Addressing Disruptive Physician Behavior Counseling Peers William Hopkinson, MD Orthopaedic Program Director, Loyola University Medical Center AAOS Fall.
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Addressing DisruptivePhysician Behavior
Counseling PeersCounseling Peers
William Hopkinson, MDWilliam Hopkinson, MDOrthopaedic Program Director, Loyola University Medical CenterOrthopaedic Program Director, Loyola University Medical Center
AAOS Fall Meeting, October 19, 2012AAOS Fall Meeting, October 19, 2012
XXX Disclosure XXX
Any opinions expressed in this presentation are solely my own
Retired USA MC
Part-time VA
Full time academic faculty at private university
Member AAOS Committee on Professionalism
Judiciary Committee
No financial conflicts of interest
““SPECIAL BEHAVIORSPECIAL BEHAVIOR””
Disruptive = InappropriateDisruptive = Inappropriate
Interferes with function/flow of workplaceInterferes with function/flow of workplace
If unaddressed, usually escalates.If unaddressed, usually escalates.
Disruptive Behavior ExamplesDisruptive Behavior Examples
YellingYelling
Profanity/Verbal abuseProfanity/Verbal abuse
Threatening body gesturesThreatening body gestures
Failing to adhere to usual authority, such Failing to adhere to usual authority, such as:as:– Not providing IDNot providing ID– Not participating in Time OutNot participating in Time Out– Not returning calls/pagesNot returning calls/pages
More Serious BehaviorMore Serious Behavior
ThreateningThreatening– Physical actions just short of contactPhysical actions just short of contact– Oral/ written /implied threatsOral/ written /implied threatsLegally defined as assaultLegally defined as assault
ViolentViolent– Physical behavior or specific threats of physical Physical behavior or specific threats of physical
harmharm– Harmful or offensive contactHarmful or offensive contactLegally defined as batteryLegally defined as battery
Is there a rationale for DB?Is there a rationale for DB?
Surgical Stress/ Frustrations Surgical Stress/ Frustrations -Increased complexity/ more regulations-Increased complexity/ more regulations-High volumeHigh volume-Low marginLow margin
of errorof error
Reason for DBReason for DB
Substance abuse/psych issuesSubstance abuse/psych issues
Narcissism/perfectionismNarcissism/perfectionism
Personal issuesPersonal issues
Reasons for Tolerating DB
None……but– Majority of surgeons are non-confrontational– Respect/tolerance of “rainmakers”– Rationalizing behavior– “Not my …..” problem /patient/ resident/ issue– If I ignore, maybe the problem will go away– ETC
Perception is RealityPerception is RealityWhat they think
they are
What others see
Why deal with disruptive behavior?Why deal with disruptive behavior?EasyEasy
Directly linked to adverse eventsDirectly linked to adverse events
Professionalism issueProfessionalism issue
LawsuitsLawsuits
Poor moralePoor morale
How to deal with disruptive behavior?How to deal with disruptive behavior?The Hard PartThe Hard Part
Pyramid upside downPyramid upside down
My ExperienceMy Experience
Department Vice-ChairDepartment Vice-Chair
Residency Program DirectorResidency Program Director
Professional Standards and Peer Review Professional Standards and Peer Review Committee, LoyolaCommittee, Loyola
Loyola PARS ProgramLoyola PARS Program– Co-chair and mentorCo-chair and mentor
AAOS Committee on ProfessionalismAAOS Committee on Professionalism
My Experience in the trenchesMy Experience in the trenches
One-on-one- peer interactionsOne-on-one- peer interactions
Authority figureAuthority figure
Our local PARS activityOur local PARS activity
LUMC Professionalism CommitteeLUMC Professionalism Committee
AAOS COP and Judiciary CommitteeAAOS COP and Judiciary Committee
Cup of coffeeCup of coffeeconversationconversation
Why – behavior notedWhy – behavior noted
When – soonWhen – soon
Where – safe/quiet placeWhere – safe/quiet place
How – balance empathy and objectivityHow – balance empathy and objectivity
stay on messagestay on message
Expectations Self-correctionExpectations Self-correction
Cup of coffee conversationCup of coffee conversation
To be meaningful – stay on topicTo be meaningful – stay on topic
Avoid the following tendenciesAvoid the following tendencies– Control contestControl contest– ““Curbside therapy”Curbside therapy”– EnablingEnabling– ““Oh, by the way, now that we are here……”Oh, by the way, now that we are here……”
Can an authority figure do this?Can an authority figure do this?Can you do this to the boss?Can you do this to the boss?
