1. Michael Kaufmann MD Director, Physician Health Program; Medical Director, PWSP Ontario Medical Association “Ain’t Misbehavin’” Respectful Behaviour in the Medical Workplace

2. Dedicated to Doctors. Committed to Patients. “The age of the cowboy surgeon is over.” Wayne and Mary Sotile “The Resilient Physician”

3. Dedicated to Doctors. Committed to Patients. Learning objectives: 1.Understand the nature and causes of disruptive behaviour in doctors; 2. Learn about the many strategies available to manage disruptive behaviour in physicians based upon a staged approach in a systems paradigm; 3. Learn about the Physician Workplace Support Program of the Ontario Medical Association.

4. Dedicated to Doctors. Committed to Patients.

5. PRIMUM NON NOCERE

6. Dedicated to Doctors. Committed to Patients.

7. NOT SO PRIMUM NON NOCERE

8. Dedicated to Doctors. Committed to Patients.

10. “Where is it written that I have to be nice?” orthopedic surgeon

11. Dedicated to Doctors. Committed to Patients. It is written: Medical Association Code of Ethics Institutional Codes of Conduct CanMeds Roles Occupational Health Law (harassment and violence) Regulatory Policies Other

12. Dedicated to Doctors. Committed to Patients. Disruptive behaviour is defined by the College of Physicians and Surgeons of Ontario (CPSO) as: “inappropriate conduct, whether in words or action, which interferes with, or has the potential to interfere with, quality health care delivery.” Single egregious act Pattern of behavioural incidents

13. Dedicated to Doctors. Committed to Patients. Examples: Abusive and aggressive behaviour Intimidation, bullying, physically threatening, throwing objects Blaming, shaming, belittling language Unnecessary sarcasm or cynicism Harassment and violence

14. Dedicated to Doctors. Committed to Patients. Examples: Passive-aggressive behaviour Late or no replies to pages Non-compliance with policies and procedures Non-attendance at committee meetings Rigid, inflexible or non-responses to requests for cooperation Intentional delay or obstruction of hospital procedures

15. Dedicated to Doctors. Committed to Patients. Examples: Boundary crossings Sexual comments or innuendoes Sexual harassment – unwelcome flirtation Inappropriate touching Interference with management of other doctors’ patients

16. Dedicated to Doctors. Committed to Patients. Examples: Other Racial, cultural slurs Disparaging remarks about colleagues and administrators (including hostile e-mails, notes in patient records) Refusing to see certain categories of patients Lack of respect for comfort of others

17. Dedicated to Doctors. Committed to Patients. What Disruptive Behaviour isn’t: Healthy criticism offered respectfully and in good faith with the intention of improving patient care or facilities Making a complaint to an outside agency when indicated Testifying against a colleague Good faith patient advocacy Problems with competence

18. Dedicated to Doctors. Committed to Patients. 18 Disruptive behaviour Prevalence 1%- 5% (Linney, 1997) 3% – 5% (Leape, 2006) 6% of physicians have >25 complaints on same theme in 5 years (Hickson, 2002)

19. Behaviour Distressed Physician colleagues co-workers Hospital systems patients Family

20. Dedicated to Doctors. Committed to Patients. Causes Temperament and personality structure

22. Dedicated to Doctors. Committed to Patients. Causes Temperament and personality structure “Doctor behaviour”

23. Dedicated to Doctors. Committed to Patients. Traditional Medical Culture Encourages “Doctor Behaviour” Perfectionism Like to be ‘In-Control’ Dedication to patients above all Problem solvers, solution focused Successful in achieving goals Resist Change Obsessive Emotionally reserved

24. Dedicated to Doctors. Committed to Patients. Causes Temperament and personality structure “Doctor behaviour” Marital and family tensions Mismanaged stress – “shoot the first thing that moves.” Burnout and other occupational tensions / workplace factors Psychiatric disorders Mood and anxiety disorders such as bipolar type II and OCD Adjustment disorders Character problems and disorders Substance use disorders Physical health problems

25. Dedicated to Doctors. Committed to Patients. The PHP Experience: Approx. 10% of calls to PHP due to conduct problems specifically Many referred with other problem types display disruptive behaviour 88% male One third Surgeons Ob-Gyn & Anesthetists approximately 10% each.

26. Dedicated to Doctors. Committed to Patients. Good intentions, but… Lack of insight into how behavioral choices affect relationships with others (intention-impact)

27. Dedicated to Doctors. Committed to Patients. Surgeon referring to the impact of his behaviour on others. “It’s like a summer rain shower – short, sharp, then over.”

28. Dedicated to Doctors. Committed to Patients. “I reached into my toolkit and pulled out the only tool I knew how to use – a hammer.” orthopedic surgeon

29. Dedicated to Doctors. Committed to Patients. Effective tools Code of Conduct with functional, accepted procedural guidelines. Leadership training – skills for having motivating and compassionate conversations. –Understanding how to fairly apply management principles. Awareness of available resources, when and how to use them. Understanding a systems approach.

