2007 Annual Conference DISRUPTIVE PROFESSIONALS Raymond M. Pomm, M.D. Professionals Resource Network

2007 Annual Conference

DISRUPTIVE PROFESSIONALS

Raymond M. Pomm, M.D.

Professionals Resource Network

Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference

WHAT IT IS NOT...

SUBSTANCE RELATED

DISORDERS

PSYCHOTIC DISORDERS

MAJORDEPRESSIO

BIPOLAR I / II

WHAT IT IS...

A Continuum

Dangerous Disruptive

Difficult

Different Lo Disruptive

Hi Disruptive

Disruptive Professionals

are ultimately...

TEAMBUSTERS!

The Underlying Issues...

PredisposingCharacter

Poor Role Models

Stress

Poor Coping Skills

Disruptive

Incidents

Hospital Culture

PERSONALITY

DISORDERS

NARCISSISTIC PERSONALITY

DISORDER

THIS IS NO ORDINARY PERSON YOU’RE

DEALING WITH!

WHAT TO DO...

There is no law that says one

cannot be Disruptive

The: -Hospital -Group

-Corporation

-Leadership holds the

hammer

The steps to validate and protect the hammer:

The intent of this policy and procedure is to assist the referral source in utilizing the services of PRN in the management of the disruptive practitioner. The goal of these steps is to determine whether rehabilitation is a viable medical option. Before PRN will accept the referral of a disruptive practitioner, the following protocol must be followed:

PRN DISRUPTIVE PRACTITIONER

POLICY & PROCEDURE

1) The referral source must document all disruptive

behaviors, ramifications of said behaviors and any

action taken due to the behaviors.

2) Confidential, one-on-one discussion of the behaviors

in question between a “friendly” colleague

(representative of the referral source) and the

disruptive practitioner. The practitioner will be

informed, prior to the discussion, that the

confidentiality may be rescinded if the behaviors

continue. Slide 2 of 8

POLICY & PROCEDURE

3) Non-confidential, formal meeting with the admin level representative of the referral source, supervisor (if applicable) and the disruptive practitioner to discuss documented disruptive behaviors that need to be corrected, resulting in a warning that outlines consequences, if not corrected.

** An optional step can be inserted at this point if the referring source has an associated Impaired Practitioner Committee. This committee can be authorized to refer to PRN (step #4 b-e) or a recommendation will be made to the disciplinary body for suspension/termination (step 4a) of the disruptive practitioner.

POLICY & PROCEDURE

4) Meeting of disciplinary body of the referral source: a) disciplinary body must be ready to

suspend/terminate the disruptive practitioner if he/she is unwilling to proceed and comply with the following steps;

b) if both parties are in agreement, the disruptive practitioner must contact PRN in order to avoid suspension/termination;

c) disruptive practitioner must sign release for PRN to communicate with referral source;

POLICY & PROCEDURE

d) phone call made by referral source to

PRN in presence of the disruptive

practitioner;

e) all of the documentation must be faxed to

PRN by referral source within five (5)

business days of the referral to PRN;

f) documentation must be of adequate detail

for PRN to take appropriate action;

POLICY & PROCEDURE

5) Refer for evaluation, to be arranged by PRN, to

a DOH/PRN approved evaluator. The

evaluation must be comprehensive. The

evaluation must be completed within ten (10)

business days of the referral or PRN

will recommend the hospital follow through with

suspension/termination (unless delay is caused

by the evaluator and/or PRN).

POLICY & PROCEDURE

6) If evaluation is not completed in timely fashion, PRN will make decision whether information is sufficient for referral to Department of Health to compel an evaluation within a certain time frame.7) If appropriate, contract with PRN under Behavioral Management Contract to include: a) therapeutic recommendations of the evaluator, b) behavioral requirements and consequences

as agreed to by the referral source, evaluator and disruptive practitioner,

POLICY & PROCEDURE

8) The disruptive practitioner must execute the contract within ten (10) business days of its receipt.

** PRN is available to the referral source to discuss situation/issues/procedures at any time during this process

POLICY & PROCEDURE

Let’s look at Evaluation/Treat

ment/Monitoring Process...

Speaker Contact Information

Raymond M. Pomm, M.D.

Professionals Resource Network

P.O. Box 1020

Fernandina Beach, FL 32035

(800) 888 - 8776

Disruptive Professionals: New Approaches to

Evaluation and ManagementLarry Harmon, PhD

Physicians Development Program

Disruptive Behavior is …

… a pattern of conduct which

reduces or disrupts

the ability of the

healthcare (or other) team

to do it’s best work

Who are the Disruptive Docs?• MBAs

• “Good Doc … Bad Talk”

Clinical Evaluation• Clinical Interview

• Extensive Personal History • Psychological & Cognitive Testing• Criminal Background Checks• Drug Testing• “Workplace Behavior Assessment”

P.hysicians + Professionals

U.niversal

L.eadership + Teamwork

S.kills

E.ducation Survey

Workplace Behavioral

Assessment

360° P.U.L.S.E.

