Clinical Approach to the Clinical Approach to the Disruptive Physician: The Disruptive Physician: The

Tennessee ExperienceTennessee Experience

Anderson Spickard Jr., MDAnderson Spickard Jr., MDReid Finlayson, MDReid Finlayson, MDRon Neufeld, LADCRon Neufeld, LADCRoland Gray, MDRoland Gray, MD

Bill Swiggart, MS, LPC/MHSPBill Swiggart, MS, LPC/MHSPCharles Samenow, MD, MPHCharles Samenow, MD, MPH

IntroductionIntroduction

Distressed Physician Distressed Physician TeamTeam

Vanderbilt Center for Professional Vanderbilt Center for Professional HealthHealth

Anderson Spickard, Jr MD -- Anderson Spickard, Jr MD -- DirectorDirector

William Swiggart, MS, LPC/MHSP William Swiggart, MS, LPC/MHSP -- Training Director-- Training Director

Charles Samenow, MD, MPH -- Charles Samenow, MD, MPH -- Research AssistantResearch Assistant

Ron Neufeld, LADC -- Clinical Ron Neufeld, LADC -- Clinical Assessment, TeachingAssessment, Teaching

Tobi Fischel-Ingram, PhD -- Tobi Fischel-Ingram, PhD -- Teaching, CurriculumTeaching, Curriculum

Jennifer Blackford, PhD -- Jennifer Blackford, PhD -- BiostatisticsBiostatistics

David Dodd, MD -- TeachingDavid Dodd, MD -- TeachingDianna Phillips -- AdministrativeDianna Phillips -- AdministrativeJan Cao -- AdministrativeJan Cao -- Administrative

Vanderbilt Vanderbilt Comprehensive Comprehensive Assessment ProgramAssessment Program

Reid Finlayson, MDReid Finlayson, MD

Ron Neufeld, LCSWRon Neufeld, LCSW

Tennessee Medical Tennessee Medical FoundationFoundation

Roland Gray, MDRoland Gray, MD

Vince ParishVince Parish

ResearchResearch

Education, Education, PreventionPreventionAdvocacy, Advocacy, OutreachOutreach

Assessment Assessment and and TreatmentTreatment

VANDERBILT VANDERBILT COMPREHENSIVE COMPREHENSIVE

ASSESSMENT ASSESSMENT PROGRAMPROGRAM

…for Professionals…for Professionals

www.mc.vanderbilt.edu/root/www.mc.vanderbilt.edu/root/vcapvcap

615 322-4567615 322-4567

Reid Finlayson, MDReid Finlayson, MDRon Neufeld, LADCRon Neufeld, LADC

V-CAP MISSIONV-CAP MISSION

Providing the highest quality Providing the highest quality behavioral health evaluation and behavioral health evaluation and treatment planning services to treatment planning services to professionals in crisis due to professionals in crisis due to addictions, mental health issues, addictions, mental health issues, sexual boundary related problems sexual boundary related problems and burnout.and burnout.

Assessment ComponentsAssessment Components

Psychological TestingPsychological Testing MMPI – II; SCT; TAT; PAI; COPE Coping MMPI – II; SCT; TAT; PAI; COPE Coping

Scale; State-Trait Anger Expression Scale; State-Trait Anger Expression Inventory; DSFI (sexual functioning); Inventory; DSFI (sexual functioning); GARS (stress)GARS (stress)

Psychiatric Evaluation and Addiction Psychiatric Evaluation and Addiction ScreeningScreening MAST; DAST; SAST; BVI; TSI; BDI; Mini-MAST; DAST; SAST; BVI; TSI; BDI; Mini-

Mental Status Exam; Flooding self-testMental Status Exam; Flooding self-test

Assessment Components, Assessment Components, cont’d.cont’d.

