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Maintaining Proper Boundaries in Medicine: Ethical Considerations
and Disruptive/Distressed Physicians
William Swiggart, MS, LPC/MHSPAssociate in Medicine
Co-DirectorVanderbilt Center for Professional Health
www.mc.vanderbilt.edu/cph
October 22, 2011
Continuing Medical Education Courses
Maintaining Proper Boundaries©
Prescribing Controlled Drugs©
Program for Distressed Physicians©
Vanderbilt Center for Professional Health
Goals
Provide learners with information about sexual boundaries and sexual misconduct in medicine, and expose them to a preventative educational program that addresses these issues.
“Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine”
Hazardous Affairs Learning Module Goals
1. Instruct participants on the general definitions, rules and guidelines around professional conduct regarding professional boundaries and sexual misconduct in the medical profession;
2. make physicians aware of their own vulnerabilities,
3. help physicians understand how to prevent sexual boundary crossings, and
4. stimulate reflection on current and future professional practice behaviors.
Hazardous Affairs Learning Module
List the levels of sexual misconduct. Define sexual harassment. Compare and contrast the types of sexual
misconduct as defined by the Federation of State Medical Boards (FSMB).
Identify three main risk behaviors for sexual misconduct based on various issues like self-wellness, stress, social behaviors, and medical cultures.
Identify five behaviors on the slippery slope.
Hazardous Affairs Learning Module
Identify three preventive measures to avoid sexual misconduct.
Practice phrases to help define professional boundaries.
Describe the professional obligations for reporting sexual misconduct.
Develop an individual action plan to set proper boundaries in your office.
“Hazardous Affairs: Preventing Sexual
Boundary Violations in Medicine”
Take a test
Hazardous
Affairs
“Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine”
DVD Observation 1 – Sexual Harassment 1. What behaviors did the doctor portray
that resulted in the accusation of sexual harassment?
2. How did his behavior create a hostile work environment?
3. What action would you take if you were his superior/supervisor/department head?
“Hazardous Affairs: Preventing Sexual Boundary Violations in Medicine”
DVD Observation 2 – Doctor-Patient1. What type of misconduct occurred?2. How did Dr. James set himself up for
this sexual boundary crossing?
Slippery Slope Late appointments with no chaperone Business transactions/dual relationships Excessive physician self-disclosure Some forms of language use Personal gifts Special favors Flirting, jokes etc. Grooming behavior Casual workplace
“Hazardous Affairs: Preventing Sexual Boundary Violations in
Medicine”
DVD Observation 3 – Teacher-Student1. Identify five slippery slope behaviors.2. How does the power differential
come into play in this scenario?
Hazardous Affairs – Test Answers
1. D - In most situations, dating a patient will be viewed as wrong. Even if the relationship is mutual and doing well. The power differential makes dating a patient wrong because the patient cannot give appropriate informed consent. The physician will be held accountable.
2. F - Dr K should NOT accept this invitation and should restate the general policy that doctors cannot date patients. Dr K is vulnerable and doesn’t know the intentions of the patient asking. This could be a set up.
3. A - Correct answer is 2: Sexual impropriety and sexual violations.
4. B - This is an example of sexual impropriety. Impropriety is usually gestures, behaviors or expressions that are seductive, reflecting lack of respect for the patient’s privacy. Contrasting impropriety with violations – violations most often include physical contact or a behavior resulting from pressure to perform sexual acts for favors.
5. C - Grooming is a slippery slope behavior. It is when patients or others attempt to adjust your clothing, hair, jewelry, etc.
6. F - None of these options are true. Doctors, especially psychiatrist, are not supposed to engage in relationships with patients. There are other individuals who can show you the town. Patients can give you information and advice about your new town but allowing them to “take you out and show you the town” is not acceptable and puts you at risk of being investigated by your medical board.
7. D - Once you prescribe medications to your partner you entered the doctor-patient relationship. Thus you are now having a sexual relationship with your patient. While giving a small amount may be seen as reasonable if you were covering this patient over the weekend, the key point is you prescribed a controlled substance for a patient with whom you are engaged in a sexual relationship.