Yes – Yes – with carewith care
– Non-judgmentalNon-judgmental– Empathy and objectivityEmpathy and objectivity– Focus on the behaviorFocus on the behavior
Perception is realityPerception is reality
Prepare for full range of Prepare for full range of responsesresponses
When a lot of coffee doesn’t When a lot of coffee doesn’t workwork
CreCre
Self-creating an improvement plan
Local Hospital Task Force
Generating a report
Review by Committee of Peers
Actions taken can range from– No action– Fines– Mandated activities – local/national programs– Dismissal
The Loyola PARS ProgramThe Loyola PARS Program
Using “unsolicited” patient complaints to Using “unsolicited” patient complaints to measure physician riskmeasure physician risk
At Loyola, 2 co-chairs and 20 mentorsAt Loyola, 2 co-chairs and 20 mentors
Program started in 2003Program started in 2003– Mentor selection and trainingMentor selection and training– Assigning mentorsAssigning mentors– Annual updateAnnual update
Conceptual Framework – ProfessionalismConceptual Framework – Professionalism Professionals commit to:Professionals commit to:
Technical and cognitive excellenceTechnical and cognitive excellence
Professionals also commit to:Professionals also commit to: Clear and effective communicationClear and effective communication Modeling respectModeling respect Being availableBeing available
Professionalism promotes teamworkProfessionalism promotes teamwork
Professionalism demands self-regulationProfessionalism demands self-regulation
PARS: Reducing Malpractice Risk, PARS: Reducing Malpractice Risk, Professionalism and Self-RegulationProfessionalism and Self-Regulation
Loyola PARS ExperienceLoyola PARS Experience
2003-20112003-2011 Phys. Interventions Phys. Interventions No.No.
2003-20072003-2007 First InterventionsFirst Interventions 28 2820082008 First Interventions First Interventions 9 920092009 First InterventionsFirst Interventions 7 720102010 First InterventionsFirst Interventions 7 720112011 Proposed First YearProposed First Year 6 6
(Excluding 1 Recidivist) (Excluding 1 Recidivist) TotalTotal 5757
Results to date - LUMCResults to date - LUMC
Total # high complaint physiciansTotal # high complaint physicians 57 57First follow-up in First follow-up in ’’1212 6 6Departed After Initial InterventionDeparted After Initial Intervention 4 4Total with follow-up resultsTotal with follow-up results 47 47Results for those with follow-up data:Results for those with follow-up data: Good – Intervention visits suspendedGood – Intervention visits suspended 21 21 (45%)(45%) Good – Anticipate suspension in Good – Anticipate suspension in ’’1212 9 (19%) 9 (19%) Some improvement -- Still need tracking 1Some improvement -- Still need tracking 1 (2%)(2%)
SubtotalSubtotal 31 31 (66%)(66%)Unimproved/worseUnimproved/worse 14 14 (30%)(30%)Departed UnimprovedDeparted Unimproved 2 2 (4%)(4%)Total follow-up results Total follow-up results 47 47
AAOS Standards of Professionalism
6 SOPs establishing “minimum standards of acceptable conduct for Orthopaedic surgeons”
Each SOP has an aspirational statement with one or more mandatory standards
AAOS SOPsAAOS SOPs
Covers a range of professional topicsCovers a range of professional topics
One AAOS member files a grievance One AAOS member files a grievance against anotheragainst another
All other administrative actions should All other administrative actions should have been completedhave been completed
SOP on Professional SOP on Professional RelationshipsRelationships
AspirationalAspirational– Good relationships among physicians, nurses, Good relationships among physicians, nurses,
and other health care professionals are and other health care professionals are essential for good patient careessential for good patient care
– The orthopaedic surgeon should promote the The orthopaedic surgeon should promote the development and utilization of an expert development and utilization of an expert health care team that will work together health care team that will work together harmoniously to provide optimal patient care.harmoniously to provide optimal patient care.
SOP on Professional SOP on Professional RelationshipsRelationships
Mandatory standards: Mandatory standards:
An Orthopaedic surgeon:An Orthopaedic surgeon:– Shall maintain fairness, respect, and Shall maintain fairness, respect, and
appropriate confidentiality…appropriate confidentiality…– Shall conduct themselves in a professional Shall conduct themselves in a professional
manner in interactions…manner in interactions…– Shall work collaboratively with others to Shall work collaboratively with others to
reduce medical errors, increase patient reduce medical errors, increase patient safety, and optimize outcomes …safety, and optimize outcomes …
Professional Compliance Professional Compliance ProgramProgram
Actions to date (April 2012)Actions to date (April 2012)
125 grievances submitted125 grievances submitted
47 COP Hearings47 COP Hearings
21 Appeals to Judiciary Committee21 Appeals to Judiciary Committee
ResultsResults– 18 No action18 No action– 2 Letters of concern2 Letters of concern
Grievances Filed by SOPGrievances Filed by SOP
Providing MS Services 3
Professional Relationships 9
Expert Witness Testimony 94
Expert Opinion 9
Research/academic responsibility
0
Advertising 9
Conflicts of interest 1
AAOS Professionalism ProgramAAOS Professionalism Program
30 Official Actions of AAOS BOD30 Official Actions of AAOS BOD
7 Censures7 Censures
23 Suspensions 23 Suspensions
Ranging from months to 3 yearsRanging from months to 3 years
0 Expulsions0 Expulsions
SummarySummary
Disruptive behavior is Disruptive behavior is disabling to health caredisabling to health care
An organized process can be An organized process can be effectiveeffective
It starts with one-on-oneIt starts with one-on-one
Elimination of DB requires an Elimination of DB requires an organizational commitment organizational commitment
We all need to be involvedWe all need to be involved
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