clinical Competence (Knowledge of Medicine)
Professional Health & Wellness
Professional Culture
Dewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006
Slide 5
Two Systems Interact
The External System
“Personal & Institutional Vitality”
Functional
& Nurturing
The Internal System
Good Skills
& Well
Work Environment
Clinician
Poor Skills
&/or Not Well
Dysfunctional
“The Perfect Storm”
Slide 6
Professional vs. Unprofessional
Slide 7
Professional vs. Unprofessional
“We judge ourselves by our
motives whereas others judge
us by our behavior.”
~AA saying
Slide 8
Goals
• The purpose of the session is to provide
information and discussion around
professionalism and lapses in
professionalism and how the overall culture
is influenced by both individual behaviors
and institutional norms.
Slide 9
Objectives
Upon completion of the session, participants
will be able to:
1. List and discuss four types of professionalism
lapses.
2. Analyze the roles of the individual and the
institution as they shape the overall culture of
professionalism.
3. Accept that both individuals and the institution
are responsible for promoting a culture of
professionalism.
Slide 10
Agenda
1.
2.
3.
4.
5.
6.
Four examples of professionalism lapses
Individual & institutional roles
Stress & burnout
Influencing professional cultures
Resources
Summary
Slide 11
Center for Professional Health
• Faculty and Physician Wellness Committee
• 3 CME accredited professional development
programs
– Distressed Physician
– Maintaining Proper Boundaries
– Proper Prescribing CPD
• ~15 years in training/remeding physicians
• Demographics:
–
–
–
–
Mandated > voluntary
IM, FP - but all specialties
Males > females
Rural, solo practices > academic health center
http://www.mc.vanderbilt.edu/cph
Slide 12
Professional Lapses
•
•
•
•
•
•
661,400 physicians/surgeons in US in 2008
>32,000 sanctions btw 2004 - 2008 (~5-10%)
955 criminal
Many uncategorized
Many events not reported
Physician Survey 2007:
– 96% agreed physicians should report
impaired or incompetent colleagues
– 45% who encountered such colleagues
did not report events
Campbell, et al. “Professionalism in Medicine: Results of a National Survey of Physicians” Ann In Med, 2007
Slide 13
Professionalism Lapses
Four major professionalism lapses:
1.
2.
3.
4.
Distressed/disruptive behaviors
Boundary violations
Improper prescribing
Impairment
Slide 14
Distressed/Disruptive Behaviors
Slide 15
Disruptive Behavior
• “Behavior or behaviors that undermine a
culture of safety.”1
• Disruptive behavior is a sentinel event2
1) The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD.03.01.01, elements of performance (EP) 4 and 5, Spring 2012;
2) Joint Commission, Issue 40 July 9, 2008
Slide 16
Spectrum of Disruptive Behaviors
Aggressive
Inappropriate anger,
threats
Yelling, publicly degrading
team members
Intimidating staff,
patients, colleagues, etc.
Pushing, throwing objects
Swearing
Outburst of anger &
physical abuse
Passive
Passive
Aggressive
Hostile notes, emails
Derogatory comments about
institution, hospital, group,
etc.
Inappropriate joking
Sexual
Harassment
Chronically late
Failure to return calls
Inappropriate/
inadequate chart notes
Avoiding meetings & individuals
Non-participation
Ill-prepared, not prepared
Complaining,
Blaming
Swiggart, Dewey, Hickson, Finlayson. “A Plan for Identification, Treatment, and remediation of Disruptive Behaviors in Physicians.”
Frontier's of Health Services management, 2009; 25(4):3-11.
Slide 17
Distressed/Disruptive Behaviors
Etiologies-Individuals:
• Psychological Factors1:
– Substance use/abuse,
trauma history, religious
fundamentalism, familial
high achievement
• MH issues2:
– Personality disorders,
narcissism, depression,
bipolar, OCD, etc.
1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002
• Genetic/developmental
issues:
– Asperger’s, non-verbal
learning differences, etc.
