TREATING DISRUPTIVE BEHAVIOR IN PHYSICIANS

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TREATING DISRUPTIVE BEHAVIOR IN PHYSICIANS

• Alexis Polles, MD
• Philip Hemphill, LCSW
• Professional Enhancement Program
• Hattiesburg, MS
• 601-288-4772
• apolles_at_forrestgeneral.com

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Establishing a Need for Comprehensive
Interventions Issues with Professional Training
and Practice

• Social isolation
• Sleep deprivation
• Pressure to excel
• Self-neglect
• Cynicism
• Family discord
• Expectations of perfection
• Conflict of values

• Extreme competition
• Difficult decisions
• Lack of limits
• Suppressed emotions
• Operating a business
• Living up to the position
• Lack of balance
• Adversarial nature of the
• work

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OBJECTIVES

• To identify warning signs of individuals whom may
  be at increased risk for disruptive workplace
  behavior
• To explore the impact of disruptive behavior on
  organizations and develop strategies for managing
  the physician and employees affected within the
  workplace
• To understand the components of a multi-modal
  approach for physicians with disruptive behavior
  which integrates biological, psychological,
  systemic, and addictive interventions

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Defining the Term

• The term disruptive physician applies to
  physicians who exhibit behavior that interferes
  with patient care or could reasonably be expected
  to interfere with the process of delivering
  quality care.

Federation of State Medical Boards. Report of the
Special Committee on Professional Conduct and
Ethics. Dallas, TX 2000
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Disruptive Physician Behavior

• JC adopted this issue as a National Patient
  Safety Goal for 2007. This requires that
  physician behavior that is destabilizing patient
  care be addressed. This creates both an
  opportunity and a challenge. (Wardrop,
  2006)
• Closely linked to an organizations culture

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Creating and Maintaining a Culture of Safety

• Setting expectations for behavior
• Working in teams
• Respecting self and others
• Code of Conduct for all hospital workers
• Education
• Free online program from Texas Med. Assoc.
  (charge for CME credit)
• Define desirable behaviors
• Incident Reports
• Created by any person, employee, practitioner,
  patient, or visitor who observes disruptive
  behavior
• JC standards says policy includes disruptive
  behavior by ANYONE who works in the
  organization. (e.g. board members, management,
  volunteers, clinical staff, etc.)

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Hospitals Perspective

• When a physicians conduct
• disrupts the operation of the hospital
• affects the ability of others to get their jobs
  done
• creates a hostile work environment for hospital
  employees or other physicians on the medical
  staff
• begins to interfere with the physicians own
  ability to practice competently
• One court has held that hospitals have a duty to
  take action in such situations.

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Counter Point

• Abuse of the disruptive physician clause
• The term disruptive is vague and subjective
• Allowed by non-vigilant physicians who did not
  seek legal advice on bylaws changes urges by
  hospital administrators
• Part of strategic plan developed in 1990 by the
  hospital industry with the goal of gaining more
  control of physicians in hospitals

Huntoon, L J of Am Physicians and Surgeons, Vol.
9, No. 3, Fall 2004
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MEMO TO THE DISRUPTIVE PHYSICIAN

• Oh how we strive for quality high,
• For health and most of all safety.
• But a word to the wise reproof we despise
• And outspoken physicians We hate thee
• Feel free to opine, but note we define
• All critics as never constructive.
• And, thus shall ensue a sham peer review
• And henceforth youre labeled disruptive

Huntoon, L J of Am Physicians and Surgeons, Vol.
9, No. 3, Fall 2004
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Behavior Outcomes Nurses and Physicians

• Follow-up survey to one that examined
  Nurse/Physician relationships and their impact on
  nursing satisfaction and retention
• 50 VHA hospitals participated with 1500
  participants
• Nurses disruption nearly as frequent as
  physicians
• Behavior impacts general stress and workplace
  relationships
• But more importantly results in adverse events,
  medical errors, patient safety, patient
  mortality, quality of care, and patient
  satisfaction.
• Thus consequences go beyond nurses job
  satisfaction

Nursing Management June 2002, January 2005
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Respondents (Nurses, Physicians, and
Administrators) Who Witnessed Disruptive Behavior
in Physicians and Nurses
86 (583)
75 (12)
75 (12)
74 (714)
72 (481)
68 (653)
49 (123)
47 (116)
Nursing Management, January 2005
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Respondents Answers to Selected Survey Questions
Do you think that disruptive bx could potentially
have a negative impact on patient outcomes?
(n962)
94 (904)
YES
NO
6 (58)
60 (896)
Are you aware of any potential adverse events
that could have occurred from disruptive bx?
(n1,487)
YES
NO
40 (591)
YES
17 (249)
Are you aware of any specific adverse events that
did occur as a result of disruptive bx? (n1,441)
83 (1,192)
NO
YES
78 (195)
Could this (adverse event) have been prevented?
(n249)
NO
22 (54)
Nursing Management, January 2005
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SCOPE OF THE PROBLEM

• Survey by the ACPE (n1600)
• 95 reported encountering these behaviors on a
  regular basis
• 1 in 3 said they observe problems with physician
  behavior either weekly or monthly
• (Keogh Martin, 2004)

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Breakdown of typical problems

• Refusal to complete tasks or carry out duties
  52
• Physical abuse (includes throwing items)
  9
• Insults 37
• Disrespect 83
• Yelling 41
• Other 13.5

ACPE 2004 Physician Behavior Survey
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Summary

• All of the behaviors involve inappropriate and
  indirect communications.
• Communication failures are the leading cause of
  inadvertent patient harm
• (Leonard, et al, The human factor the critical
  importance of effective teamwork and
  communication in providing safe care. Quality
  Safe Health Care 2004 13

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Why is a diagnosis important?

