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2007 Annual Conference. DISRUPTIVE PROFESSIONALS. Raymond M. Pomm, M.D. Professionals Resource Network. WHAT IT IS NOT. SUBSTANCE RELATED DISORDERS. PSYCHOTIC DISORDERS. MAJOR DEPRESSION. BIPOLAR I / II. WHAT IT IS. A Continuum . Hi Disruptive. Dangerous Disruptive

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disruptive professionals

2007 Annual Conference

DISRUPTIVE PROFESSIONALS

Raymond M. Pomm, M.D.

Professionals Resource Network

what it is not
WHAT IT IS NOT...

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substance related disorders
SUBSTANCE RELATED DISORDERS

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psychotic disorders
PSYCHOTIC DISORDERS

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slide5

MAJORDEPRESSION

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slide6

BIPOLAR I / II

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what it is
WHAT IT IS...

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a continuum
A Continuum

Hi Disruptive

Dangerous

Disruptive

Difficult

Different

Lo Disruptive

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disruptive professionals are ultimately
Disruptive Professionals are ultimately...

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team busters
TEAMBUSTERS!

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the underlying issues
The Underlying Issues...

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slide12

PredisposingCharacter

Hospital Culture

Stress

Disruptive

Incidents

Poor Coping Skills

Poor Role Models

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PERSONALITY DISORDERS

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NARCISSISTIC PERSONALITY DISORDER

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THIS IS NO ORDINARY PERSON YOU’RE DEALING WITH!

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what to do
WHAT TO DO...

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there is no law that says one cannot be disruptive
There is no law that says one cannot be Disruptive

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the hospital group corporation leadership holds the hammer
The: -Hospital -Group -Corporation -Leadership holds the hammer

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the steps to validate and protect the hammer
The steps to validate and protect the hammer:

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prn disruptive practitioner policy procedure
PRN DISRUPTIVE PRACTITIONERPOLICY & PROCEDURE

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:

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prn disruptive practitioner policy procedure27
PRN DISRUPTIVE PRACTITIONERPOLICY & 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.

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prn disruptive practitioner policy procedure28
PRN DISRUPTIVE PRACTITIONERPOLICY & 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.

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prn disruptive practitioner policy procedure29
PRN DISRUPTIVE PRACTITIONERPOLICY & 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;

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prn disruptive practitioner policy procedure30
PRN DISRUPTIVE PRACTITIONERPOLICY & 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;

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prn disruptive practitioner policy procedure31
PRN DISRUPTIVE PRACTITIONERPOLICY & 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).

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prn disruptive practitioner policy procedure32
PRN DISRUPTIVE PRACTITIONERPOLICY & 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,

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prn disruptive practitioner policy procedure33
PRN DISRUPTIVE PRACTITIONERPOLICY & 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

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let s look at evaluation treatment monitoring process
Let’s look at Evaluation/Treatment/Monitoring Process...

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speaker contact information
Speaker Contact Information

Raymond M. Pomm, M.D.

Professionals Resource Network

P.O. Box 1020

Fernandina Beach, FL 32035

(800) 888 - 8776

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disruptive professionals new approaches to evaluation and management

2007 Annual Conference

Disruptive Professionals: New Approaches to Evaluation and Management

Larry Harmon, PhD

Physicians Development Program

disruptive behavior is
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

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who are the disruptive docs
Who are the Disruptive Docs?
  • MBAs
  • “Good Doc … Bad Talk”

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clinical evaluation
Clinical Evaluation
  • Clinical Interview
  • Extensive Personal History
  • Psychological & Cognitive Testing
  • Criminal Background Checks
  • Drug Testing
  • “Workplace Behavior Assessment”

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workplace behavioral assessment 360 p u l s e survey
Workplace Behavioral Assessment360° P.U.L.S.E. Survey

P.hysicians + Professionals

U.niversal

L.eadership + Teamwork

S.kills

E.ducation Survey

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workplace behavioral assessment
Workplace Behavioral Assessment
  • Each physician scores self on survey
  • Other physicians and healthcare team members give physician survey feedback
  • Feedback Report is prepared

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3 types of assessments
3 Types of Assessments
  • Individual- Continued disruptive pattern despite progressive warnings
  • Small Group or Section (2-10)
    • Individual resists
    • Protect identity of subject
  • Department or Hospital Program

Annual Leadership Feedback Reports

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conducting an individual workplace behavioral assessment
Conducting an Individual Workplace Behavioral Assessment

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phase i assessment

Phase I:Assessment

Step 1: Referral Letter

Step 2: Physician Orientation

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slide45

Step 3. Select “Feedback Groups”

Administration

Supervisors

Colleagues

Other

Depts.