Survey

Workplace Behavioral

Assessment1. Each physician scores self on survey

2. Other physicians and healthcare team members give physician survey feedback

3. Feedback Report is prepared

3 Types of Assessments1. Individual - Continued disruptive

pattern despite progressive warnings

2. Small Group or Section (2-10)

• Individual resists

• Protect identity of subject

3. Department or Hospital ProgramAnnual Leadership Feedback Reports

Conducting an

Individual Workplace Behavioral Assessmen

Phase I:

Assessment Step 1: Referral Letter

Step 2: Physician Orientation

Dr. Disruptive

Administration

Supervisors

OtherDepts.

Colleagues

Patients**Patient Pulse survey

Nurses+Healthcare StaffSupport

Step 3. Select “Feedback Groups”

Dr. Disruptive

Administration

Supervisors

OtherDepts.

Colleagues

Patients**Patient Pulse survey

Nurses+Healthcare Staff

Step 3. Select “Feedback Groups”

SupportStaff

“Validator” Adds Any

Missing Names (Chief of Staff, CEO,

i.e., the “Boss”)

Step 4. “Self-Rating”

Motivating/Encouraging Dimensions

Disruptive/Discouraging Dimensions

TO: My Team Members and ColleaguesRE: Invitation for Honest Feedback

I am participating in a national Physicians Leadership Development Program, and part of the program is to obtain feedback to help me better understand my workplace interpersonal leadership style and people skills.

I have requested the Physicians Development Program to distribute their physician people skills survey, called the “P.U.L.S.E. Leadership Survey,” to my team members, so I can get group feedback.

Be honest…survey is anonymous…

Dirk Disruptive, MD

Step 5.Step 5. Writes Cover Letter Cover Letter

1. Mailed / Emailed to Raters

Step 6:Step 6: Send Surveys+Create Report Send Surveys+Create Report

2. Raters Complete Surveys

3. Feedback Report Prepared

Dr. Disruptive requests your honest and anonymous feedback

Dirk Disruptive, MD

Treating us with common courtesy. Explaining rather than yelling.Saying please and thank you.

Talking down to us.Yelling and screaming. Scaring me. I call in sick when you’re here.

Being an excellent doctor.Having great technical skills.Taking good care of patients.

“Discourager” or “Disruptive” Feedback Report

LEADERSHIP FEEDBACK REPORT

Physicians P.U.L.S.E. Program P.hysicians U.niversal L.eadership S.kills E.ducation Program

Prepared for

Dr. Disruptive

This report includes feedback from 22 individuals, including your self-rating if you completed one.

January 1, 2007

Self-Rating

Nursing Staff

PhysicianPeers

Self-RatingNursing StaffPhysician-Peers

Nursing Staff

Physic-ians

Findings & Recommendatio

ns• No Disruptive

• Mild

• Moderate

• Serious

• Severe Disrup-

tive Behavior

• No Recommendation

• Anger Mgmt. Videos

• Anger Mgmt. Program• Weekly Group

• Psychotherapy

• Tele-Coaching (month)• Survey Monitoring

Phase II:

Distance

Education

Teamwork-Leadership

Training Using Emotional Intelligence

Managing Anger at Work

Resolving Conflicts

Managing Difficult Staff

Managing/Motivating Teams

Managing Frustration

Managing Time

Emotional Self-discipline

Managing Medical Mistakes Constructively

Phase III.

Follow-up

“Graduation” requires 4 consecutiveacceptable Feedback Reports

NO RED BEHAVIORS!

Phase IV:

Group Program or

Treatment

3 Types of Assessments1. Individual - Continued disruptive

pattern despite progressive warnings

2. Small Group or Section (2-10)

A. Individual resists

B. Protect identity of subject

3. Department or Hospital ProgramA. Annual Leadership Feedback Reports

Other Professionals • Immigration and Naturalization

Service (INS)–Law Enforcement–Naturalization Services

• Telephone Marketers• Hospital Executives• Attorneys

Research Findings

1. Do Disruptive Physicians – enrolled in the P.U.L.S.E. Program and other interventions … A. REDUCE their Disruptive behaviors?