• Should a physicians disruptive behavior
  reflect a health problem, the JC standards go
  further to require the medical staff to implement
  a process to identify and manage the individual
  physicians health-related matters disruptive
  behavior may be reasonably interpreted to require
  anger and/or stress management or formal
  behavioral counseling and monitoring.

Youssi, MD The Physician Executive, Nov.-Dec.
2002
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Level of Care Determinations

• Follow by-laws
• Assessment (local or specialized)
• No further treatment needed
• Assessment and structured monitoring
• Outpatient individual and/or group work
• Intensive profession specific focused work
• Cognitive Behavioral
• Educational
• Psychodynamic
• Addictions focused
• Retirement from practice / suspension or
  revocation of license

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Values
Values are principles, standards, or qualities
considered worthwhile or desirable.
Values provide guidance to help set priorities
and make decisions.
Values allow us to Live in harmony within
ourselves Live in relationship with others and
our world Guide us deeper into our spiritual
journeys
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The values upon which our work is based are

• Open, honest, direct communication

• Respect for self and others

• Responsibility for ones choices

• Accountability to others and willingness
• to hold others accountable

• Inclusion

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GOOD LIVES MODEL

• What this means is that it is not enough to
  simply equip individuals with skills to control
  or manage their risk factors, it is imperative
  that we also give the opportunity to fashion a
  more adaptive personal identity, one that bestows
  a sense of meaning and fulfillment (Maruna,
  2001).

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Intensive Residential

• This physician was referred for disruptive
  workplace behavior in 2 separate hospitals,
  though more pronounced at one, as evidenced by
  angry and belittling behavior toward staff
  (particularly subordinates).
• Four years earlier, he was evaluated for anger
  issues and was followed by an outpatient
  therapist. Shortly after that evaluation, he
  entered into a contract with the state monitoring
  board at the request of the hospital.
• He was an only child with no issues of abuse.
  There was no evidence of inappropriate anger in
  social or religious settings.
• The only significant family history was maternal
  grandmother with grief following death of her
  spouse.
• Presented as overly cautious with a defensive
  profile, reluctant to disclose much, and
  concerned about making a good impression.

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RESULTS

• Collateral information
• Described as hostile, argumentative, and
  demeaning.
• Sources stated if anything goes wrong he finds
  someone to blamehis response is out of
  proportion and his behavior is out of control.
• Another said, it was just awful, it was ugly, he
  was pounding the counter enraged and calling
  another physician stupid.
• A third said he looked like a psychotic patient
  fleeing from the psych ward.
• Some felt he was dishonest while others thought
  he tried to prove himself by being the best
  surgeon and making the most money.
• Our recommendations were that he enter an
  intensive, structured treatment program to deal
  with narcissistic personality disorder and
  disruptive workplace behavior.

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Data from Consecutive Admissions from 10/1/02 to
10/31/07

• Total Admissions 355
• Males 282 79
• Female 73 21
• Average Age 46
• Average Tx Days 44
• Physicians 163 46
• Pharmacists 15 4
• Dentists 11 3
• Nurses 6 1
• Physician Assistants 3 1
• Veterinarians 2 1
• Other Professionals 156 44

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Most Common Axis I and Axis II Diagnosis

• AXIS I (n160)
• Drug Abuse/Dep. 64
• Alcohol Abuse/Dep. 34
• Depressive Disorders 34
• Anxiety Disorders 26
• Psychosexual Disorders 13
• Bipolar Disorders 11
• Eating Disorders 8
• Intermittent Explosive Disorders 2
• Other 55
• AXIS II (Personality DO and traits) (n90)
• Narcissistic 34
• Obsessive Compulsive 18
• Pers. Disorder, NOS 16
• Paranoid 11
• Histrionic 11

Axis I N 163 Axis II N 90 Individuals
may have more than one Axis I diagnosis. Every
individual may not have an Axis II diagnosis and
some individuals may have more than one Axis II
diagnosis.
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PEP-CARE On-Site Monitoring

• On-site visit for treatment participants prior to
  discharge provides feedback.
• Self, staff, peers, and supervisors complete an
  anonymous survey.
• Online survey is completed on a quarterly basis.
• Feedback report is provided to monitoring
  program, ratee, supervisor, and other relevant
  parties (e.g., psychiatrist, physician
  executives, PHP, therapist).

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PEP-CARE Monitoring Points of Interest

• Highlights need to collect data from multiple
  sources
• Discrepancy between staff, peer, supervisor, and
  self ratings.
• Feedback provides roadmap for behavior change
• Some people work with therapists to make changes.
  
• Return visit to treatment helpful
• Initial months of monitoring typically display no
  significantly disruptive behavior..but, after a
  few months patterns begin to show.

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PEP-CARE Online Survey

• 33 questions
• 28 Likert-type questions regarding ratees
  behavior
• 1 question concerning how many hours rater works
  with ratee
• 1 question about the raters title
• 3 open-ended questions that solicit comments

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Ratings of Items by Rating Source (lower scores
preferred) 0 Never 16.7 Very Rarely 33.3
Rarely 50 Sometimes 66.7 Frequently 83.3
Very Frequently 100 Always
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Conclusions

• Professionals exhibiting disruptive behavior in
  the workplace require intensive specialized
  interventions.
• Many can make positive, lasting changes by
  utilizing an approach that is consistent during
  the evaluation, treatment and monitoring phases
  of care.