8. E - All of the above are examples of the power differential. In each example there is an obvious hierarchy.
9. A - In every situation, the physician will always be held responsible for crossing a sexual boundary and committing an act of sexual impropriety or violation.
10. A - Sexual violations usually involve a form of physical contact. Kissing, intercourse, touching of sexualized body parts, encouraging masturbation or exchanging medical care, drugs, etc. for sexual favors is a sexual violation.
11. C - This question is appropriate for anyone in an academic teaching facility where medical students are involved. The correct answer is C – sexual impropriety. The patient must give informed consent for medical students to witness or perform sensitive genitourinary exams.
12. B - Performing a genital exam without the use of gloves is considered a sexual impropriety.
13. C - In this item, clearly joking around and flirting is certainly risky unprofessional behavior. But if touch is involved – boundaries are being crossed. When individual team members feel unsafe or that their rights have been infringed upon due to repeated acts this becomes a “hostile or offensive work environment” and is sexual harassment.
14. C - This is sexual harassment. This is a very important point – even if the comment was targeted at another individual, meaning the recipient was not the intended target, it is still considered harassment if that person was offended. Thus keeping unprofessional specific comments to oneself is the best course of action or limit conversations to the intended party only.
15. A - You must formally discharge a patient; meaning written documentation. However, the power differential or the knowledge, emotions or influence you possess over this individual may be considered unethical as it still gives you power over that individual. In psychiatry – the once a pt always a patient may hold true as well.
16. E - The best option for this scenario is call to check on the pt, develop a plan and then educate the pt on the proper ways to contact their providers as well as reinforcing the general rules against using personal emails.
PHYSICIAN DEMOGRAPHICS
No: 584 Gender: Males 95% Females 5% Age range: 31-80 Mean age: 49.5 yrs. Ethnic Origin: 78% Caucasian; 10%
African Americans, 9% Asian and 4% Hispanic
PHYSICIAN SPECIALITY
Family Practice/GP 28% Internal Medicine 10% Med. Specialty 6% Surgery Specialty 9% General Surgery 4% OB/Gyn 7% Psychiatry 10% Other 26*
* anesthesiology, neurology, emergency, dentist
SOURCE OF REFERRAL
Board of Medical ExaminersPhysician Health ProgramTreatment CenterSelf Referral
REASONS FOR REFERRAL
Complaints from patients, family members, nurses
Affair with patient, office nurse/staff Flirting Cybersex
How to get into Trouble
Step 1
Date someone you supervise such as office staff, i.e., nurse, secretary, a resident or intern.
Step 2
If someone objects to your sexual jokes or flirting assume it is their problem. You can say anything you want to.
Step 3
Prescribe scheduled drugs or operate on someone with whom you are sexually involved.
Step 4
Use the hospital or office computer to view or download pornography.
Step 5
Avoid even the appearance of professional boundaries in regards to dress, language and behavior in the office.
Step 6
Make comments about your patient’s underclothing, e.g. “how pretty” or “where did you buy that?”
Step 7
Tell stories about your own sexual life. This will certainly impress your patients and make them feel more at ease during the breast exam.
Step 8
Be present when your patient is disrobing and offer to help with those hard to reach items. Don’t use a chaperone in your office. They only make the patient uncomfortable.
Step 9
Accept offers to meet after-hours from your patients even if it is just for coffee or a meal.
Step 10
Flood your life with work, long hours, and ignore your personal needs. A lack of balance between professional and personal life are set-ups for problems.
Step 11
Disregard your own emotional life and any past trauma you may have experienced which impacts you today. Stress, lack of balance between professional and personal life are set-ups for problems.
Step 12
Ignore state, federal and professional guidelines regarding sexual harassment, sexual impropriety and sexual misconduct.
Prevalence of Sexual Boundary Violations
3% 10%
954,224 physicians currently in practice
Swiggart, W., K. Starr, et al. (2002). Sexual boundaries and physicians: overview and educational approach to the problem. Sexual Addiction & Compulsivity 9: 139-148.
Boundaries Differ in Different Specialties
Psychiatry once a patient always a patient
Primary Care Surgeon Pediatrician patient surrogate Anesthesiology Rheumatology ????
