“Creating a Culture of Professionalism”

Charlene M. Dewey, M.D., M.Ed., FACPAssociate Professor of Medical Education and Administration

Associate Professor of MedicineCenter for Professional Health

Vanderbilt University School of Medicine

Marshall University Joan C. Edwards School of MedicineAugust 28, 2012

Professionalism1. 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

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.

Professionalism

Dewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006

Professional Health & Wellness

Professional Culture

“Personal & Institutional Vitality”

“The Perfect Storm”

Two Systems Interact

ClinicianWork Environment

The Internal SystemGood Skills & Well

Poor Skills&/or Not Well

The External SystemFunctional & Nurturing

Dysfunctional

Professional vs. Unprofessional

Professional vs. Unprofessional

“We judge ourselves by our motives whereas others judge

us by our behavior.”~AA saying

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.

ObjectivesUpon 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.

Agenda

1. Four examples of professionalism lapses

2. Individual & institutional roles

3. Stress & burnout

4. Influencing professional cultures

5. Resources

6. Summary

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

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

Professionalism Lapses

Four major professionalism lapses:1. Distressed/disruptive behaviors

2. Boundary violations

3. Improper prescribing

4. Impairment

Distressed/Disruptive Behaviors

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

Aggressive Passive

PassiveAggressive

Inappropriate anger, threats

Yelling, publicly degrading team members

Intimidating staff, patients, colleagues, etc.

Pushing, throwing objects

Swearing

Outburst of anger &physical abuse

Hostile notes, emails

Derogatory comments about institution, hospital, group,

etc.

Inappropriate joking

SexualHarassment

Complaining,Blaming

Chronically late

Failure to return calls

Inappropriate/inadequate chart notes

Avoiding meetings & individuals

Non-participation

Ill-prepared, not prepared

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.

Spectrum of Disruptive Behaviors

Distressed/Disruptive BehaviorsEtiologies-Individuals:• Psychological Factors1:

– Substance use/abuse, trauma history, religious fundamentalism, familial high achievement

• MH issues2: – Personality disorders,

narcissism, depression, bipolar, OCD, etc.

• Genetic/developmental issues: – Asperger’s, non-verbal

learning differences, etc.

• Family systems• Stress/physiologic

reactions• Burnout3

• Reduced wellness

1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002

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

Distressed/Disruptive Behaviors

CycleHorizontal Hostility Poor

Communication

Reduced PtSafety

Lost of Finances& Reputation

Staff Turnovers

Increase Liability and Risk

Poor Work Environment

Boundary Violations

Boundary Violations• Power differential

• Sexual misconduct– Sexual impropriety– Sexual violations

• Sexual harassment

• Social media– Unprofessional, disinhibition, anonymity

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.

Misprescribing CPD

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.

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

Impairment

ImpairmentAMA: “…any physical, mental or behavioral disorder thatinterferes with ability to engage safely in professional activities...”

1.Physical impairment2.Cognitive impairment3.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-physicain-health.pdf - Accessed 8/13/2012

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

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

Unprofessional Conduct

Four major professionalism lapses:1. Distressed/disruptive behaviors

2. Boundary violations

3. Improper prescribing

4. Impairment

“Personal & Institutional Vitality”

“The Perfect Storm”

Two Systems Interact

ClinicianWork Environment

The Internal SystemGood Skills & Well

Poor Skills&/or Not Well

The External SystemFunctional & Nurturing

Dysfunctional

Clinician

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.

Professional Health & Wellness Spectrum

High FunctioningHigh Productivity

Fair FunctioningDecreasing Productivity

Fair FunctioningReduced ProductivityRelationships Suffer

Fair-Not FunctioningFair-Not ProductiveInstitution & Family Loses

Burnout

Coping MechanismsFailing

Risk of MH issues and suicide

No Coping Mechanisms

Professionally Healthy& Well

Stressed

Coping Mechanisms Strong

Physical

Mental

Emotional

Spiritual

Work &

Family

Relations

Dewey, CM and Swiggart, WH. Center for Professional Health – Vanderbilt University School of Medicine, 2009.

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.

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.htmLin 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

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.

Clinician Health & Wellness• Self-care• Stress & burnout• Emotional intelligence• Family systems• Training experiences – hidden curriculum• Coping skills• Conflict management• Personality types

Self-Care

Seven key areas:1. Sleep

2. Balanced meals

3. Physical activity

4. Socialization/hobbies

5. Vacations/down times

6. Spiritual engagement

7. 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.

Stress & Productivity

Declining Function

Produ

ctiv

e Str

ess

No Prolonged Stress

BurnoutStressedSituational Stress

Non-Functional

Prolonged Stress

Reduced Cognition

“Impairment” ???

Dewey, CM “Professionalism and the Health and Wellness of the Internist.” Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010.

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

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.”

Six Sources of Burnout

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

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

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-physicain-health.pdf - Accessed 8/13/2012

Work Environment

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.

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

Promoting Professionalism

“If you keep doing the same thing you always did….you will keep getting the same results you always got!”

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.

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

Resources

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

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.

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.

Questions & Answers