• Family systems
• Stress/physiologic
reactions
• Burnout3
• Reduced wellness
Slide 18
Distressed/Disruptive Behaviors
Etiologies-Institutional:
– System reinforces behavior
– Leadership ignores problems for productivity
– Scapegoats
– Individual pathology may over-shadow
institutional pathology
Williams and Williams, 2004
Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007
Slide 19
Distressed/Disruptive Behaviors
Increase Liability and Risk
Poor Work
Environment
Lost of Finances
& Reputation
Reduced Pt
Safety
Cycle
Horizontal
Hostility
Poor
Communication
Staff
Turnovers
Slide 20
Boundary Violations
Slide 21
Boundary Violations
• Power differential
• Sexual misconduct
– Sexual impropriety
– Sexual violations
• Sexual harassment
• Social media
– Unprofessional, disinhibition, anonymity
Slide 22
Boundary Violations
• Etiologies:
– Environment:
• Relaxed professional culture – “slippery slope”
– Individual:
• Stress & burnout
• Lack of self-care
• Lack of knowledge
– Patients:
• Predators & drugs
Dewey, Swiggart, Manley, & Spickard. “Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine” – CPH 2011.
Slide 23
Misprescribing CPD
Slide 24
Six Categories of
Misprescribing Physicians
Dated: Fails to keep current
Disabled: Failed judgment due to impairment
Duped: Fails to detect
Dishonest: Personal or financial gain
Dismayed: Rx as a quick fix due to time
Dysfunctional: Fails to say no
Brown, Swiggart, Dewey, & Ghulyan, “Searching for answers: proper prescribing of controlled prescription drugs.” J Psychoactive
Drugs. 2012 Jan-Mar;44(1):79-85.
Slide 25
Misprescribing CPD
• Rules and guidelines:
– DEA – “Practitioner's Manual”
– SMB & FSMB
• Drug seeking patients – “Confrontational
phobia”
• Prescribing for non-patient colleagues,
friends, families
• Self-prescribing
Dewey, Swiggart, Brown, Baron, & Ghulyan, “Proper Prescribing of CPDs: What Every Physician Needs to Know”,submitted 2012
Slide 26
Impairment
Slide 27
Impairment
AMA: “…any physical, mental or behavioral disorder that
interferes with ability to engage safely in professional
activities...”
1. Physical impairment
2. Cognitive impairment
3. Psychological impairment
–
–
Substance use disorders (licit and illicit drugs)
Mental health disorders (depression & suicide)
Affects: individual, family, patients, institution
AMA Polices Related to Physician Health, 2011 http://www.ama-assn.org/resources/doc/physician-health/policies-physicainhealth.pdf - Accessed 8/13/2012
Slide 28
Impairment
“Every physician is responsible for protecting
patients from an impaired physician and for
assisting an impaired colleague.”
~ACP Ethics Manual
Ethics Manual, 5th Edition. American College of Physicians 190 N. Independence Mall West. Philadelphia, PA. 19106-1572
Slide 29
Professionalism Lapses
• Consequences:
– Restriction or loss of DEA registration
– Restricted or loss of medical license
– Loss of job
– Law suites and restriction of insurance coverage
– Loss of relationships – personal and work
– Loss of self
Slide 30
Unprofessional Conduct
Four major professionalism lapses:
1.
2.
3.
4.
Distressed/disruptive behaviors
Boundary violations
Improper prescribing
Impairment
Slide 31
Slide 32
Two Systems Interact
The External System
“Personal & Institutional Vitality”
Functional
& Nurturing
The Internal System
Good Skills
& Well
Work Environment
Clinician
Poor Skills
&/or Not Well
Dysfunctional
“The Perfect Storm”
Slide 33
Clinician
Slide 34
Clinician
“These are the duties of a physician: First... to
heal his mind and to give help to himself
before giving it to anyone else.”
~ Epitaph of an Athenian doctor, AD 2.
Boisaubin & Levine. Identifying and Assisting the Impaired Physician Am J Med Sci, 2001; 322(1):31-6.
