Creating a Culture of ProfessionalismCharlene M. Dewey, M.D., M.Ed., FACPAssociate Professor of Medical Education and AdministrationAssociate Professor of MedicineCenter for Professional HealthVanderbilt University School of Medicine

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

ProfessionalismAMA Code of Ethics 1847ACP Ethics Manual 2005A Physician Charter: ABIM, ACP, European Federation of Internal Medicine 2007Sterns professionalism modelInstitutional codes of conduct and policies

Sterns Professionalism ModelProfessionalism 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.

ProfessionalismDewey & Swiggart. Vanderbilt University School of Medicine, 2009; Adopted from Stern, 2006Professional Health & WellnessProfessional Culture

Two Systems Interact

Professional vs. Unprofessional

Professional vs. Unprofessional

We judge ourselves by our motives whereas others judge us by our behavior.~AA saying

GoalsThe 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:List and discuss four types of professionalism lapses.Analyze the roles of the individual and the institution as they shape the overall culture of professionalism.Accept that both individuals and the institution are responsible for promoting a culture of professionalism.

AgendaFour examples of professionalism lapsesIndividual & institutional rolesStress & burnoutInfluencing professional culturesResourcesSummary

Center for Professional HealthFaculty and Physician Wellness Committee3 CME accredited professional development programsDistressed PhysicianMaintaining Proper BoundariesProper Prescribing CPD~15 years in training/remeding physiciansDemographics:Mandated > voluntaryIM, FP - but all specialtiesMales > femalesRural, solo practices > academic health centerhttp://www.mc.vanderbilt.edu/cph

Professional Lapses661,400 physicians/surgeons in US in 2008>32,000 sanctions btw 2004 - 2008 (~5-10%)955 criminalMany uncategorizedMany events not reportedPhysician Survey 2007:96% agreed physicians should report impaired or incompetent colleagues45% who encountered such colleagues did not report eventsCampbell, et al. Professionalism in Medicine: Results of a National Survey of Physicians Ann In Med, 2007

Professionalism LapsesFour major professionalism lapses:Distressed/disruptive behaviorsBoundary violationsImproper prescribingImpairment

Distressed/Disruptive Behaviors

Disruptive BehaviorBehavior or behaviors that undermine a culture of safety.1Disruptive behavior is a sentinel event2The Joint Commission's Comprehensive Accreditation Manual for Hospitals, LD.03.01.01, elements of performance (EP) 4 and 5, Spring 2012; Joint Commission, Issue 40 July 9, 2008

AggressivePassive 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,BlamingChronically late

Failure to return calls

Inappropriate/inadequate chart notes

Avoiding meetings & individuals

Non-participation

Ill-prepared, not preparedSwiggart, 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 achievementMH issues2: Personality disorders, narcissism, depression, bipolar, OCD, etc. Genetic/developmental issues: Aspergers, non-verbal learning differences, etc.Family systemsStress/physiologic reactionsBurnout3Reduced wellness1) Valliant, 1972; 2) Gabbard, 1985; 3) Spickard and Gabbe, 2002

Distressed/Disruptive BehaviorsEtiologies-Institutional:System reinforces behaviorLeadership ignores problems for productivityScapegoatsIndividual pathology may over-shadow institutional pathologyWilliams and Williams, 2004 Sutton, R. The No Asshole Rule: Building a Civilized Workplace and Surviving on the Isnt. Business Plus, New York, 2007

Distressed/Disruptive BehaviorsCycleHorizontal Hostility

Boundary Violations

Boundary ViolationsPower differentialSexual misconductSexual improprietySexual violationsSexual harassmentSocial mediaUnprofessional, disinhibition, anonymity

Boundary ViolationsEtiologies:Environment:Relaxed professional culture slippery slopeIndividual:Stress & burnoutLack of self-careLack of knowledgePatients:Predators & drugsDewey, Swiggart, Manley, & Spickard. Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine CPH 2011.

Misprescribing CPD

Six Categories of Misprescribing PhysiciansBrown, Swiggart, Dewey, & Ghulyan, Searching for answers: proper prescribing of controlled prescription drugs. J Psychoactive Drugs. 2012 Jan-Mar;44(1):79-85.

Dated:Fails to keep currentDisabled:Failed judgment due to impairmentDuped:Fails to detectDishonest:Personal or financial gainDismayed:Rx as a quick fix due to timeDysfunctional:Fails to say no

Misprescribing CPDRules and guidelines:DEA Practitioner's ManualSMB & FSMBDrug seeking patients Confrontational phobiaPrescribing for non-patient colleagues, friends, familiesSelf-prescribingDewey, 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...Physical impairmentCognitive impairmentPsychological impairmentSubstance use disorders (licit and illicit drugs)Mental health disorders (depression & suicide)Affects: individual, family, patients, institutionAMA 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 ManualEthics Manual, 5th Edition. American College of Physicians 190 N. Independence Mall West. Philadelphia, PA. 19106-1572

Professionalism LapsesConsequences:Restriction or loss of DEA registrationRestricted or loss of medical licenseLoss of jobLaw suites and restriction of insurance coverageLoss of relationships personal and workLoss of self

Unprofessional ConductFour major professionalism lapses:Distressed/disruptive behaviorsBoundary violationsImproper prescribingImpairment

Two Systems Interact

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

Clinician Health & WellnessLittle education on topic30-60% MD are distressed and at burnoutMS & residents Primary care (IM, FP, ER)MDs suicide > other prof. & gen pop.One physician per day; PhD unclearGrossly underestimatedDepression/bipolar & substance abuse = suicide riskFaculty Health in Academic Medicine: Physicians, Scientists, and the Pressure of Success. Cole, Goodrich & Gritz, 2009 & Shannafelt, Arch In Med, 2012.