Dr. Disruptive

Nurses+

Healthcare Staff

Patients*

*Patient Pulse survey

Support

Staff

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slide46

Step 3. Select “Feedback Groups”

Administration

“Validator” Adds Any Missing Names(Chief of Staff, CEO, i.e., the “Boss”)

Supervisors

Colleagues

Other

Depts.

Dr. Disruptive

Nurses+

Healthcare Staff

Patients*

*Patient Pulse survey

Support

Staff

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step 4 self rating
Step 4. “Self-Rating”

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Motivating/Encouraging Dimensions

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Disruptive/Discouraging Dimensions

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Step 5.Writes Cover Letter

TO: My Team Members and Colleagues

RE: 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

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slide51

Step 6: Send Surveys+Create Report

1. Mailed / Emailed to Raters

2. Raters Complete Surveys

3. Feedback Report Prepared

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slide52

Dr. Disruptive requests your honest and anonymous feedback

Dirk Disruptive, MD

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slide53

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.

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slide54

“Discourager” or “Disruptive”Feedback Report

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

LEADERSHIP FEEDBACK REPORT

Prepared for

Dr. Disruptive

January 1, 2007

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

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Self-Rating

PhysicianPeers

Self-RatingNursing StaffPhysician-Peers

Nursing Staff

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Nursing Staff

Physic-ians

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findings recommendations
Findings & Recommendations
  • No Recommendation
  • Anger Mgmt. Videos
  • Anger Mgmt. Program
  • Weekly Group
  • Psychotherapy
  • Tele-Coaching (month)
  • Survey Monitoring
  • NoDisruptive
  • Mild
  • Moderate
  • Serious
  • Severe Disrup-

tive Behavior

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Phase II:Distance Education

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teamwork leadership training
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

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slide60

Phase III.

Follow-up“Graduation” requires 4 consecutiveacceptable Feedback Reports

NO RED BEHAVIORS!

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slide61

Phase IV:Group Program or Treatment

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3 types of assessments62
3 Types of Assessments
  • Individual- Continued disruptive pattern despite progressive warnings
  • Small Group or Section (2-10)
    • Individual resists
    • Protect identity of subject
  • Department or Hospital Program
    • Annual Leadership Feedback Reports

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other professionals
Other Professionals
  • Immigration and Naturalization Service (INS)
    • Law Enforcement
    • Naturalization Services
  • Telephone Marketers
  • Hospital Executives
  • Attorneys

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research findings

Research Findings

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?

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slide65

160 Disruptive Physicians Participants

  • 74 Active Physicians / 86 Physicians completers

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

ROLE MODELS (N=68)

NORMALS (N=97)

120.5% Improvement

LEADERSHIP INDEX

DISRUPTIVE (N=117)

572% Improvement

MOST DISRUPTIVE 25% (N=30)

(3.5 years)

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**At baseline, all groups significantly different at (p) <.01.

Baseline 1 vs. follow-up 2 for disruptive physicians: significantly different at (p) < .01.

top improved behaviors in disruptives
Top Improved Behaviors in Disruptives
  • Remains approachable even when stressed out
  • Treats team members with respect
  • Handles difficult team members effectively
  • Is open to suggestions
  • Responds to conflict by working out solutions
  • Adapts to changing policies, procedures, priorities

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slide68

Underlying

Principle

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

“Feedback Creates Change!”

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slide70

Curious Questions? Concerned Comments?Interesting Ideas?

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

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the neurobiology of disruptive behavior

2007 Annual Conference

The Neurobiology of Disruptive Behavior

Mick Oreskovich, MD

Medical Director and CEO

Washington Physicians Health Program

our every thought every feeling every action is chemically mediated

Our every thoughtEvery feelingEvery actionIs chemically mediated!

Disruptive behavior is a chemical event in the brain!

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Transference

Countertransference

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how to deal with the fear this behavior generates in us
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

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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

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slide79

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

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slide82

Amygdala:

  • How we associate things in the world with emotional responses and process emotional information.
  • Allows us to overrule instinctive responses by connecting the cortex’s memories of things to the emotions they engender.
  • Allows us to respond to fear stimuli.

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about dna
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

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genetic markers with behavioral correlates
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)

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5 httlpr s allele driven amygdala hyper reactivity to environmental cues
5-HTTLPR S allele driven amygdalahyper-reactivity to environmental cues

Hariri et al., Science 2002

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s allele driven amygdala hyper reactivity
S allele driven amygdala hyper-reactivity

Hariri et al., Science 2002

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slide93

5-HTTLPR also effects information processing related to temperament between the amygdala and the cortex

Hamann, Nature Neuroscience 2005

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it appears that if we inherit the 5 httlpr s allele
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”

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slide95

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

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our every thought every feeling every action is chemically mediated96

Our every thoughtEvery feelingEvery actionIs chemically mediated!

Disruptive behavior is a chemical event in the brain!

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slide97

Mick Oreskovich, MD

moreskovich@wphp.org

www.wphp.org

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