Physician Problems Problem Physicians

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Physician Problems?Problem Physicians?

• Martha Illige, MD
• Rose Family Medicine, Denver
• AUR-APDR website April 2007

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The Problem Physician

• Seminar co-developers 2003 - one day
  session for medical leaders
• CPEP, the Center for Personalized Education for
  Physicians www.cpepdoc.org
• Dr. Rick Sheff of the Greeley Company, a
  division of hcPro www.greeley.com

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Three areas

• Health impairment
• Dyscompetence
• Unprofessional behavior
• How do they relate to ACGME competencies?
• Which ones are easier to handle?

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Competencies graphic

• Patient Care
• surrounds everything our PURPOSE
• Professionalism
• constitutes the CENTER
• Medical Knowledge
• is NECESSARY AND NOT SUFFICIENT for the practice
  of medicine
• although we admire and respect medical
  knowledge it alone is not enough

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Consider your experience

• Think of specific persons or encounters
• Write a one-sentence summary of the problem as
  you see it

• Note types of issues
• Write down potential categories for problems in
  your case

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Three categories

• Health
• Mental
• Physical
• Competence
• Ability
• Dys-competence is a gentler and broader phrase
  than incompetence
• Behavior
• Workplace performance, professionalism

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Stories from educators

• He would lose his temperbut he was so smart that
  we forgave him.
• We were all shocked when he committed suicide.
• She could not go beyond simplistic algorithm
  management it turned out shed missed areas of
  basic medical knowledge that impaired her ability
  to go forward.

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Residents education

• Advantages
• Learners
• Structured setting
• Support
• Supervision
• Clear goals What makes a great
  radiologist?

• Disadvantages
• One size fits all
• Struggle between adult learning and patient
  safety
• Variation in competencies of graduates
• Assumptions about learners

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Career arc

• Medical school admissions
• Students
• Residents
• Fellows
• Practicing Physicians

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Opportunities

• EARLY in the career arc DO
• Communicate expectations
• Analyze professional behavior
• Intervene
• Ignoring a problem
  or a potential problem is NO
  FAVOR to the resident

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Consequences

• Investigation
• Educational focus
• Quality improvement oriented
• Possible early intervention
• NOT reportable
• Discipline academic probation
• Punitive
• Reportable

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Investigation

• Document facts
  in the residents file
• Note trends
• Offer early and prompt feedback
• Compare data accurate, useful data
• Surveillance-by-objective
• Studies of physician behavior showing that
  outliers will bring their performance into line
  with the group

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Competence Performance

• Abilities
• Within the individual
• Linked to inborn talent as well as learning
• May not be expressed in all settings
• Interacts with performance

• Actual behaviors in the workplace
• Affected by circumstances within and without the
  individual
• Application of knowledge
• Organization
• Teamwork
• Interacts with systems

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Competence-Performance

• A resident must be competent in order to perform
  effectively at work
• A resident, competent in all or some areas, may
  not perform effectively at work
• Outside stressors health, family, finance
• Variation in previous training, experience
• Systems problems, like work overload

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Who cares?

• Patient safety
• Patient satisfaction
• Healthcare worker turnover
• Regulators like JCAHO
• Working environment
• Opportunities for improvement and excellence

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Red flag data

• Out of proportion complaints
• Unusual comparative aggregate outcomes
• Changed and atypical behavior
• Same unacceptable old behavior but changed
  expectations

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How do you know?

• Heart sinking
• Gut churning
• Afterthoughts puzzling
• Response sighing
• Reactions of avoiding
• Theres something about

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Pay attention ignoring problems is no favor to
the learner

• Letting a problem slide---boomerangs
• AUR 2007 disruptive physician scenario of a
  possible relationship between supervisor and
  resident observations in month 1, 4, 20 with
  eventual questions about favoritism or harassment
• James Stewarts investigative report, Blind Eye,
  about a serial murderer, Dr. Michael Swango, who
  behaved oddly in medical school
• How do you speak up?
• Can you change the outcome by speaking up early?

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Speaking up

• Practice
• Practice
• Practice
• Resources from USC Learners in Difficulty
• Steve Bogdewic, PhD

• The STOP model
• Stop pause to identify a problem in the
  moment
• Take a moment to calm and be nonjudgmental
• Observe directly what you saw/heard
• Procure information about the context and plan
  for future behavior change

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Multiple intelligences

• Emotional intelligence EQ
• Social intelligence SQ
• Reference authors
• Daniel Goleman
• Emotional Intelligence 1996
• Social Intelligence 2006
• Mel Levine
• A Mind at a Time 2003
• Marcus Buckingham
• First, Break All the Rules 2001

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Competencies - Intelligences

• Medical Knowledge IQ
• Communication EQ, SQ
• Practice-based learning IQ, SQ
• System based practice EQ, SQ
• Professionalism EQ, SQ
• Patient Care IQ, EQ, SQ

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Enhancing competencies

• Easier
• Medical Knowledge
• Communication skills
• Sparse learning resource tools
• Who owns the problem?

• Harder
• Professionalism
• Organization
• Application of knowledge
• Attitude

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Adult development

• Erik Erikson and George Vaillant
• Adults continue to mature psychologically
• Bud Baldwin
• Medical education impedes moral development
• Ron Zemke, Claire Raines, and Bob Filipczak
• Generations at Work experience and values in the
  workplace
• How can I be more effective?
• How can I understand this?