Clinician Health & WellnessGender differences:Females > anxiety, depression, burnoutF>M MD suicides (>50% vs 40% higher risk)Women chairs more stressedMale physicians (regardless of race) live longer than other professionalsReduced use of care by physicianStigma & 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 & WellnessAcademic faculty:Worked longer hoursTook less vacation10% with mild depression27% with elevated anxietyNo sig difference clinical vs. academicLin 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 & WellnessSelf-careStress & burnoutEmotional intelligenceFamily systemsTraining experiences hidden curriculumCoping skillsConflict managementPersonality types

Self-CareSeven key areas:SleepBalanced mealsPhysical activitySocialization/hobbiesVacations/down timesSpiritual engagementHaving a personal physicianDewey, CM Professionalism and the Health and Wellness of the Internist. Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010.

Stress & ProductivityBurnoutStressedSituational StressNon-FunctionalProlonged StressDewey, CM Professionalism and the Health and Wellness of the Internist. Tennessee American College of Physicians Chapter Scientific Meeting, Sept 17, 2010.

BurnoutIn 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 MaslachThe Truth About Burnout: How Organizations cause Personal Stress and What to Do About It. Maslach & Leiter pg 9; 1997

Lack of controlWork overloadInsufficient rewardUnfairnessBreakdown of communityValue conflictMaslach & Leiter, 1997. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It.Six Sources of Burnout

Risk Factors for BurnoutSingleGender/sexual orientation># of children at homeFamily problemsMid-late careerPrevious mental health issues (depression)Fatigue & sleep deprivation

General dissatisfactionAlcohol and drugs Minority/internationalTeaching & research demandsPotential 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 BurnoutChronic exhaustionCynical and detachedIncreasingly ineffective at workLeads to: isolation avoidance interpersonal conflicts high turnoverMaslach & Leiter, 1997. The Truth About Burnout: How Organizations Cause Personal Stress and What to Do About It. pg 17

Physician Health and WellnessTo 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-140.886AMA 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 EnvironmentCan work environment influence individual health?Stress: physician, environment, patientsEnvironment was the only sig predictor of stressJob stress predicts job satisfactionJob sat is positive predictor of positive mental healthPerceived stress was a stronger predictor of both poorer reports of physical and mental healthTherefore, environment influenced healthPowerful model how practice environment can impact physician healthWilliams et al. Physician, practice and patient characteristics related to primary care physician physical and mental health: Results of the physicians work-life study. Health Services Research, 2002; 37(1):121-43.

Work EnvironmentInstitutional factors to address:Inadequate systems & supports1System reinforces behavior1Need for a scapegoat1,3Money/financial benefit1Culture more, faster, better, longer2Failure to recognize costs to individuals, pts, institution31) 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 Isnt. Business Plus, New York, 2007

Promoting ProfessionalismIf you keep doing the same thing you always did.you will keep getting the same results you always got!

Promoting ProfessionalismLeadership commitmentSupportive institutional policiesProgram or model to guide graduated interventionsSurveillance tools to capture allegationsProcesses for reviewing allegationsInterventionsMulti-level trainingResources to help:Unprofessional colleaguesVictims (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 ProfessionalismMedical education & training: focus is cognitive Emotional & self-regulation activities for MS and residentsResidency programs need to assess, train/prepare residents for the challenges in medicine1 & provide remediation as neededFaculty development - need training/coaching (emotional intelligence (EI), coping mech., conflict management, early identification, etc.) in order to teach & role model professional behaviorsAAMC Council of Deans 2004

Resources

ResourcesPhysician 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

ResourcesTraining programs: PACE, Case western, etc.Treatment programsPrivate counseling servicesProfessional Coaching - Center for Women in Med: Debbie Smith (www.cwmedicine.org)Suicide prevention hotline: 1-800-273-TALKSubstance use: (AA, NA, Evelyn Fry, etc.)Community-based wellness programs: YMCA/YWCA, Massage envy, etc.

SummaryListed and discussed four types of professionalism lapses.Analyzed the roles of the individual and the institution as they shape the overall culture of professionalism.Accepted that both individuals and the institution are responsible for promoting a culture of professionalism.

Questions & Answers

**************Marshall University School of Medicine - WorkshopAugust 28, 2012Dewey, CM - 2012 Vanderbilt University School of Medicine*****************************************************