1. Addressing Disruptive Physician Behavior Counseling Peers William Hopkinson, MD Orthopaedic Program Director, Loyola University Medical Center AAOS Fall Meeting, October 19, 2012

2. XXX Disclosure XXX Any opinions expressed in this presentation are solely my own Retired USA MC Part-time VA Full time academic faculty at private university Member AAOS Committee on Professionalism Judiciary Committee No financial conflicts of interest

3. SPECIAL BEHAVIORSPECIAL BEHAVIOR Disruptive = Inappropriate Interferes with function/flow of workplace If unaddressed, usually escalates.

4. Disruptive Behavior Examples Yelling Profanity/Verbal abuse Threatening body gestures Failing to adhere to usual authority, such as: –Not providing ID –Not participating in Time Out –Not returning calls/pages

5. More Serious Behavior Threatening – Physical actions just short of contact –Oral/ written /implied threats Legally defined as assault Violent –Physical behavior or specific threats of physical harm –Harmful or offensive contact Legally defined as battery

7. Is there a rationale for DB? Surgical Stress/ Frustrations -Increased complexity/ more regulations -High volume -Low margin of error of error

8. Reason for DB Substance abuse/psych issues Narcissism/perfectionism Personal issues

9. Reasons for Tolerating DB None……but – –Majority of surgeons are non-confrontational – –Respect/tolerance of rainmakers – –Rationalizing behavior – –Not my ….. problem /patient/ resident/ issue – –If I ignore, maybe the problem will go away – –ETC

10. Perception is Reality Perception is Reality What they think they are What others see

11. Why deal with disruptive behavior? Easy Directly linked to adverse events Professionalism issue Lawsuits Poor morale

12. How to deal with disruptive behavior? The Hard Part

13. Pyramid upside down

14. My Experience Department Vice-Chair Residency Program Director Professional Standards and Peer Review Committee, Loyola Loyola PARS Program –Co-chair and mentor AAOS Committee on Professionalism

15. My Experience in the trenches One-on-one- peer interactions Authority figure Our local PARS activity LUMC Professionalism Committee AAOS COP and Judiciary Committee

16. Cup of coffee conversation Why – behavior noted When – soon Where – safe/quiet place How – balance empathy and objectivity stay on message Expectations Self-correction

17. Cup of coffee conversation To be meaningful – stay on topic Avoid the following tendencies –Control contest –Curbside therapy –Enabling –Oh, by the way, now that we are here……

18. Can an authority figure do this? Can you do this to the boss? Yes – with care –Non-judgmental –Empathy and objectivity –Focus on the behavior Perception is reality

19. Prepare for full range of responses

20. When a lot of coffee doesnt work Cre Self-creating an improvement plan

21. Local Hospital Task Force Generating a report Review by Committee of Peers Actions taken can range from – –No action – –Fines – –Mandated activities – local/national programs – –Dismissal

22. The Loyola PARS Program Using unsolicited patient complaints to measure physician risk At Loyola, 2 co-chairs and 20 mentors Program started in 2003 –Mentor selection and training –Assigning mentors –Annual update

23. Conceptual Framework – Professionalism Professionals commit to: Professionals commit to: Technical and cognitive excellence Technical and cognitive excellence Professionals also commit to: Professionals also commit to: Clear and effective communication Clear and effective communication Modeling respect Modeling respect Being available Being available Professionalism promotes teamwork Professionalism promotes teamwork Professionalism demands self-regulation Professionalism demands self-regulation PARS: Reducing Malpractice Risk, Professionalism and Self-Regulation

24. Loyola PARS Experience 2003-2011 Phys. Interventions No. 2003-2007First Interventions 28 2008 First Interventions 9 2009First Interventions 7 2010First Interventions 7 2011Proposed First Year 6 (Excluding 1 Recidivist) (Excluding 1 Recidivist) Total 57 Total 57

25. Results to date - LUMC Total # high complaint physicians 57 First follow-up in 12 6 Departed After Initial Intervention 4 Total with follow-up results 47 Results for those with follow-up data: Good – Intervention visits suspended 21(45%) Good – Intervention visits suspended 21(45%) Good – Anticipate suspension in 12 9 (19%) Good – Anticipate suspension in 12 9 (19%) Some improvement -- Still need tracking 1(2%) Some improvement -- Still need tracking 1(2%) Subtotal 31(66%) Subtotal 31(66%) Unimproved/worse 14(30%) Departed Unimproved 2(4%) Total follow-up results 47

26. AAOS Standards of Professionalism 6 SOPs establishing minimum standards of acceptable conduct for Orthopaedic surgeons Each SOP has an aspirational statement with one or more mandatory standards

27. AAOS SOPs Covers a range of professional topics One AAOS member files a grievance against another All other administrative actions should have been completed

28. SOP on Professional Relationships Aspirational –Good relationships among physicians, nurses, and other health care professionals are essential for good patient care –The orthopaedic surgeon should promote the development and utilization of an expert health care team that will work together harmoniously to provide optimal patient care.

29. SOP on Professional Relationships Mandatory standards: An Orthopaedic surgeon: –Shall maintain fairness, respect, and appropriate confidentiality… –Shall conduct themselves in a professional manner in interactions… –Shall work collaboratively with others to reduce medical errors, increase patient safety, and optimize outcomes …

31. Professional Compliance Program Actions to date (April 2012) 125 grievances submitted 47 COP Hearings 21 Appeals to Judiciary Committee Results –18 No action –2 Letters of concern

32. Grievances Filed by SOP Providing MS Services3 Professional Relationships9 Expert Witness Testimony94 Expert Opinion9 Research/academic responsibility 0 Advertising9 Conflicts of interest1

33. AAOS Professionalism Program 30 Official Actions of AAOS BOD 7 Censures 23 Suspensions Ranging from months to 3 years 0 Expulsions

34. Summary Disruptive behavior is disabling to health care An organized process can be effective It starts with one-on-one Elimination of DB requires an organizational commitment We all need to be involved