The Difficult Physician Educator

1. The Difficult Physician Educator Program Director Retreat 9/26/2013 Barbara C. Cahill, MD Associate Dean Professionalism, Evaluation & Learning

2. 2013 AAMC Graduation Questionnaire (GQ) • established 1978, administered by AAMC • identify issues critical to medical education and med student well‐being • satisfaction with residency preparation • career and specialty plans • costs of medical education • experiences of mistreatment in the learning environment • a tool used by medical schools, faculty, students, researchers, and the LCME for benchmarking and improving medical education

3. 2012 Graduation Questionnaire Changes in Mistreatment Questions 2012 experiences of types of mistreatment substantially revised Focus changed from students’ perception of mistreatment to behaviors personally experienced Respondents presented 15 behaviors they might have experienced Asked to indicate frequency with which they personally experienced each behavior Never Once Occasionally Frequently

4. 2013 Graduation Questionnaire Changes in Mistreatment Questions • In 2012, 34% of students reported they’d been publically humiliated • Public humiliation numbers more inclusive than intended • students reported being publicly embarrassed • not intentionally perpetrated, not considered mistreatment • Publicly embarrassed added to list of negative or offensive behaviors • Cannot compare data in 2012, 2013 for public humiliation domain

5. 2013 AAMC GQ - Types of Mistreatment Reported

6. 2013 AAMC GQ - Sources of Reported MistreatmentPublically Humiliated

7. 2013 AAMC GQ - Sources of Reported Mistreatment All Others

8. Utah 2012 vs. 2013 Mistreatment Domains

9. Utah 2012 vs. 2013 Mistreatment Domains

10. Eliminating Mistreatment • 2009 curriculum transformation and implementation included efforts to • better understand perceived mistreatment sources • effectively address student complaints of mistreatment • Wellness Director and Student Body Officers • student on student mistreatment • Medical student orientation • GME office – intern and resident orientation • Town Hall Meetings • MS3 - End of Clerkship Evaluations, Debriefings • On-the-Fly comments • Professional Conduct Policy (Faculty and Resident)

11. 2011-13 Mistreatment Complaints All Clerkships “ I have experienced mistreatment in this clerkship.”

12. Sources of Reported Mistreatment All Clerkships 2011-12, 2012-13

13. 2013 GME Resident Report 2% of residents reported seeing other residents mistreating medical students. Resident comments : I have seen attendings mistreating students and residents. It starts from the attendings, they set the tone. Stop blaming residents for mistreatment of medical students.

14. Consequences of Mistreating Trainees On stage at all times Physicians have a responsibility to demonstrate professionalism in all their actions Physician behavior impacts the way trainees behave Unprofessional physician educator behavior casts a long shadow Residency choice Epitope spread Lack of, or miscommunication leads to medical errors compromise of patient safety

15. Legal liability for the organization & individual Title VII of the Civil Rights Act - discrimination in the workplace unprofessional behavior related to sexual, racial, ethnic, religious, or other characteristics Title IX of the Civil Rights Act - gender-based discrimination at educational programs receiving federal funding sexual harassment ≈ gender discrimination An individual who believes he/she has been sexually harassed at an educational institution can file a lawsuit under Title IX

16. Modifying Bad Physician Behavior in the Educational Environment Recognize the limits - hierarchy Is there a pattern What is the cause Is this an environmental issue, a physician problem, or both Does the behavior extend beyond trainees

17. What does the conversation look like? Describe the other person’s behavior objectively – use “I” Use concrete terms Describe the action/behavior, not the “motive” Be respectful, avoid minimizing Direct the conversation to the offending behavior, not the person’s character Ask explicitly for change in the person’s behavior Swiggart et al. “Program for Distressed Physicians”, Center for Professional Health, Vanderbilt University School of Medicine.

18. Limits and Concerns The Department Chair Buzz words – the M word, the D word Introduction of the term “disruptive behavior” triggered significant criticism that this [Joint Commission] report was opening the door to increasing the vulnerability of medical staff to disciplinary action (including loss of privileges) if they were judged or classified as “disruptive physicians.” http://www.ama-assn.org/resources/doc/csaph/a11csaph2.pdf

19. Encourage demanding, not demeaning behavior from medical educators Disruptive innovation, a term of art coined by Clayton Christensen, describes a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors. http://www.claytonchristensen.com/key-concepts/