Clinical Approach to the Disruptive Physician: The Tennessee Experience Anderson Spickard Jr., MD Reid Finlayson, MD Ron Neufeld, LADC Roland Gray, MD Bill Swiggart, MS, LPC/MHSP Charles Samenow, MD, MPH

Introduction

Distressed Physician Team Vanderbilt Center for Professional Health Anderson Spickard, Jr MD -- Director William Swiggart, MS, LPC/MHSP -- Training Director Charles Samenow, MD, MPH -- Research Assistant Ron Neufeld, LADC -- Clinical Assessment, Teaching Tobi Fischel-Ingram, PhD -- Teaching, Curriculum Jennifer Blackford, PhD -- Biostatistics David Dodd, MD -- Teaching Dianna Phillips -- Administrative Jan Cao -- Administrative Vanderbilt Comprehensive Assessment Program Reid Finlayson, MD Ron Neufeld, LCSW Tennessee Medical Foundation Roland Gray, MD Vince Parish

Research Education, Prevention Advocacy, Outreach Assessment and Treatment Education, Prevention Advocacy, Outreach

VANDERBILT COMPREHENSIVE ASSESSMENT PROGRAM …for Professionals Reid Finlayson, MD Ron Neufeld, LADC www.mc.vanderbilt.edu/root/vcap 615 322-4567

V-CAP MISSION Providing the highest quality behavioral health evaluation and treatment planning services to professionals in crisis due to addictions, mental health issues, sexual boundary related problems and burnout.

Assessment Components Psychological Testing MMPI – II; SCT; TAT; PAI; COPE Coping Scale; State-Trait Anger Expression Inventory; DSFI (sexual functioning); GARS (stress) Psychiatric Evaluation and Addiction Screening MAST; DAST; SAST; BVI; TSI; BDI; Mini-Mental Status Exam; Flooding self-test

Assessment Components, cont’d. Psychosocial Assessment and Genogram Nursing Assessment Lab work and urine drug screen Other components as needed, including H&P, AASI, Neuropsych workup Collaborative information from family, peers, administrators, coworkers, etc. with written permission by client Written report and review session with client and designated others

Reasons for Referral

Disruptive Referrals Axis I Diagnosis Intermittent Explosive Disorder Adjustment Disorder Impulse Control Disorder None (or rule out) Substance Dependence (either active or in remission)

Disruptive Referrals Axis II Diagnosis Personality Disorder, NOS Narcissistic (and other) traits Compulsive personality traits Others

Problematic Physicians: A Comparison of Personality Profiles by Offense Type* 88 Physicians evaluated for “Fitness for Duty” 82 male (M age 46.8 / SD=9.5) 6 female (47.5 / 12.2) 80% married; 13% divorced; 7% single 89% White; 5% Black; 4% Hispanic; 1% Asian A – Behavior Disruptive (anger, demeaning others) B – Sexual Boundary Violations C – Others (SUD, emotional instability, etc.) All 3 groups similar demographics: age, race, marital status (all ps >.05) * Canadian Journal of Psychiatry 2007 – in press

Problematic Physicians MMPI -2 PAI CATEGORIES A - DISRUPTIVE N = 39 B – SEXUAL N = 25 C – OTHER N = 24 CATEGORY ANALYSIS MMPI-2: Ds=distress, Ch=character, Nl=normal, nV=invalid PAI: D=distress, I-interpersonal, AS=antisocial, N=normal

Problematic Physicians A (Disruptive) Valid profiles, open, high interpersonal dysfunction, admit and rationalize anger B (Sexual) – FEWEST NORMAL PROFILES - MOST CHARACTER PATHOLOGY Impulsive, selfish, low empathy, irresponsible Exaggerated positive light = Therapeutic Challenge C (Other)

Tennessee Medical Foundation’s Physician Health Program Roland Gray, MD Medical Director

Statistics for 2002-2006 TOTAL 667 2002-2006 YTD Identifications: Chemical 335 Behavioral 194 Psychiatric 58 Sexual Boundary 56 Over-prescribing 24 TOTAL 667

“Distressed Physician” CME Course William Swiggart, MS, LPC/MHSP www.mc.vanderbilt.edu/cph

Center for Professional Health Continuing Medical Education Courses Prescribing Controlled Drugs Maintaining Proper Boundaries Disruptive/Distressed Physician

A Program for Distressed Physicians Physicians appropriate for referral: Physician is currently working Physician does not require residential treatment Physician has some support for change i.e., the State Physician Health Program or institutional or group practice support This slide outlines the referral criteria we use for physicians referred to the CME course.

Differential Diagnosis Substance abuse or dependence Medical illnesses Stress (career choice, personal/family, skills issues,etc.) Psychiatric disorders These are the other issues in a physician’s life that we try and assess before referral. We have permission from the physician to call individuals who know the physician to compile a set of collateral information before they come to the CME course.

When “a little chat” doesn't work Mr. Bangsiding felt (and wrongly so) that a little chat would be enough to stop Bob’s disruptive behavior.

