Michael Kaufmann MD

Director, Physician Health Program; Medical Director, PWSP

Ontario Medical Association

“Ain’t Misbehavin’”Respectful Behaviour in the Medical

Workplace

Dedicated to Doctors. Committed to Patients.

“The age of the cowboy surgeon is over.”

Wayne and Mary Sotile

“The Resilient Physician”

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.

Dedicated to Doctors. Committed to Patients.

Dedicated to Doctors. Committed to Patients.

PRIMUM NON NOCERE

Dedicated to Doctors. Committed to Patients.

NOT SO PRIMUM NON NOCERE

Dedicated to Doctors. Committed to Patients.

Dedicated to Doctors. Committed to Patients.

Dedicated to Doctors. Committed to Patients.

“Where is it written that I have to be

nice?”orthopedic surgeon

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

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

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

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

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

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

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

Dedicated to Doctors. Committed to Patients.18

Disruptive behaviourPrevalence

• 1%- 5% (Linney, 1997)

• 3% – 5% (Leape, 2006)

• 6% of physicians have >25 complaints on same

theme in 5 years (Hickson, 2002)

Behaviour

Distressed Physician

colleagues

co-workers

Hospitalsystems

patients

Family

Dedicated to Doctors. Committed to Patients.

Causes

• Temperament and personality structure

Dedicated to Doctors. Committed to Patients.

Causes

• Temperament and personality structure

• “Doctor behaviour”

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

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

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.

Dedicated to Doctors. Committed to Patients.

Good intentions, but…

Lack of insight

into how behavioral choices

affect relationships with others

(intention-impact)

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.”

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

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.

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

Dedicated to Doctors. Committed to Patients.

Dedicated to Doctors. Committed to Patients.

Staged Approach

Informal talk: “cup of coffee”

Stage one – Awareness

Stage two -- Action Plan (Authority)

Stage three – Formal Discipline

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

CPSO Framework:

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; and7. 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; and5. 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

Dedicated to Doctors. Committed to Patients.

Dedicated to Doctors. Committed to Patients.

Look, I can’t promise I’ll change, but I can promise I’ll

pretend to change

Dedicated to Doctors. Committed to Patients.

Physician Workplace Support Program

Mary Yates, Director

Michael Kaufmann, Medical Director

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

Dedicated to Doctors. Committed to Patients.

•Physician Focus

•Doctors’ Health

•Confidentiality

Civil Doctors

Patient Safety

•Legislative Mandate

•Public Responsibility

PHP CPSOPWSP

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)

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

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

Dedicated to Doctors. Committed to Patients.

We have two clients:

• The doctor

• The workplace

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

Dedicated to Doctors. Committed to Patients.

Recommendations for “Next Steps”

Advice & referral Comprehensive

Assessment

PWSP follow up6-12 months

Other?

Dedicated to Doctors. Committed to Patients.

Comprehensive Assessment

360 Behaviour Assessment

IMEsPsychiatric AddictionCognitive

Family / MaritalRisk of violence

Physical

Recommendations for Behavioural Rehabilitation

any or all the following may be recommended:

Workplace Interviews

Dedicated to Doctors. Committed to Patients.

Rehabilitation Framework

Motivation

Support

Information

Skills developmentTreatment

Personal supportWorkplace support

Awareness of self & othersFeedback about how others “see me”Clarify expectations &

ConsequencesAccountability

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

www.physiciansdevelopmentprogram.com

“360” Behavioural Monitoring

Dedicated to Doctors. Committed to Patients.

4 Months Later

Dedicated to Doctors. Committed to Patients.

43

6 1

PWSP Cases; June 2010 to April 2013

residentsmedical students

practicing physicians

Dedicated to Doctors. Committed to Patients.

18

15

6

43

4

PWSP cases by specialty; June 2010 to April 2013

N=50

surgery

medicine

anesthesia

other

paediatrics

family medicine

Dedicated to Doctors. Committed to Patients.

0

5

10

15

20

25

30

35

33

14

4

PWSP activity; completed & in progress June 2010 to April 2013

comprehensive assessments

monitoring contracts

preliminary assessments

Dedicated to Doctors. Committed to Patients.

Paradigm change

Old New

The physician is a “jerk” The physician / hospital needs help

These physicians are bad These are usually good doctors

It’s all the doctor’s fault Context matters

Be cautious, delay action Act promptly and decisively

“Fix” the doctor Consider the entire system

The situation is incorrigible Use a rational, staged approachand good results are possible

michael.kaufmann@oma.org

416-340-2972

php.oma.org