Psychosocial Assessment and GenogramPsychosocial Assessment and Genogram Nursing AssessmentNursing Assessment Lab work and urine drug screenLab work and urine drug screen Other components as needed, including H&P, Other components as needed, including H&P,

AASI, Neuropsych workupAASI, Neuropsych workup Collaborative information from family, peers, Collaborative information from family, peers,

administrators, coworkers, etc. with written administrators, coworkers, etc. with written permission by clientpermission by client

Written report and review session with client and Written report and review session with client and designated othersdesignated others

Reasons for ReferralReasons for Referral

0

10

20

30

40

50

60

70

BoundaryViolations

DisruptiveBehavior

AddictionScreening

Court Return towork/Fit to

practice

MentalHealth

Screening

Disruptive ReferralsDisruptive ReferralsAxis I DiagnosisAxis I Diagnosis

Intermittent Explosive DisorderIntermittent Explosive Disorder Adjustment DisorderAdjustment Disorder Impulse Control DisorderImpulse Control Disorder None (or rule out)None (or rule out) Substance Dependence Substance Dependence (either active or (either active or

in remission)in remission)

Disruptive ReferralsDisruptive ReferralsAxis II DiagnosisAxis II Diagnosis

Personality Disorder, NOSPersonality Disorder, NOS Narcissistic (and other) traitsNarcissistic (and other) traits Compulsive personality traitsCompulsive personality traits OthersOthers

Problematic Physicians:Problematic Physicians:A Comparison of Personality Profiles by A Comparison of Personality Profiles by

Offense Type*Offense Type*

88 Physicians evaluated for “Fitness for Duty” 88 Physicians evaluated for “Fitness for Duty” 82 male (M age 46.8 / SD=9.5) 6 female (47.5 / 12.2)82 male (M age 46.8 / SD=9.5) 6 female (47.5 / 12.2) 80% married; 13% divorced; 7% single80% married; 13% divorced; 7% single 89% White; 5% Black; 4% Hispanic; 1% Asian89% White; 5% Black; 4% Hispanic; 1% Asian

A – Behavior Disruptive (anger, demeaning others)A – Behavior Disruptive (anger, demeaning others)

B – Sexual Boundary ViolationsB – Sexual Boundary Violations

C – Others (SUD, emotional instability, etc.)C – Others (SUD, emotional instability, etc.) All 3 groups similar demographics: age, race, marital status (all ps All 3 groups similar demographics: age, race, marital status (all ps

>.05) >.05)

* Canadian Journal of Psychiatry 2007 – in press

Problematic PhysiciansProblematic Physicians

MMPI -2 PAI MMPI -2 PAI CATEGORIESCATEGORIES

0

20

40

60

Ds Ch Nl nV

DisruptSexualOther

020406080

D I AS N

DisruptSexualOther

A - DISRUPTIVE N = 39A - DISRUPTIVE N = 39

B – SEXUAL N = 25B – SEXUAL N = 25

C – OTHER N = 24C – OTHER N = 24

CATEGORY ANALYSISCATEGORY ANALYSIS

MMPI-2MMPI-2: Ds=distress, Ch=character, Nl=normal, : Ds=distress, Ch=character, Nl=normal, nV=invalidnV=invalid

PAIPAI: D=distress, I-interpersonal, AS=antisocial, : D=distress, I-interpersonal, AS=antisocial, N=normalN=normal

Problematic PhysiciansProblematic Physicians A (Disruptive)A (Disruptive)

Valid profiles, open, high interpersonal dysfunction, Valid profiles, open, high interpersonal dysfunction, admit and rationalize angeradmit and rationalize anger

B (Sexual) – FEWEST NORMAL PROFILESB (Sexual) – FEWEST NORMAL PROFILES - MOST CHARACTER PATHOLOGY- MOST CHARACTER PATHOLOGY

Impulsive, selfish, low empathy, irresponsibleImpulsive, selfish, low empathy, irresponsible Exaggerated positive light = Therapeutic Challenge Exaggerated positive light = Therapeutic Challenge

C (Other)C (Other)

Tennessee Medical Tennessee Medical Foundation’s Foundation’s

Physician Health Physician Health ProgramProgramRoland Gray, MDRoland Gray, MD

Medical DirectorMedical Director

Statistics for 2002-Statistics for 2002-20062006

2002-2006 YTD2002-2006 YTD

Identifications:Identifications:

ChemicalChemical 335335

BehavioralBehavioral 194194

PsychiatricPsychiatric 5858

Sexual Sexual BoundaryBoundary

5656

Over-Over-prescribingprescribing

2424

TOTALTOTAL 667667

““Distressed Physician” Distressed Physician” CME CourseCME Course

www.mc.vanderbilt.edu/cph

William Swiggart, MS, William Swiggart, MS, LPC/MHSPLPC/MHSP

Center for Center for Professional Professional

HealthHealthContinuing Medical Education Continuing Medical Education CoursesCourses

Prescribing Controlled Prescribing Controlled Drugs Drugs

Maintaining Proper Maintaining Proper Boundaries Boundaries

Disruptive/Distressed Disruptive/Distressed PhysicianPhysician

A Program for Distressed A Program for Distressed PhysiciansPhysicians

Physicians appropriate for referral:Physicians appropriate for referral: Physician is currently workingPhysician is currently working Physician does not require residential Physician does not require residential

treatmenttreatment Physician has some support for change Physician has some support for change

i.e., the State Physician Health Program i.e., the State Physician Health Program or institutional or group practice supportor institutional or group practice support

Differential DiagnosisDifferential Diagnosis

Substance abuse or dependenceSubstance abuse or dependence Medical illnessesMedical illnesses Stress (career choice, Stress (career choice,

personal/family, skills personal/family, skills issues,etc.)issues,etc.)

Psychiatric disorders Psychiatric disorders

When “a little chat” When “a little chat” doesn't workdoesn't work

Mr. Bangsiding felt (and wrongly so) that a littlechat would be enough to stop Bob’s disruptive

behavior.

A Program for Distressed A Program for Distressed PhysiciansPhysicians(Phase I)(Phase I)

Components:Components: Comprehensive EvaluationComprehensive Evaluation Screening with additional measuresScreening with additional measures

Trauma (Trauma Symptom Inventory™)Trauma (Trauma Symptom Inventory™) Flooding Flooding (Gottman)(Gottman)

Workplace assessment (PULSE)Workplace assessment (PULSE) Phone interviewPhone interview Collateral interviewCollateral interview

FloodingFlooding

1.1. After a conflict I want to keep away After a conflict I want to keep away or isolate for a while.or isolate for a while.

2.2. I can never seem to soothe myself I can never seem to soothe myself after a conflict.after a conflict.

3.3. When I get negative, stopping it is When I get negative, stopping it is like trying to stop an oncoming like trying to stop an oncoming truck.truck.

4.4. I can never tell when a blowup is I can never tell when a blowup is going to happen.going to happen.

FloodingFlooding

The average flooding score was The average flooding score was reduced by 50% from the pre-reduced by 50% from the pre-course test. course test.

Pre-course average = 8.29Pre-course average = 8.29

Post-course average = 4.06Post-course average = 4.06

Range 0-24Range 0-24

Components of the Components of the ProgramProgram(Phase II)(Phase II)

Three-day CME course up to 46.5 CMEThree-day CME course up to 46.5 CME Didactic lectures - e.g., shame reaction, Didactic lectures - e.g., shame reaction,

family of origin connections family of origin connections GenogramGenogram Teach Specific tools/skills – e.g., Teach Specific tools/skills – e.g.,

grounding skills, Alter sheet, grounding skills, Alter sheet, communication strategiescommunication strategies

Role-playingRole-playing HomeworkHomework

Role Play ExerciseRole Play Exercise

Describe an incident you are Describe an incident you are concerned about.concerned about.

Who was there?Who was there? Pick someone to play you.Pick someone to play you. A powerful cathartic exercise A powerful cathartic exercise

viewing their behavior from multiple viewing their behavior from multiple points of view.points of view.

Example.Example.

Components of the VUMC Components of the VUMC ProgramProgram

(Phase III)(Phase III) Three follow-up sessions with the core Three follow-up sessions with the core

group over the next six months; group over the next six months; importance of group processimportance of group process

Repeat workplace assessment (PULSE)Repeat workplace assessment (PULSE)

Workbook (Workbook (The Anger Book, The Anger Book, M McKay, M McKay, P Rogers, 2000)P Rogers, 2000)

Characteristics Characteristics and Behavioral and Behavioral Change in the Change in the

First 20 First 20 Disruptive Disruptive PhysiciansPhysiciansCharles P. Samenow, MD, Charles P. Samenow, MD,