Key Concepts
The physician holds the balance of power over patients, staff and students.
Mutual consent is not recognized as a defense for the physician.
Patient and physician emotional vulnerabilities are at the core of boundary violations.
Self care by the physician is critical to prevent hazardous romantic relationships.
Summary/Recommendations
Physicians lack training in the complexity of sexual boundary misconduct.
An educational approach can resolve most of the problem.
A pre-emptive approach is better than a post-violation intervention.
The process is complaint generated.
Demographic of the CoursesCourses N Ave Age Sex
Distressed 99 49 11% F 89% M
Boundaries 710 50 5% F 95% M
Prescribing 828 51 13% F 87% M
Total 1637
Distressed Boundaries Prescribing
IM subspecialties* IM/FP IM/FM
IM/FM Psychiatry Psychiatry
OB/GYN Surgery Surgery
Surgery OB/GYN ER
*(interventionalists) Last Updated October 2011
Part TwoDistressed/Disruptive Physicians
Take a break
Vanderbilt Center for
Professional Health
Continuing Medical Education Courses
Prescribing Controlled Drugs©
Maintaining Proper Boundaries© Program for Distressed Physicians©
Goals
Give learners an overview of disruptive/distressed behavior and provide resources for interventions.
Disruptive/Distressed Physician Behavior Objectives
Joint Commission requirementsExamples of disruptive behaviorImpact of disruptive behaviorEtiology of disruptive behaviorDescribe an educational approachIdentify some appropriate resources
2004 AAMC Council of Deans
“Physicians are often poorly socialized and enter medical school with inadequate social skills for practice.”
“There is a growing body of literature documenting that residency programs do not prepare resident physicians adequately for the practice of medicine.”
Joint Commission, Issue 40July 9, 2008
Defined disruptive behavior as a Sentinel Event
Recognition that disruptive behavior can:Foster medical errorsContribute to poor patient satisfactionContribute to preventable adverse outcomesIncrease the cost of care (including malpractice)Lead to turnover/loss of qualified medical staff
Sentinel Events
Defined by The Joint Commission as:
“Any unanticipated event in a healthcare setting resulting in death or serious physical injury or psychological injury to a person or persons not related to the natural course of the patient’s illness.”
Joint Commission
Goal of including Disruptive Behavior as a Sentinel Event:
Reform health care settings to address the problem
There is a history of tolerance and indifference
Promote a culture of safetyImprove the quality of patient care by
improving the communication and collaboration of health care teams
Joint Commission Requirements
Hospitals establish a formal Code of Conduct
Leadership creates a process for reporting, evaluating and managing disruptive behavior
Joint Commission Recommendations
Educate all team members about professionalism
Hold all team members accountable for modeling desirable behaviors
Enforce the code consistently and equitably
Non-confrontational intervention strategies
Progressive discipline
57
Definition of Disruptive Behavior
Disruptive behavior includes, but is not limited to, words or actions that:
Prevent or interfere w/an individual’s or group’s work, academic performance, or ability to achieve intended outcomes (e.g. intentionally ignoring questions or not returning phone calls or pages related to matters involving patient care, or publicly criticizing other members of the team or the institution);
Create, or have the potential to create, an intimidating, hostile, offensive, or potentially unsafe work or academic environment (e.g. verbal abuse, sexual or other harassment, threatening or intimidating words, or words reasonably interpreted as threatening or intimidating);
Threaten personal or group safety, such as aggressive or violent physical actions;
Violate Vanderbilt University and/or VUMC policies, including those related to conflicts of interest and compliance.
Vanderbilt University and Medical Center Policy #HR-027,
2010
Policies will not work if Disruptive Behavior goes
unreported and unaddressed.
58
Aggressive Anger Outbursts
Profane/Disrespectful
Language
Throwing Objects Demeaning Behavior
Physical Aggression
Sexual Comments or Harassment
Racial/Ethnic Jokes
PassiveAggressive
Derogatory comments about institution, hospital, group, etc.
