Resources for the Resources for the DistressedDistressedPhysicianPhysician

The Program for The Program for Distressed Distressed

Physicians©Physicians©

www.mc.vanderbilt.edu/cph

The Program for Distressed The Program for Distressed Physicians©Physicians©

www.mc.vanderbilt.edu/cph

William Swiggart, MS, LPC/MHSPWilliam Swiggart, MS, LPC/MHSPAssociate in MedicineAssociate in Medicine

Training DirectorTraining DirectorVanderbilt Center for Professional Vanderbilt Center for Professional

HealthHealth

Vanderbilt CenterVanderbilt Center forfor

Professional HealthProfessional Health

Continuing Medical Education Continuing Medical Education CoursesCourses

Prescribing Controlled Drugs©

Maintaining Proper Boundaries©

Program for Distressed Physicians©

www.mc.vanderbilt.edu/cph

PhysicianHospital/Clinic

Well functioning hospital system

MD with good skills; team player; emotional intelligence; knows conflict resolution

Periodic anger outbursts; poor team player

Narcissistic traits; recurrent anger outbursts; generally frustrated; passive aggressive; nurses take brunt of anger

Partially functioning system

Totally inadequate hospital/clinic function

Spectrum of Hospital/Clinic FunctionSpectrum of Hospital/Clinic Function& &

Physician BehaviorPhysician Behavior

When “a little chat” doesn't When “a little chat” doesn't workwork

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

behavior.

Distressed (Disruptive) Distressed (Disruptive) PhysiciansPhysicians

►Disrupt office and homeDisrupt office and home►Ignore feelingsIgnore feelings►BurnoutBurnout

Distressed PhysiciansDistressed PhysiciansNarcissistic TraitsNarcissistic Traits

►Restricted ability to express Restricted ability to express warm and tender emotionswarm and tender emotions

►PerfectionismPerfectionism►Insistence that others submit to Insistence that others submit to

their waytheir way►Excessive devotion to work to Excessive devotion to work to

the exclusion ofthe exclusion of personal and personal and interpersonal relationshipsinterpersonal relationships

Glenn Gabbard

A Program for Distressed A Program for Distressed PhysiciansPhysicians

Physicians appropriate for Physicians appropriate for referral:referral:

►Physician is currently workingPhysician is currently working►Physician does not require Physician does not require

residential treatmentresidential treatment►Physician has some support for Physician has some support for

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

Differential DiagnosisDifferential Diagnosis

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

personal/family, skills issues, etc.)personal/family, skills issues, etc.)►Psychiatric disordersPsychiatric disorders

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

Components:Components:►Comprehensive EvaluationComprehensive Evaluation►Screening with additional Screening with additional

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

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

FloodingFlooding

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

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

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

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

FloodingFloodingThe 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 = 8.29Post-course average = 4.06Post-course average = 4.06

Range 0 -24Range 0 -24

Components of the ProgramComponents of the Program(Phase II)(Phase II)

►Three-day CME course up to 46.5 Three-day CME course up to 46.5 CMECME

►Didactic lectures - e.g., shame Didactic lectures - e.g., shame reaction, family of origin connections reaction, 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 viewing their behavior from multiple points of view.multiple 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 nextgroup over the next six months; 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)

OverheadsOverheads

Characteristics and Characteristics and Behavioral Change in Behavioral Change in

the First 20 the First 20 Disruptive PhysiciansDisruptive Physicians

Charles P. Samenow, MD, MPHDepartment of PsychiatryVanderbilt University Medical Center

DemographicsDemographics

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

CPH mean age 49)CPH mean 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 60% Married, 30% Divorced

(1/2 multiple)(1/2 multiple)►States Represented: 11States Represented: 11

Specialty TypesSpecialty TypesEmergency MedicineEmergency Medicine 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 (General)Pediatrics (General) 1 (5%)1 (5%)

Pediatrics (Specialty)Pediatrics (Specialty) 1 (5%)1 (5%)

Surgery (General)Surgery (General) 2 (10%)2 (10%)

Surgery (Specialty)Surgery (Specialty) 2 (10%)2 (10%)

Referral SourcesReferral Sources

►Employer (35%)Employer (35%)►PHP (35%)PHP (35%)►Board of Licensure Board of Licensure

(15%)(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 Previous Psychotropic

Medications (25%)Medications (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 At 3 months, significant changes in all domainsin all 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.

General Trends (Continued)General Trends (Continued)

►Analysis of individual physicians Analysis of individual physicians demonstrates:demonstrates: Improvement in 12 of the 14 Improvement in 12 of the 14

physiciansphysicians Although mean behaviors do not Although mean behaviors do not

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

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

Who is affected?Who is affected?

►Colleagues 100%Colleagues 100%►Staff (Hospital and/or Staff (Hospital and/or

Practice) 77%Practice) 77%►Supervisors 63%Supervisors 63%►Direct effects on patients Direct effects on patients

are rare are rare

General TrendsGeneral Trends

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

►Limited by small sample Limited by small sample sizesize

LimitationsLimitations

►Most behaviorally severe Most behaviorally severe physicians may not be physicians may not be includedincluded

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

►Difficulty in measuring Difficulty in measuring longitudinal changelongitudinal change

Lessons LearnedLessons Learned ►Physicians are referred by physician Physicians are referred by physician

health programs, hospital or practicehealth programs, hospital or practice►Full psychiatric assessment not Full psychiatric assessment not

always necessaryalways necessary►Group process addressed the Group process addressed the

loneliness of their professionloneliness of their profession►Participants were younger than Participants were younger than

other coursesother 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 PULSE indicates behavioral change for

a subset of physicians is not only a subset of physicians is not only possible, but can be maintained.possible, 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 Future studies needed to identify which physicians are most likely to which physicians are most likely to succeed and to understand role that succeed and to understand role that system plays in enabling/facilitating system plays in enabling/facilitating behaviors.behaviors.

PowerPoint Presentation is available at:www.mc.vanderbilt.edu/cph