Slide 35
Professional Health & Wellness
Spectrum
Work &
Family
Relations
High Functioning
High Productivity
Fair Functioning
Decreasing Productivity
Fair Functioning
Reduced Productivity
Relationships Suffer
Fair-Not Functioning
Fair-Not Productive
Institution & Family Loses
Physical
Mental
Emotional
Spiritual
Professionally Healthy
& Well
Stressed
Burnout
Coping Mechanisms
Strong
Coping Mechanisms
Failing
Risk of MH issues and
suicide
No Coping Mechanisms
Dewey, CM and Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine, 2009.
Slide 36
Clinician Health & Wellness
•
•
•
•
•
Little education on topic
30-60% MD are distressed and at burnout
MS & residents
↑ Primary care (IM, FP, ER)
MDs suicide > other prof. & gen pop.
– One physician per day; PhD – unclear
– Grossly underestimated
– Depression/bipolar & substance abuse = suicide risk
“Faculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success.” Cole, Goodrich & Gritz, 2009 &
Shannafelt, Arch In Med, 2012.
Slide 37
Clinician Health & Wellness
• Gender differences:
•
•
•
•
Females > anxiety, depression, burnout
F>M MD suicides (>50% vs 40% higher risk)
Women chairs more stressed
Male physicians (regardless of race) live longer than other
professionals
• Reduced use of care by physician
• Stigma & anonymity – slow to prioritize MH issues
for physicians; licenses, etc.
http://www.aamc.org/members/gwims/statistics/stats09/start.htm
Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82.
(Schindler et al 2006) and “High physician suicide rates suggest lack of treatment for depression.” - MD Consult News June 11, 2008
Slide 38
Clinician Health & Wellness
• Academic faculty:
– Worked longer hours
– Took less vacation
• 10% with mild depression
• 27% with elevated anxiety
– No sig difference clinical vs. academic
Lin et al.1985. Health status, job satisfaction, job stress, and life satisfaction among academic and clinical faculty. JAMA 254(19):2775-82.
Schindler et al. The Impact onof the changing Health Care Environment on the Health and Well-being of faculty at Four Medical Schools.
Academ Med 2006 81(1):27-34.
Slide 39
Clinician Health & Wellness
•
•
•
•
•
•
•
•
Self-care
Stress & burnout
Emotional intelligence
Family systems
Training experiences – hidden curriculum
Coping skills
Conflict management
Personality types
Slide 40
Self-Care
Seven key areas:
1.
2.
3.
4.
5.
6.
7.
Sleep
Balanced meals
Physical activity
Socialization/hobbies
Vacations/down times
Spiritual engagement
Having a personal physician
Mind
Body
Soul
Emotion
Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter
Scientific Meeting, Sept 17, 2010.
Slide 41
Stress & Productivity
Prolonged
Stress
Reduced
Cognition
“Impairment” ???
No
Prolonged
Stress
Situational Stress
Stressed
Burnout
Non-Functional
Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter
Scientific Meeting, Sept 17, 2010.
Slide 42
Burnout
“In the current climate, burnout thrives in the
workplace. Burnout is always more likely
when there is a major mismatch between the
nature of the job and the nature of the person
who does the job.”
~Christina Maslach
The Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997
Slide 43
Six Sources of Burnout
1. Lack of control
2. Work overload
3. Insufficient reward
4. Unfairness
5. Breakdown of community
6. Value conflict
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.”
Slide 44
Risk Factors for Burnout
•
•
•
•
•
•
Single
Gender/sexual orientation
># of children at home
Family problems
Mid-late career
Previous mental health
issues (depression)
• Fatigue & sleep
deprivation
•
•
•
•
General dissatisfaction
Alcohol and drugs
Minority/international
Teaching & research
demands
• Potential litigation
1) Puddester D. West J Med 2001;174:5-7; 2) Myers MJ West J Med 2001;174:30-33; 3) Gautam M West J Med 2001;174:37-41
Slide 45
Symptoms of Burnout
1. Chronic exhaustion
2. Cynical and detached
3. Increasingly ineffective at work
4. Leads to:
•
•
•
•
isolation
avoidance
interpersonal conflicts
high turnover
Maslach & Leiter, 1997. “The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.” pg 17
Slide 46
Physician Health and Wellness
To preserve the quality of their performance,
physicians have a responsibility to maintain
their health and wellness, construed broadly
as preventing or treating acute or chronic
diseases, including mental illness, disabilities,
and occupational stress.