Refusing to do tasks
Passive
Chronically late Alcohol and other drugs
Not responding to call
Inappropriate or inadequate chart notes
Spectrum of Disruptive Behaviors
Case Presentation (1)
Dr. A is a 40 year old anesthesiologist referred for evaluation following several angry outbursts in his hospital’s OR. The most egregious (and final) outburst involved his threatening to shoot one of his OR staff. Although he reportedly immediately told staff that he wasn’t serious about the threat, a complaint was filed because he was commonly known to have an extensive gun collection at his home, and this staff member lived in the same neighborhood.
Case presentation (2)
Dr. B reported that he was chronically fatigued and had been working at nearly twice his normal workload in the three months prior to his assessment. In addition, he reported several incidents involving his anger while in undergraduate school, medical school and residency. He reported no use of medications, and no prior treatment for anger management, except for referral to a psychiatrist over the course of a semester while in school.
“RN did not call MD about change in patient condition because he had a history of being abusive when called. Patient suffered because of this.”
Rosenstein, A., O’Daniel, M. Impact and Implications of Disruptive Behavior in the Perioperative Arena. J Am Coll Surg. 2006;203:96-105.
But More Common…“___ came late to the meeting, then spent
remaining time on a Blackberry… didn’t listen to the discussion”
“___ doesn’t exactly say anything you could object to, but always rolls eyes and makes faces in meetings… not helpful…later mocks the discussion…disputes wisdom of decisions”
And Increasingly Common“___ writes an online Blog with implied
criticisms of some of our units”“___ (resident) puts feelings about patients
on Facebook - unnamed, but potentially identifiable”
63
Why bother dealing with disruptive behavior?
Failure to Address Disruptive Conduct Leads to:
Perceptions of inequality when members of the team compare their contributions to those of the disruptive member (Kulik & Ambrose, 1992)
Some team members will decrease their contributions, withdraw (Schroeder et al, 2003; Pearson & Porath, 2005)
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
Failure to Address Disruptive Conduct Leads To:
Team members may adopt disruptive person’s negative mood/anger (Dimberg & Ohman, 1996)
Lessened trust among team members can lead to lessened task performance (always monitoring disruptive person)... effects quality and pt safety (Lewicki & Bunker, 1995; Wageman, 2000)
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
Failure to Address Disruptive Conduct Leads To:
High turnoverPearson et al, 2000 found that 50% of
people who were targets of disruptive behavior thought about leaving their jobs
Found that 12% of people actually quitThese results indicate a negative
effect on return on investment
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
Failure to Address Disruptive Conduct Leads to:
disharmony and poor morale1, staff turnover2, incomplete and dysfunctional
communication1, heightened financial risk and litigation3, reduced self-esteem among staff1, reduced public image of hospital1, financial cost1, unhealthy and dysfunctional work
environment1, and potentially poor quality of care1,2,3
1. Piper, 20002. Rosenstein, 20023. Hickson, 2002
Disruptive Behavior Leads to Communication Problems…
Communication Problems Lead To Adverse Events1
Communication breakdown factored in OR errors 50% of the time2
Communication mishaps were associated with 30% of adverse events in OBGYN3
Communication failures contributed to 91% of adverse events involving residents4
Gerald B. Hickson, MDJames W. Pichert, PhDCenter for Patient & Professional AdvocacyVanderbilt University School of Medicine
1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44. 3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038.
2. Gewande et al, Surgery 2003; 133: 614-621. 4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334
Disruptive Behavior Creates fear confusion or uncertainty vengeance vs. those
who oppose/oppress them
hurt ego/pride grief (denial, anger,
bargaining) apathy burnout unhealthy peer pressure
ignorance (expectations, behav. standards, rules, protocols, chain of command, standards of care)
distrust of leaders dropout: early
retirement or relocation errors disruptive behavior
begets disruptive behavior
Vanderbilt University and Medical Center Policy #HR-027
Etiologies
Why Might a Medical Professional Behave in
Ways that are Disruptive?