30. Dedicated to Doctors. Committed to Patients. Role of the Institution Strong leadership is required How will workplace issues be addressed? Who will follow-up? How will others in the work environment be included in a remediation plan? The workplace is a rehab partner

31. Dedicated to Doctors. Committed to Patients.

32. Staged Approach  Informal talk: “cup of coffee”  Stage one – Awareness  Stage two -- Action Plan (Authority)  Stage three – Formal Discipline

33. Apparent pattern Single “unprofessional" incidents (merit?) “Hickson” Framework Mandated Issues "Informal" Cup of Coffee Intervention Level 1 "Awareness" Intervention Level 2 "Authority" Intervention Level 3 "Disciplinary" Intervention Pattern persists No ∆ Vast majority of professionals-no issues Hickson GB, Pichert JW, Webb LE, Gabbe SG, Acad Med, Nov, 2007

34. CPSO Framework:

35. Suspension/restriction/ regulatory action etc. Behaviour controlled by monitoring etc. Stage 3 response: 1.Confirm facts of report; 2.Notify physician and discuss; 3.MAC or other highest, formal authority to be notified; 4.Essential to obtain assessment of cause (if not done previously); 5.Consider suspension of privileges, etc.; 6.If practice still possible, supervision likely required; and 7.Consider obligation to notify CPSO. YESNO Behaviour repeated? Stage 2 response: 1.Confirm facts of report; 2.Notify physician and discuss; 3.Advisable to obtain assessment of cause; 4.Obtain commitment to change/remediation activities (preferably in contract form); and 5.Record in file. YESNO Behaviour repeated? Stage 1 response: 1.Confirm facts of report; 2.Notify physician and discuss appropriateness; 3.Obtain commitment that behaviour will not be repeated; 4.Record in file; and 5.Follow up or monitor behaviour. Risk of harm to patients or staff Particularly egregious behaviour First incident – relatively mild disruptive behaviour Behaviour Management Flow Chart – CPSO Paradigm

36. Dedicated to Doctors. Committed to Patients.

37. Look, I can’t promise I’ll change, but I can promise I’ll pretend to change

38. Dedicated to Doctors. Committed to Patients. Physician Workplace Support Program Mary Yates, Director Michael Kaufmann, Medical Director

39. Dedicated to Doctors. Committed to Patients. PWSP Guiding Principles: Good doctors…behaviour change is possible Context matters…in order to help somebody change, we need to understand them as individuals and the context in which they live and work Iterative process; PWSP is evolving, we’re learning and adapting as we go along Our intention is to provide customized solutions Financial self-sufficiency – cost recovery

40. Dedicated to Doctors. Committed to Patients. Physician Focus Doctors’ Health Confidentiality Civil Doctors Patient Safety Legislative Mandate Public Responsibility PHPCPSO PWSP

41. Dedicated to Doctors. Committed to Patients. Governance Ontario Medical Association –Board of Directors Advisory Committee –OMA –CPSO (regulatory body) –Ontario Hospital Association –Residents Association –Canadian Medical Protective Association –HIROC (Hospital protective association)

42. Dedicated to Doctors. Committed to Patients. Spectrum of PWSP Services Case management assessment, rehabilitation, long term follow up Education Medical schools, community hospitals, rounds, brief seminars Intensive workshops, communication skills Training / Coaching for Physician Leaders early intervention strategies Organizational consulting workplace/team assessments, recommendations for creating respectful workplaces

43. Dedicated to Doctors. Committed to Patients. PWSP Services: Case management for referred physicians 4 phases –Preliminary Intake Assessment; all referrals start here –Comprehensive Assessment –Rehabilitation and Monitoring –Long term follow up each phase is contracted for separately

44. Dedicated to Doctors. Committed to Patients. We have two clients: The doctor The workplace

45. Dedicated to Doctors. Committed to Patients. Clarify expectations of PWSP involvement and invoicing Review of documentation Understand reason for referral Interviews with referring and referred physicians Physician factors Workplace factors Letter of recommendations Preliminary Intake Assessment

46. Dedicated to Doctors. Committed to Patients. Recommendations for “Next Steps” Advice & referral Comprehensive Assessment PWSP follow up 6-12 months Other?

47. Dedicated to Doctors. Committed to Patients. Comprehensive Assessment 360 Behaviour Assessment IMEs Psychiatric Addiction Cognitive Family / Marital Risk of violence Physical Recommendations for Behavioural Rehabilitation any or all the following may be recommended: Workplace Interviews

48. Dedicated to Doctors. Committed to Patients. Rehabilitation Framework Motivation Support Information Skills development Treatment Personal support Workplace support Awareness of self & others Feedback about how others “see me” Clarify expectations & Consequences Accountability

49. Dedicated to Doctors. Committed to Patients. Behavioural Rehabilitation: Behavioural change interventions: –Education, coaching, individual and group counselling, clinical treatment / therapies as indicated Behavioural monitoring contract: –Baseline 360 with Feedback Report Review –Quarterly 360’s (8 over 2 years) –Coaching –Workplace monitoring and reports to PWSP –PWSP advocacy / progress reports Workplace Reintegration Meeting(s) Other workplace recommendations

50. www.physiciansdevelopmentprogram.com “360” Behavioural Monitoring

52. Dedicated to Doctors. Committed to Patients. 4 Months Later

53. Dedicated to Doctors. Committed to Patients.

56. Paradigm change OldNew The physician is a “jerk”The physician / hospital needs help These physicians are badThese are usually good doctors It’s all the doctor’s faultContext matters Be cautious, delay actionAct promptly and decisively “Fix” the doctorConsider the entire system The situation is incorrigibleUse a rational, staged approach and good results are possible

57. michael.kaufmann@oma.org 416-340-2972 php.oma.org