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Response to feedback

• Normal
• Oh, wow
• Im sorry
• Ill work on that
• Really? What can I do?
• How can I change?
• Thanks, Ill do better

• Abnormal
• Thats not so
• Its not my fault
• Who are you to criticize?
• Everybody does it
• Thats my way
• Prove it

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Mind the gap
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Gap between response and expectation

• What might cause an unexpected response to
  feedback, that while painful, can lead to better
  patient care?
• Culture of intimidation within the program
• Disorganization within the learner
• Rebellious style
• Depression and frustration
• Low EQ or SQ
• What to do?
• INVESTIGATE

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What problem?

• Health impairment
• Dyscompetence
• Unprofessional behavior

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Blink-the value of impression

• Myers-Briggs Personality Inventory - MBTI
• Introversion-Extroversion
• Sensing-Intuition
• Thinking-Feeling
• Judging-Perceiving
• Application to medical education
• Physicians, as professionals, need to have
  command of both ends of all four spectra,
  whatever their preferences
• Intuition
• Expert analysis based on sensory data and
  experience
• Malcolm Gladwell
• Blink, The Power of Thinking Without Thinking 2005

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When you see it

• Marginal performance
• Out of range aggregate data
• Blink moments
• Chatter

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The Medical Model - Parallels

• Medicine
• Education
• Human resource management
• Investigation in these models is similar

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The Medical Model

• Gather information logically
• Know the differential diagnosis list
• Apply problem-solving skills
• Consider a diagnosis
• Plan further analysis or intervention
• Follow up and determine effectiveness

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Health

• Illness does not equal impairment
• Substance abuse is a cause, not the
  cause
• Physician incidence rates the same
• Depression, dementia, diabetes, alcoholism and
  other substances
• Physician issues disproportionate
• Stress, disruptive behavior

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Health treatment

• Physicians tend to
• Choose healthy behaviors
• Maintain recovery after illness
• Want to return to work
• Be able to re-enter practice safely
• Physicians preserve their work environment and
  manifest dysfunction there last

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Dyscompetence

• Physician missed skills in training
• Physician got out of date
• System allowed errors
• Team did not function well
• Workplace stressed

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Behavior

• Professionalism
• Attitude
• Ethics
• Leadership
• Papadakis study of disciplinary actions
• Two associations between licensing board actions
  and prior educational record
• Poor response to criticism
• Boundaries - doing what a doctor should do (like
  show up for work!)

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Consider your experience

• Go back to your original notes about your problem
  encounters
• Re-categorize them
• Note whether you could have intervened
• Differently
• Earlier
• More effectively

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DO INVESTIGATE

• Evidence-based practice!
• Logical approach and thinking
• Dont jump to conclusions
• Dont assume
• Dont anchor
• Dont ignore problems or human factors
• Do consider your resources
• Patients deserve professionalism

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Investigation resources

• Your management experience
• The physician him or herself
• Peer review, quality improvement data
• Collateral sources (partners, peers, staff,
  family)
• Outside organizations
• State and national data comparison
• Specialty organizations and guidelines

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You might find

• Bad things happen to good physicians
• Bad things happen to bad physicians
• Physicians may be
• Impaired physically
• Impaired emotionally
• Impaired by substances
• Cantankerous chronically
• Deficient educationally

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Outside resources

• State Physician Health Programs
• Physician Assessment/Education Programs
• Physician Ethics/Behavior Programs
• Continuing Professional Development that focuses
  on
• self-measurement
• small group interaction
• application to actual practice

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Behavior modification

• Clear expectations
• Measurable change
• Social norms
• Monitored outcomes
• Behavior
• Performance numbers
• Feedback from staff, peers, consultants

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When you worry

• Check it out
• Know your options
• Know your differential diagnosis
• Know your resources and supports
• Use experts and outside help
• Frame a win-win strategy
• Understand your benefit-loss lines

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How do you intervene?

• Reference your role and its obligations
• Stay professional
• Calm
• Non-judgmental
• State your higher purpose
• Patient safety
• Optimal education
• Anticipate resistance

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Practice Most of us are not natural interveners

• Who
• What
• Where
• When
• Why
• How long (limited time)

• Im responsible for patient care/training
• We agree on these expectations
• Specific issues includewith data
• Behavior, not personal focus
• Persist

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Remedial options

• Refer to a health, competence, or behavior
  program
• If you have a diagnosis and resources
• Medical knowledge learning modules
• Communications training
• Leadership training
• Videotape analysis

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Videorecording review a gift

• How do others see me?
• How do I see myself?
• Where can I practice safely?
• Who can help?
• Faculty consultants
• Standardized patients
• Standardized residents
• Standardized colleagues

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Learning opportunities

• Teacher manager attitudes
• Cultures of improvement

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Dealing with problems

• Workplace performance
• Physicians manifest dysfunction here LAST
• Expectations
• Clear agreement
• Analysis
• Apply logic
• Resources
• Know them
• Intervention
• Follow-up

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References

• Federation of State Physician Health Programs
  www.fsphp.org
• Coalition for Physician Enhancement
  www.physicianenhancement.org
• International Physician Assessment Coalition
  www.interpac.org
• Center for Professional Well-Being
  www.cpwb.org
• Goldman et al 2000 The Handbook of Physician
  Health (AMA)
• Pew Commission 1998 Professionalism in Medicine
• Quirk 2006 Intuition and Metacognition in Medical
  Education
• Cox et al 2006 Understanding Doctors Performance
• National Patient Safety Agency/National Clinical
  Assessment Service 2006 Handling Concerns about
  the Performance of Healthcare Professionals
  Principles of Good Practice
• King Kitchener 1994 Developing reflective
  judgment Understanding and promoting
  intellectual growth and critical thinking in
  adolescents and adults www.umich.edu/refjudg/inde
  x.html

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Contact

• Martha Illige, MD
• martha.illige_at_rfmr.com
• Rose Family Medicine
• 4545 E 9th Avenue 010
• Denver, CO 80220