MPHMPHDepartment of PsychiatryDepartment of PsychiatryVanderbilt University Vanderbilt University Medical CenterMedical Center

DemographicsDemographics

Total Physicians Studied = 20Total Physicians Studied = 20 Mean Age: 44.6 (compare to CPH mean Mean Age: 44.6 (compare to CPH mean

age 49)age 49) Age Range: 27 - 61Age Range: 27 - 61 Predominantly Male (90%) and Predominantly Male (90%) and

Caucasian (100%)Caucasian (100%) 60% Married, 30% Divorced (1/2 60% Married, 30% Divorced (1/2

multiple)multiple) States Represented: 11States Represented: 11

Specialty TypesSpecialty TypesEmergency Emergency MedicineMedicine

3 (5%)3 (5%)

Family MedicineFamily Medicine 2 (10%)2 (10%)

Internal Medicine Internal Medicine (Specialty)(Specialty)

6 (30%)6 (30%)

Ob/GynOb/Gyn 3 (15%)3 (15%)

PathologyPathology 1 (5%)1 (5%)

Pediatrics Pediatrics (General)(General)

1 (5%)1 (5%)

Pediatrics Pediatrics (Specialty)(Specialty)

1 (5%)1 (5%)

Surgery Surgery (General)(General)

2 (10%)2 (10%)

Surgery Surgery (Specialty)(Specialty)

2 (10%)2 (10%)

Referral SourcesReferral Sources

Employer (35%)Employer (35%) PHP (35%)PHP (35%) Board of Licensure (15%)Board of Licensure (15%) Treatment Center (10%)Treatment Center (10%) Self (5%)Self (5%) Other (5%)Other (5%)

AggressiveAggressive

Anger outburst, verbal threats, swearing (90%) Physical contact and throwing objects (20%)

Sexual Harassment (10%)

PassivePassiveAggressiveAggressive

Derogatory comments about institution, hospital, group, etc.

Refusing to do tasks (20%)

PassivePassive

Chronically late, not responding to call (15%)

Inappropriate/inadequate chart notes, not dictating (15%)

Categories of Reported Disruptive Categories of Reported Disruptive BehaviorsBehaviors

InterventionsInterventions

Confrontation by Practice (95%)Confrontation by Practice (95%) Required Assessment (35%)Required Assessment (35%) Involvement of PHP (35%)Involvement of PHP (35%) Formal Disciplinary Action (30%)Formal Disciplinary Action (30%) Board of Licensure Involvement Board of Licensure Involvement

(10%)(10%) Termination (10%)Termination (10%)

Physician Mental HealthPhysician Mental Health

Previous Psychotherapy (65%)Previous Psychotherapy (65%) Previous Psychotropic Medications Previous Psychotropic Medications

(25%)(25%)

Study DesignStudy Design

Retrospective, Cohort DesignRetrospective, Cohort Design Total Physicians: 20Total Physicians: 20 Behavior Measured By PULSEBehavior Measured By PULSE

Motivating BehaviorsMotivating Behaviors Disruptive BehaviorsDisruptive Behaviors Motivating Impact on OthersMotivating Impact on Others Disruptive Impact on OthersDisruptive Impact on Others Both Self and “Others” (Colleagues, Both Self and “Others” (Colleagues,

Staff, Supervisors)Staff, Supervisors)

Study DesignStudy Design

Pre-Course PULSE: 15Pre-Course PULSE: 15 3-month Follow-up PULSE: 143-month Follow-up PULSE: 14 6-month Follow-up PULSE: 56-month Follow-up PULSE: 5 Average # of “Others”: 20Average # of “Others”: 20

General TrendsGeneral Trends

At 3 months, significant changes in At 3 months, significant changes in all domainsall domains Increased motivating behaviors and Increased motivating behaviors and

motivating impactmotivating impact Decreased disruptive behaviors and Decreased disruptive behaviors and

disruptive impactdisruptive impact Changes in behavior reported by Changes in behavior reported by

“others” more significant than “others” more significant than changes reported by self.changes reported by self.