©CPPA, 2008
Why Might a Medical Professional Behave in Ways
that are Disruptive?1. Substance abuse, psych issues2. Narcissism, perfectionism3. Spillover of family/home problems4. Poorly controlled anger (2° emotion)/Snaps
under heightened stress, perhaps due to:a. Poor clinical/administrative/systems
supportb. Poor mgmt skills, dept out of controlc. Back biters create poor practice
environments
©CPPA, 2008
Why Might a Medical Professional Behave in Ways
that are Disruptive?
5. Well, it seems to work pretty well6. No one addressed it earlier (why? See #5)7. Family of origin issues—guilt and shame8.9.
“The Perfect Storm”
PhysicianHospital/Clinic
The external system The internal system
Two Systems Interact
Good skills
Poor skills
Functional & nurturing
Dysfunctional
Systems
"Every system is perfectly designed to get the results it
gets.”
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting
2010
EtiologiesIndividual Factors
• Predisposing Psychological Factors (1) Alcohol and Drug Family History Trauma History Religious Fundamentalism Familial High Achievement, lack of skills regarding conflict
and negotiation and other family of origin patterns• Personality Traits (2)
Narcissism Obsessive/Compulsive
• Physician Burnout (3)• Clinical Skills Satisfactory or Above Average (4)
1. Valliant, 1972 2. Gabbard, 19853. Spickard and Gabbe, 2002 4. Papadakis, 2004, 2005
Etiologies
Institutional Factors (1)ScapegoatsSystem Reinforces BehaviorIndividual Pathology may over-shadow
institutional pathology
Williams and Williams, 2004
Methods to Address Behavioral Problems
Mr. Bangsiding felt (and wrongly so) that a little chat would be enough to stop Bob’s disruptive behavior.
Methods to Address Behavioral Problems
The role of a comprehensive evaluation
The importance of consequencesEducational programsFeedback from colleagues, patients,
staff, etc.Monitoring and accountabilityExternal resources
Comprehensive Evaluation
APA guidelines for Fitness for Duty Evaluations
Multidisciplinary: 1-5 days MedicalPsychiatric evaluationPsychological testingPsychosocial including genogramAddiction screeningCollateral information
Comprehensive report with recommendations
What We Have Learned? Monitoring contracts need to be
flexible 360 evaluations are imperative for
monitoring and to see how the professional is progressing
Not all can be helped or saved Intensive small group CME with
monitoring works for many
A Program for Distressed Physicians
Components: Phone interview Three-day CME course (47.5 AMA PRA
Category 1 Credits ™) Teach Specific tools/skills - e.g.,
grounding skills, Alter, communication strategies
Three follow-up sessions with the core group over the next six months; importance of group process
Flooding*
“ This means you feel so stressed that you become emotionally and physically overwhelmed…”
“Pounding heart, sweaty hands, and shallow breathing.”
“When you’re in this state of mind…you are not capable of hearing new information or accepting influence.”
*John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.
SKILLS TO USE WHEN FLOODING
GROUNDING
Categories exercise Judge versus describe Mindfulness with all senses Breathe
SELF-TEST: FLOODING 1. At times, when I get angry I feel confused. Yes No 2. My discussions get far too heated. Yes No 3. I have a hard time calming down when I discuss disagreements. Yes No 4. I’m worried that I will say something I will regret. Yes No 5. I get far more upset than is necessary. Yes No 6. After a conflict I want to keep away or isolate for a while. Yes No 7. There’s no need to raise my voice the way I do in a discussion. Yes No
8. It really is overwhelming when a conflict gets going. Yes No 9. I can’t think straight when I get so negative. Yes No 10. I think, “Why can’t we talk things out logically?” Yes No
John M. Gottman, All Rights Reserved (revised 11/17/03)
11. My negative moods come out of nowhere. Yes No 12. When my temper gets going there is no stopping it. Yes No 13. I feel cold and empty after a conflict. Yes No 14. When there is so much negativity I have difficulty focusing my thoughts. Yes No 15. Small issues suddenly become big ones for no apparent reason. Yes No 16. I can never seem to soothe myself after a conflict. Yes No 17. Sometimes I think that my moods are just crazy. Yes No 18. Things get out of hand quickly in discussions. Yes No 19. My feelings are very easily hurt Yes No
20. When I get negative, stopping it is like trying to stop an oncoming truck. Yes No 21. My negativity drags me down. Yes No 22. I feel disorganized by all this negative emotion. Yes No 23. I can never tell when a blowup is going to happen. Yes No 24. When I have a conflict it takes a very long time before I feel at ease again. Yes No