~ AMA H-140.886
AMA Polices Related to Physician Health, 2011 http://www.ama-assn.org/resources/doc/physician-health/policies-physicainhealth.pdf - Accessed 8/13/2012
Slide 47
Work Environment
Slide 48
Work Environment
• Can work environment influence individual
health?
–
–
–
–
–
Stress: physician, environment, patients
Environment was the only sig predictor of stress
Job stress predicts job satisfaction
Job sat is positive predictor of positive mental health
Perceived stress was a stronger predictor of both poorer
reports of physical and mental health
– Therefore, environment influenced health
– Powerful model how practice environment can impact
physician health
Williams et al. Physician, practice and patient characteristics related to primary care physician physical and mental health: Results of
the physician’s work-life study. Health Services Research, 2002; 37(1):121-43.
Slide 49
Work Environment
Institutional factors to address:
– Inadequate systems & supports1
– System reinforces behavior1
– Need for a scapegoat1,3
– Money/financial benefit1
– Culture – more, faster, better, longer2
– Failure to recognize costs to individuals, pts,
institution3
1) Williams and Williams, 2004; 2) Maslach, C & Leiter, MP. “The Truth About Burnout: How Organizations Cause Personal Stress and What to do About It.”
1997 3) Sutton, R. “The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isn’t.” Business Plus, New York, 2007
Slide 50
Promoting Professionalism
“If you keep doing the
same thing you always
did….you will keep
getting the same results
you always got!”
Slide 51
Promoting Professionalism
• Leadership commitment
• Supportive institutional policies
• Program or model to guide graduated interventions
– Surveillance tools to capture allegations
– Processes for reviewing allegations
– Interventions
• Multi-level training
• Resources to help:
– Unprofessional colleagues
– Victims (staff, patients, students, trainees, colleagues)
Hickson GB, Pichert JW, Webb LE, Gabbe SG. A Complementary Approach to Promoting Professionalism: Identifying, Measuring
and Addressing Unprofessional Behaviors. Academic Medicine. November, 2007.
Slide 52
Promoting Professionalism
• Medical education & training: focus is cognitive
– Emotional & self-regulation activities for MS and
residents
– Residency programs need to assess, train/prepare
residents for the challenges in medicine1 & provide
remediation as needed
– Faculty development - need training/coaching
(emotional intelligence (EI), coping mech., conflict management, early
identification, etc.) in
order to teach & role model
professional behaviors
AAMC Council of Deans 2004
Slide 53
Resources
Slide 54
Resources
• Physician Health Programs (PHP)
• Federation of State Physician Health programs
(FSPHP)
• Some model institutional resources:
– CPH, FPWC, EAP, VCAP & CPPA programs
(Vanderbilt)
– Faculty Health Committee & Ombuds Office (UT
Houston)
– Relationship Center Care Initiative (IUSM)
– Others
Slide 55
Resources
•
•
•
•
Training programs: PACE, Case western, etc.
Treatment programs
Private counseling services
Professional Coaching - Center for Women in Med:
Debbie Smith (www.cwmedicine.org)
• Suicide prevention hotline: 1-800-273-TALK
• Substance use: (AA, NA, Evelyn Fry, etc.)
• Community-based wellness programs:
YMCA/YWCA, Massage envy, etc.
Slide 56
Summary
1. Listed and discussed four types of
professionalism lapses.
2. Analyzed the roles of the individual and
the institution as they shape the overall
culture of professionalism.
3. Accepted that both individuals and the
institution are responsible for promoting
a culture of professionalism.
Slide 57
Questions & Answers