Professionalism: beyond platitudes - Federation of State Physician ...

Professionalism:
Beyond Platitudes
Jo Shapiro, MD
Director, Center for Professionalism
and Peer Support
Chief, Division of Otolaryngology
Brigham and Women’s Hospital
Boston, MA
Deep Bow
Louis Sanchez
Linda Bresnahan
PHS
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Team sport
Stan Ashley (BWH CMO)
Debra Leven (CMO’s office)
Lawrence Tsen (Associate Director, CPPS)
Janet Barnes and Risk Management Team
Joan Stoddard (Office of General Counsel, PHS)
CPPS Staff-Sara Nadelman and Julie Burns
Gwen Gilchrist
Beth Cushing, Mark Horgan, Ann-Louise Puopolo;
Debbie LaValley (CRICO/RMF)
Leading Organizations to Health
The Center's mission is to
encourage…a culture that values
and promotes mutual respect, trust
and teamwork.
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Professionalism
Initiative
Peer
Support
Center for Professionalism
and Peer Support
Wellness
Disclosure
Coaching
Dr. Dismissive
Defendant
Support
You are called by Patient Family Relations re: a
recent series of patient complaints about a
general surgeon. Patients state that the
surgeon is arrogant, dismissive and
insensitive. In addition, various members of
the anesthesia team have informed you that
Dr. Dismissive can be demeaning and hostile,
blaming them for not moving the cases along
fast enough. Their sense is that he is more
interested in moving his schedule along than
he is in caring for the individual patient.
3

Word
Ethical
Respectful
Altruistic
Honest
Knowledgeable
Integrity
collegial
Cultural competence
Resource stewardship
4