Mean Motivating Mean Motivating Behaviors As Measured Behaviors As Measured

by Self and Othersby Self and Others

1

1.5

2

2.5

3

3.5

4

4.5

5

Pre-Course Post-Course (3-months)

SelfOthers

Self p =.12 “Others” p < .001

Mean Change in Mean Change in Disruptive Behaviors as Disruptive Behaviors as Measured by Self and Measured by Self and

OthersOthers

1

1.5

2

2.5

3

3.5

4

4.5

5

Pre-Course Post-Course (3-months)

SelfOthers

Self p = .14 “Others” p < .001

General Trends General Trends (Continued)(Continued)

Analysis of individual physicians Analysis of individual physicians demonstrates:demonstrates: Improvement in 12 of the 14 physiciansImprovement in 12 of the 14 physicians Although mean behaviors do not seem Although mean behaviors do not seem

severe, most physicians demonstrated severe, most physicians demonstrated severe behavioral problems in one or severe behavioral problems in one or more domains.more domains.

Reports of disruptive behavior was not Reports of disruptive behavior was not consistent across setting or those who consistent across setting or those who observed it. observed it.

Change in Motivating Change in Motivating Behaviors for Individual Behaviors for Individual Physicians as Measured Physicians as Measured

by Othersby Others

2.5

2.7

2.9

3.1

3.3

3.5

3.7

3.9

4.1

4.3

4.5

Pre-Course Post-Course

Mean % Change in Mean % Change in Disruptive Behaviors (by Disruptive Behaviors (by Severity) as Measured by Severity) as Measured by

OthersOthers

0

5

10

15

20

25

30

35

40

Pre-Course Post-Course

SevereBorderlineGood

OverheadsOverheads

Who is effected?Who is effected?

Colleagues 100%Colleagues 100% Staff (Hospital and/or Practice) 77%Staff (Hospital and/or Practice) 77% Supervisors 63%Supervisors 63% Direct effects on patients are rareDirect effects on patients are rare

General TrendsGeneral Trends

6-month data demonstrates potential 6-month data demonstrates potential for maintenance or improvement in for maintenance or improvement in behavioral changebehavioral change

Limited by small sample sizeLimited by small sample size

6-Month Trends for 6-Month Trends for Disruptive Behavior Disruptive Behavior

Change as Measured by Change as Measured by OthersOthers

0

0.5

1

1.5

2

2.5

3

Pre-Course Post (3 months) Post (6-months)

LimitationsLimitations

Most behaviorally severe physicians Most behaviorally severe physicians may not be includedmay not be included

Difficult to determine the role the Difficult to determine the role the CME course plays in causing CME course plays in causing behavioral changebehavioral change

Difficulty in measuring longitudinal Difficulty in measuring longitudinal changechange

Lessons Learned Lessons Learned Program for Program for Distressed Distressed PhysiciansPhysicians

Anderson Spickard Jr., MDAnderson Spickard Jr., MD

Lessons Learned Lessons Learned Physicians are referred by physician health Physicians are referred by physician health

programs, hospital or practiceprograms, hospital or practice Full psychiatric assessment not always Full psychiatric assessment not always

necessarynecessary Group process addressed the loneliness of Group process addressed the loneliness of

their professiontheir profession Participants were younger than other coursesParticipants were younger than other courses Collateral information was vitalCollateral information was vital Physicians with narcissistic traitsPhysicians with narcissistic traits

Lessons LearnedLessons Learned

A number of them already in outpatient A number of them already in outpatient therapy or open to that recommendation therapy or open to that recommendation by this team as another component to by this team as another component to their “recovery”their “recovery”

Some unhappy in their careerSome unhappy in their career Considered good physicians technicallyConsidered good physicians technically More open than expectedMore open than expected They liked the experiential aspects of They liked the experiential aspects of

the program especially group interactionthe program especially group interaction

Lessons LearnedLessons Learned PULSE indicates behavioral change for a PULSE indicates behavioral change for a

subset of physicians is not only possible, subset of physicians is not only possible, but can be maintained.but can be maintained.

Even when not statistically significant, Even when not statistically significant, large effect sizes and physician large effect sizes and physician testimonials point to a promising testimonials point to a promising interventionintervention

Future studies needed to identify which Future studies needed to identify which physicians are most likely to succeed and physicians are most likely to succeed and to understand role that system plays in to understand role that system plays in enabling/facilitating behaviors.enabling/facilitating behaviors.