A Program for Distressed Physicians (Phase I) Components: Comprehensive Evaluation Screening with additional measures Trauma (Trauma Symptom Inventory™) Flooding (Gottman) Workplace assessment (PULSE) Phone interview Collateral interview The next series of slides illustrate the CME program that we have developed to train distressed physicians. The TSI™ is a good, validated tool to uncover the symptoms of Post Traumatic Stress Disorder (PTSD). The Flooding instrument is a tool used to identify the presence of poor emotional control (angry outbursts, etc.) following a stressful situation. The Physicians-Practitioners Universal Leadership Skills Survey Enhancement (PULSE) is a workplace behavioral assessment that we use to evaluate the effects of our training on the physicians future behavior at the workplace.

Flooding After a conflict I want to keep away or isolate for a while. I can never seem to soothe myself after a conflict. When I get negative, stopping it is like trying to stop an oncoming truck. I can never tell when a blowup is going to happen.

Flooding The average flooding score was reduced by 50% from the pre-course test. Pre-course average = 8.29 Post-course average = 4.06 Range 0-24

Components of the Program (Phase II) Three-day CME course up to 46.5 CME Didactic lectures - e.g., shame reaction, family of origin connections Genogram Teach Specific tools/skills – e.g., grounding skills, Alter sheet, communication strategies Role-playing Homework These are the elements of the three day course.

Role Play Exercise Describe an incident you are concerned about. Who was there? Pick someone to play you. A powerful cathartic exercise viewing their behavior from multiple points of view. Example.

Components of the VUMC Program (Phase III) Three follow-up sessions with the core group over the next six months; importance of group process Repeat workplace assessment (PULSE) Workbook (The Anger Book, M McKay, P Rogers, 2000)

Characteristics and Behavioral Change in the First 20 Disruptive Physicians Charles P. Samenow, MD, MPH Department of Psychiatry Vanderbilt University Medical Center

Demographics Total Physicians Studied = 20 Mean Age: 44.6 (compare to CPH mean age 49) Age Range: 27 - 61 Predominantly Male (90%) and Caucasian (100%) 60% Married, 30% Divorced (1/2 multiple) States Represented: 11

Specialty Types Emergency Medicine 3 (5%) Family Medicine 2 (10%) Internal Medicine (Specialty) 6 (30%) Ob/Gyn 3 (15%) Pathology 1 (5%) Pediatrics (General) Pediatrics (Specialty) Surgery (General) Surgery (Specialty)

Referral Sources Employer (35%) PHP (35%) Board of Licensure (15%) Treatment Center (10%) Self (5%) Other (5%)

Categories of Reported Disruptive Behaviors Aggressive Passive Passive Aggressive Anger outburst, verbal threats, swearing (90%) Physical contact and throwing objects (20%) Sexual Harassment (10%) Chronically late, not responding to call (15%) Inappropriate/inadequate chart notes, not dictating (15%) Derogatory comments about institution, hospital, group, etc. Refusing to do tasks (20%)

Interventions Confrontation by Practice (95%) Required Assessment (35%) Involvement of PHP (35%) Formal Disciplinary Action (30%) Board of Licensure Involvement (10%) Termination (10%)

Physician Mental Health Previous Psychotherapy (65%) Previous Psychotropic Medications (25%)

Study Design Retrospective, Cohort Design Total Physicians: 20 Behavior Measured By PULSE Motivating Behaviors Disruptive Behaviors Motivating Impact on Others Disruptive Impact on Others Both Self and “Others” (Colleagues, Staff, Supervisors)

Study Design Pre-Course PULSE: 15 3-month Follow-up PULSE: 14 Average # of “Others”: 20

General Trends At 3 months, significant changes in all domains Increased motivating behaviors and motivating impact Decreased disruptive behaviors and disruptive impact Changes in behavior reported by “others” more significant than changes reported by self.

Mean Motivating Behaviors As Measured by Self and Others Self p =.12 “Others” p < .001

Mean Change in Disruptive Behaviors as Measured by Self and Others Self p = .14 “Others” p < .001

General Trends (Continued) Analysis of individual physicians demonstrates: Improvement in 12 of the 14 physicians Although mean behaviors do not seem severe, most physicians demonstrated severe behavioral problems in one or more domains. Reports of disruptive behavior was not consistent across setting or those who observed it.

Change in Motivating Behaviors for Individual Physicians as Measured by Others

Mean % Change in Disruptive Behaviors (by Severity) as Measured by Others

Overheads

Who is effected? Colleagues 100% Staff (Hospital and/or Practice) 77% Supervisors 63% Direct effects on patients are rare

General Trends 6-month data demonstrates potential for maintenance or improvement in behavioral change Limited by small sample size

6-Month Trends for Disruptive Behavior Change as Measured by Others

Limitations Most behaviorally severe physicians may not be included Difficult to determine the role the CME course plays in causing behavioral change Difficulty in measuring longitudinal change

Lessons Learned Program for Distressed Physicians Anderson Spickard Jr., MD

Lessons Learned Physicians are referred by physician health programs, hospital or practice Full psychiatric assessment not always necessary Group process addressed the loneliness of their profession Participants were younger than other courses Collateral information was vital Physicians with narcissistic traits

Lessons Learned A number of them already in outpatient therapy or open to that recommendation by this team as another component to their “recovery” Some unhappy in their career Considered good physicians technically More open than expected They liked the experiential aspects of the program especially group interaction

Lessons Learned PULSE indicates behavioral change for a subset of physicians is not only possible, but can be maintained. Even when not statistically significant, large effect sizes and physician testimonials point to a promising intervention Future studies needed to identify which physicians are most likely to succeed and to understand role that system plays in enabling/facilitating behaviors.