Trustworthy relationships
Unifying concept
• Patient safety
Burning platform:
Society, JCAHO, ACGME
• Malpractice risk
• Retention
• Morale
• Costly
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Joint Commission
Sentinel Event Alert
End intimidating and disruptive behavior
among physicians, nurses, pharmacists,
therapists, support staff and
administrators
“behaviors that undermine a culture
of safety”
Disruptive behaviors
• Verbal or physical threats
• Intimidation
• Reluctance/refusal to answer questions,
refusal to answer pages or calls
• Impatience with questions
• Condescending language or intonation
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Patient Complaints & Malpractice Risk
“Risk seems not to be predicted by patient
characteristics, illness complexity or even
physicians’ technical skills. Instead, risk
appears related to patients’
dissatisfaction with their physicians’
ability to establish rapport… and
communicate effectively.”
- Hickson et al. AMA. 2002.
It’s easy to point the finger at others.
But let’s think of ourselves as potential
victims, perpetrators or bystanders.
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What might stop you from
coming forward with concerns?
What might stop you from coming
forward with concerns?
• Burdening colleagues
• Looking weak
• Cynicism re: change
• Fear of retaliation
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Saying “just do it” doesn’t work
Why have we tolerated this for so long?
This is, fundamentally, a culture change
“The organization's culture consists of patterns of
relating that persist and change through ongoing
interaction.”
Tony Suchman, MD
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Cultural myths/excuses/delusions
• I am just advocating for my patients
• This is all fluff
• These are all systems problems
• There are just a few bad apples
• If they didn’t learn it in kindergarten, we can’t
teach them now
• The culture is intransigent
What disables professionalism?
• Lack of institutional will
• Fatigue, depression, substance abuse
• Interpersonal conflict
• Unreasonable expectations
• Lack of emotional support
• Lack of knowledge
• Cultural myths
• Character
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What enables professionalism?
• Leadership: institutional resolve
• Supportive community/ Collegiality
• Conflict and stress management
• Willingness of bystanders to speak up
• Communication and teamwork skills
• Empathy
• Systems: resources, control, accountability
Reporting Concerns at BWH
• Confidential discussion w/ Director
• Investigation
• Discussion w/ supervising MD, chief/ chair,
CMO, OGC
• Meeting w/ disruptor
• Document all interactions
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Principles of hearing concerns
• Confidential; Timely; Fair/thorough
• Protect against retaliation
• Intent vs impact
• Focus on behavior, not dx
• Balance of personal accountability and
systems issues
• Effector arm
Back to Dr. Dismissive…
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• Patient advocacy
• I’m unique
Pushback
• Team underperformance
• Political assassination
• Intentions
Identification
Prevention
Remediation
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Stop them at the door…
“The best predictor of future behavior is past
behavior.” (Janz)
“Disciplinary action among practicing physicians by
medical boards was strongly associated with
unprofessional behavior in medical school.”
(Papadakis, NEJM 2005)
___________________________________________
“To your knowledge, has this applicant ever been
reprimanded or disciplined for unprofessional
conduct, disruptive behavior, or harassment?”
“Does this applicant always work and interact well
with colleagues and staff?” (Credentialing: Stopping
Disruptive Physicians at the Door)
Interactive training
sessions
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• Reported concerns
If prevention fails…
Red flags
• Inter-professional complaints
• Patient complaint data
• 360º
• Anonymous
• Behavior-based
• User-friendly
Identification:
360º PULSE
• Ratings and qualitative
• Feedback: Suggestions for behavior
reinforcement as well as changes
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Physician
Peers
Self-Rating
Hospital
Staff
Self-Rating
Hospital Staff
Physician-Peers
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What if the behavior continues?
Sometimes more info is needed
Psychiatric evaluation
In-depth evaluation – if unsure what issues are;
multiple interviews in workplace –
Fitness for duty
Neuropsych testing
Systems issues
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• Coaching
• Group intervention
• Psychotherapy
• Rx underlying disorder
Remediation
• Conflict resolution/ interpersonal
communication skills programs
• Out of state residential programs
Professionalism
Initiative
Peer
Support
Center for Professionalism
and Peer Support
Wellness
Disclosure
Coaching
Defendant
Support
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Peer Support
Hope
"Not the conviction that something will
turn out well, but the certainty that
something makes sense, regardless of
how it turns out. The hope of fellowship,
and kindness, and service."
Vaclav Havel
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Thank you for inviting me
Professionalism Research
Attitudes and barriers to physicians receiving assistance
for personal and professional struggles: A survey of
emergency physicians, anesthesiologists, and surgeons
- Fix, Weissman, Park, Hevelone, Shapiro
Attitudes and Needs of Physicians in Emotional &
Psychological Support– Hu, Fix, Hevelone, Lipsitz,
Greenberg, Shapiro
Disrespectful Behavior at Work – Shapiro, Mullen, Perlo,
McMahon
Coping with Medical Errors: The case of the health
professional – Leeds, UK – Shapiro, Sirriyeh, Perlo
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Professionalism Research (cont)
Wisdom in Medicine: Mapping the Path through
Adversity to Wisdom – Bell, Plews-Ogan,
Owens, Shapiro, Gallagher
Research to examine frequency and efficacy of
disclosures at BWH in conjunction with Ethics
& Quality (Drs. Lehmann, Kachalia)
Center for Professionalism & Peer
Support Contact information
Phone: 617 525 9797
PikeNotes:
www.bwhpikenotes.org/employee_resources/professionalism/default.aspx
Web: www.brighamandwomens.org/CPPS/
E-mail:
BWHCPPS@partners.org
Director: Jo Shapiro, MD
jshapiro@partners.org
Associate Director: Lawrence Tsen, MD
ltsen@partners.org
Administrative Assistant: Julie Burns
jburns1@partners.org
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References
Jones J, McCullough L. Ethics of unprofessional behavior that
disrupts: Crossing the line. J Vasc Surg 2007;433-5.
Wilhelm KA, Lapsley H. Disruptive doctors. Unprofessional
interpersonal behaviour in doctors. Med J Aust 2000; 173:384-6.
Whittemore A. The impact of professionalism on safe surgical care.
Vasc Surg 2007;45:415-419.
Rosenstein A, O’Daniel M. Disruptive behavior and clinical outcomes:
perceptions of nurses and physicians. Am J Nurs 2005;105:54-64.
Rosenstein A, O’Daniel M. Impact and implications of disruptive
behavior in the perioperative arena. J Am Coll Surg 2006;203:96-
105.
Papadakis, M, Hodgson C, Teherani A, Kohatsu N. Unprofessional
Behavior in medical school is associated with subsequent
disciplinary action by a state medical board. Acad Med 2004;
79:244-249.
Baggs J, Schmitt M, Mushlin A, et al. Association
between nurse-physician collaboration and
patient outcomes in three intensive care units.
Crit Care Med 1999;27:1991-1997.
Sexton J, Thomas E, Helmreich R. Error, stress
and teamwork in medicine and aviation:cross
sectional surveys. BMJ 2000;320:745-749.
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FSMB. Report of Special Committee on
Professional Conduct and Ethics. Vol 2004:
Federation of State Medical Boards of the United
States, Inc.:2000.
Rosenstein A, O’Daniel M. A survey of the impact
of disruptive behaviors and communication
defects on patient safety. Joint Comm Jrl Qual
and Pt Safety, Aug 2008,34:464-471.
Smetzer J, Cohen M. Intimidation: Practitioners
speak out about this unresolved problem. Joint
Com Jrl Qual Patient Safety 2005;31:594-599.
Poor teamwork and communication
and their negative impact on
patient care
Rosenstein A, O’Daniel M. Impact and implications
of disruptive behavior in the perioperative arena.
J Am Coll Surg 2006;203:96-105
Whittemore A. The impact of professionalism on
safe surgical care. Jrl Vasc Surg 2007; 45:415-419.
Norton, New York. Quoted in Felblinger D. Incivility
and bullying in the workplace and nurses’ shame
responses. JOGNN 2008; 37:234-242.
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Assessment
Harmon L. Physicians Universal Leadership
Skills Survey Enhancement (PULSE).
Physicians Development: 2002.
http//www.physiciansdevelopmentprogram.com
Hickson G, Federspiel C, Pichert J, Miller C,
Gauld-Jaeger J, Boast P. Patient
complaints and malpractice risk.
JAMA. 2002; 287:2951-7.
Remediation
Samenow C, Swiggart W, Spickard A. A
CME course aimed at addressing
disruptive physician behavior. Phys Exec
2008 Jan-Feb; 32-40.
Williams M, Williams B, Speicher M. A
Systems approach to disruptive behavior
in physicians: a case study. Jrl Med
Licensure and Discipline 2004;90:18-24.
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When giving feedback, hold the
basic assumption
I assume that you are a dedicated person
who shows up at work intending to do an
excellent job.
Prevention
• Stop them at the door
• Small group interactive teaching sessions
• Grand rounds
• Orientation: HMS students, BWH interns,
residents, fellows
• Multidisciplinary group discussions
• Workshops: Giving difficult feedback
• Policies/Code of Professional Conduct
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