Scoring: If you answered “yes” to more than eight statements, this is a strong sign that you are prone to feeling flooded during conflict. Because this state can be harmful to you, it’s important to let others know how you are feeling. The antidote to flooding is to practice soothing yourself. There are four secrets of soothing yourself: breathing, relaxation, heaviness, and warmth. The first secret is to get control of your breathing. When you are getting flooded, you will find yourself either holding your breath a lot or breathing shallowly. Change your breathing so it is even and you take deep regular breaths. Take your time inhaling and exhaling. The second secret is to find areas of tension in your body and first tense and then relax these muscle groups. First, examine your face, particularly your forehead and jaw, then your neck, shoulders, arms, and back. Let the tension flow out and start feeling heavy. The secret is to meditate, focusing your attention on one calming vision or idea. It can be a very specific place you go to that was once a very comforting place, like a forest or a beach. Imagine this place as vividly as you can as you calm yourself down. The fourth part is to imagine the body part becoming warm.
Flooding - Scoring
John M. Gottman, All Rights Reserved (revised 11/17/03)
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.
ASSERTIVE COMMUNICATION GUIDELINES
When asking for something, use the acronym – DRAN
DescribeReinforce
AssertNegotiate
Describe
Describe the other person’s behavior objectively
Use concrete termsDescribe a specified time, place &
frequency of actionDescribe the action, not the “motive”
ReinforceRecognize the other person’s past
efforts
Assert Directly & Specifically
Express your feelingsExpress them calmlyState feelings in a positive mannerDirect yourself to the offending
behavior, not the entire person’s character
Ask explicitly for change in the other person’s behavior
Negotiate: Work Towards A Compromise That is Reasonable
Request a small change at firstTake into account whether the person
can meet you needs or goalsSpecify behaviors you are willing to
changeMake consequences explicitReward positive changes
Disruptive behavior Social Systems
If the physician is returned to the institution to practice, it is necessary to ensure that the behavior does not recur.There is a significant level of recidivismAs high as 20% among “severe offenders”
(Grant and Alfred 2007) Prior behavioral issues are a significant risk
factor for later disruption (Papadakis, Arnold, et. al. 2008)
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010
Disruptive behavior
Social Systems
A monitoring system that is under development measures these issues using a 360◦ survey.
Early data show the survey to be well tolerated and demonstrates face validity.
The survey was developed to facilitate integration with institutional systems.
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010
Team Behavior Survey©
It is not enough to have good motives; others respond to our behavior.
Physicians are often not given essential feedback about their behavior.
The Team Behavior Survey (TBS) is designed to provide feedback from those we work with.
© Swiggart, Williams, and Williams
The Survey is Based on the Core Competencies of the
ACGME Communication Concern for patients and families Accessibility and timeliness Work environment Ethical behavior Interpersonal behavior & respect for others Focus on medical tasks Ability to work with other members of the
medical team
Potential Resources for Healthy Coping
Courses Coaches,
counselors Comprehensive
Evaluation 360° Evaluations Risk Managers Physician Wellness Treatment Centers
Office of General Counsel
State BME Professional Societies QI Officers EAP Others State Physician Health
Program
What We Have Learned?
1. There is a need to develop standard, model policies for hospitals.
2. Information needs to be widely distributed to hospitals and medical practices that this is treatable, saves money, prevents malpractice suits, and that early intervention is best.
3. Medical student and resident training cultivates many of the disruptive behaviors as they learn from their mentor’s behavior.
Summary Disruptive behavior is a patient safety
issue. State PHPs can be an extremely valuable
resource for both physicians and institutions.
An objective, comprehensive assessment is invaluable.
It is important to understand the system’s issues related to an individual’s behavior.
Resources are available.
Center for Professional Health
Please visit our websitehttp://www.mc.vanderbilt.edu