B. INCREASE Motivating Behaviors?

2. And, if they improve, does it last?

1. COMPLETED PROGRAM BY Facility or PDP STANDARDS 77.19%

Completed by Facility Standards (61.40%)

Completed by Early PDP Standards (15.79%)

2. WITHDRAWAL -- NOT DUE TO DISRUPTIVE BEHAVIOR 10.52%

Facility withdrew Physician (5.26%)

Physician withdrew Self (5.26%)

PDP withdrew (00.00%)

3. EXPELLED -- FOR DISRUPTIVE BEHAVIOR 0.00%

By Facility (00.00%)

By PDP (00.00%)

4. OTHER (INSUFFICIENT INFORMATION) 12.28%

160 Disruptive Physicians Participants

74 Active Physicians / 86 Physicians completers

Dotted line = Projected values-20

Baseline #1** Follow-up #2* Follow-up #3* Follow-up #4* Follow-up #5*

Leadership Improvement in 282 Physicians(Disruptive vs. Normal and Role-Model) after P.U.L.S.E. Feedback from Raters

NORMALS (N=97)

**At baseline, all groups significantly different at (p) <.01. Baseline 1 vs. follow-up 2 for disruptive physicians: significantly different at (p) < .01.

120.5% Improvement

572% Improvement

ROLE MODELS (N=68)

(3.5 years)

MOST DISRUPTIVE 25% (N=30)

DISRUPTIVE (N=117)

Top Improved Behaviors in Disruptives1. Remains approachable even when stressed out

2. Treats team members with respect3. Handles difficult team members effectively4. Is open to suggestions5. Responds to conflict by working out solutions6. Adapts to changing policies, procedures, priorities

UnderlyingPrinciple

When you see Roadside Radar, what’s the first thing you do?

“Feedback Creates Change!”

Larry Harmon, PhDDirector, Physicians Development ProgramLarry@PdpFlorida.com

Curious Questions? Concerned Comments?Interesting Ideas?

The Neurobiology of Disruptive Behavior

Mick Oreskovich, MDMedical Director and CEO

Washington Physicians Health Program

Our every thoughtEvery feelingEvery action

Is chemically mediated!

Disruptive behavior is a chemical event in the brain!

Transference

Countertransference

How To Deal With The FEAR This Behavior

Generates In Us?• Acknowledge our counter transference: the set

of expectations, beliefs, and emotional responses that we bring to this relationship!

• Educate ourselves about the causes of this behavior!

• So that we can move toward seeing this behavior phenomenologically, empathically, and non-pejoratively

Gene-brain-behavior relationships: Evidence that aggression is associated with brain MAO A activity in healthy males. N Alia-Klein1, E. Shumay1, R. Goldstein1, A. Kriplani1, J. Logan1, F. Telang1, B. Williams2, I. Craig2, GJ Wang1, F. Henn1, N. Volkow3 and J. Fowler1 1 Brookhaven Center for Translational Neuroimaging, BNL, Upton, New York; ; 2 Psychological Medicine, Psychiatry, King's College, London, United Kingdom; ; 3 National Institute on Drug Abuse, NIH, Bethesda, Maryland J Nucl Med. 2007; 48 (Supplement 2):262P

Inside the middle of the brain is the limbic system and the amygdala:

1. How we associate things in the world with emotional responses and process emotional information.

2. Allows us to overrule instinctive responses by connecting the cortex’s memories of things to the emotions they engender.

3. Allows us to respond to fear stimuli.

Amygdala:

About DNA

Six feet in every cell 3.2 billion letters of coding 10 to the 3,480,000,000 More than 5,000 books just to print that #! 10,000 trillion cells…earth to moon and back,

again and again

Genetic markers with behavioral correlates

• Serotonin Transporter Gene (SLC6A4):

Chromosome 17q11.2• DRD2 receptor:

Chromosome 11q22-q23• Effects of alcohol, BZ, barbiturates

Chromosome 4p (GABA-A, GABA-1)

Chromosome 15 (GABA-3)• Serotonin level

Chromosome 11 (tyrosine hydroxylase)

5-HTTLPR S allele driven amygdalahyper-reactivity to environmental cues

Hariri et al., Science 2002

S allele driven amygdala hyper-reactivity

Hariri et al., Science 2002

Hamann, Nature Neuroscience 2005

5-HTTLPR also effects information processing related to temperament

between the amygdala and the cortex

It appears that if we inherit the 5-HTTLPR S allele:

• A “look” or tone of voice• Changes our production of serotonin in our

midbrain• Fear becomes anger in our amygdala• We perceive imminent threat in our forebrain• We respond with a maladaptive defensive

coping mechanism…ie., raise our voice, swear, and threaten

• We become the “disruptive doc”

David T George, MD, Section of Clinical Studies, NIAAA

Our every thoughtEvery feelingEvery action

Is chemically mediated!

Disruptive behavior is a chemical event in the brain!

Mick Oreskovich, MDmoreskovich@wphp.org

www.wphp.org

2007 Annual Conference DISRUPTIVE PROFESSIONALS Raymond M. Pomm, M.D. Professionals Resource Network

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