Disruptive or Impaired Physicians

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Impairment Physicians (Video1)

Introduction

This summary provides an overview of key concepts, challenges, and strategies related to physician impairment, as discussed in the source material. It highlights the nature of impairment, its potential causes and risks, the importance of self-care, and the critical responsibility of the medical profession to address impairment in oneself and colleagues.

Definition and Nature of Physician Impairment

Physician impairment, as defined by the American Medical Association, refers to physical or mental health conditions that interfere with a physician's ability to engage safely in professional activities. These conditions can put patients at risk, compromise professional relationships, and undermine trust in medicine. It is crucial to understand that being impaired is temporary and is not the same as having a disability. Impairment is also not solely linked to substance use disorders or alcoholism.

The sources emphasize that impairment is not a moral flaw. It does not indicate a lack of skill or knowledge but rather occurs when something external or internal affects a physician's ability to think clearly and perform up to the required standard. Common factors that can lead to impairment include exhaustion (such as from being on call for extended periods or dealing with sick family members), mental illness like depression, and potential decline in motor skills associated with aging.

The experience shared in the sources illustrates this point vividly. The narrator recounts an incident involving Dr. Schultz, an attending physician, who seemed tired and distant during a busy shift in the emergency department. Dr. Schultz, feeling good about her capabilities, observed her attending closely and felt confident in her own skills. However, during a busy shift, she noticed Dr. Schultz seemed off; not making eye contact or responding as usual. Later, Dr. Schultz handed off a patient, Mr. Yang, listing several injuries but notably failing to mention or assess a critical condition visible on a chest X-ray. Mr. Yang subsequently arrested due to a pneumothorax; a condition Dr. Schultz missed.

The narrator was shocked, realizing Dr. Schultz had made a basic error that even an intern should avoid. Upon checking the schedule, the narrator discovered Dr. Schultz had been on call for 36 hours and had volunteered to cover an additional shift for a colleague experiencing a family emergency. This extreme exhaustion was identified as the likely cause of her impairment, pushing her to the point of making a simple but dangerous mistake. Luckily, Mr. Yang recovered, but the incident profoundly shook the narrator's confidence, highlighting that impairment can happen to any physician, regardless of their skill level. This experience underscores that impairment is not about competence but about factors affecting performance under stress or duress.

Causes and Prevalence of Impairment

While impairment has numerous potential causes, substance use disorders are among the most studied. Data suggests that 8 to 15% of physicians have substance abuse disorders. Notably, alcohol use disorders are twice as high in female physicians compared to their male counterparts, which is the reverse of the trend seen in the non-physician public.

Beyond substance use, mental health issues are a significant concern in the medical profession. The sources describe medicine as a high-risk profession for mental stressors. Alarming statistics are presented regarding the prevalence of depression among early career physicians: up to 40% screened positive for depression, and half of residents screened showed depressive symptoms. Furthermore, suicide rates among physicians are higher than those of the public.

Other factors contributing to impairment mentioned include lack of adequate rest/exhaustion, dealing with personal issues like a sick child, and the potential for decline in motor skills with aging. The narrative involving Dr. Schultz serves as a primary example of exhaustion leading to a critical lapse in judgment.

Risks Associated with Physician Impairment

The consequences of physician impairment are severe and multi-faceted. The most immediate and perhaps most serious risk is patient safety. Errors resulting from impairment can lead to significant patient harm, as illustrated by the near-fatal outcome for Mr. Yang.

Beyond direct patient harm, impairment can also jeopardize the physician's professional standing. This includes the potential loss of a medical license and being sued.

However, the risks extend beyond legal and professional repercussions for the individual physician. Impairment can also lead to a loss of trust. Patients and communities may lose trust in the broader medical system if errors occur due to physician impairment. Within the medical team, colleagues may lose trust in an impaired physician or begin to view them with uncertainty. Significantly, impairment can also cause physicians to lose confidence and trust in their own abilities.

Self-Care as a Strategy to Combat Impairment

Recognizing that impairment is a regular obstacle for physicians, the sources highlight the importance of proactive strategies. Self-care is presented as a crucial, ongoing practice, not merely a luxury or something to consider only when completely burned out.

Self-care, in this context, is defined broadly, encompassing actions that support overall well-being. This includes getting adequate rest, eating a healthful diet, seeking support from a therapist, making time for a social life, and finding ways to connect with patients on a personal level. The sources suggest that reminding oneself of the initial joy derived from helping people can also be a powerful form of self-care.

The narrator shares a personal evolution in understanding self-care. Initially, there was worry about using sick days or taking vacations, fearing judgment or missing important learning opportunities. However, the realization came that taking vacations allows the brain to process information and return refreshed, ready to learn more. Similarly, taking a sick day is not only for the physician's health but also critically for protecting patients. An anecdote is shared about a colleague who came in with the flu, resulting in the infection of the patient, floor nurses, and residents – highlighting that dedication at the expense of health can be detrimental to others. This reinforces the idea that self-care, including taking time off when needed, is a necessary professional responsibility. It should be an ongoing daily habit, not something started only in crisis.

Physicians tend to be less likely to seek the help they need, partly due to the fear of professional repercussions. This fear can make it difficult to admit when one is struggling or needs time off. Overcoming this fear and prioritizing self-care is presented as essential for preventing impairment. Monitoring oneself for impairment and maintaining daily self-care activities, no matter how small, is crucial.

Addressing Impairment in Colleagues

While recognizing one's own impairment is challenging, the sources suggest that knowing when a colleague is impaired can be even harder, particularly if they are senior. There are no easy answers regarding how to handle different types of impairment, whether sleep deprivation in different specialties, or potential substance abuse. An impaired colleague may not even be aware of their own diminished performance.

Despite the difficulty, the sources unequivocally state that it is part of our professional responsibility to do something about our impaired colleagues. This responsibility exists even though surveys indicate a significant portion of physicians who recognize impairment or incompetence in colleagues do not report it, or do not feel it is their responsibility.

The sources offer various strategies for addressing colleague impairment:

• Direct, one-on-one conversation: This is often presented as the best initial approach. The narrator shares an example of approaching a colleague who repeatedly fell asleep during meetings. Although apprehensive about being wrong or causing anger, the narrator expressed worry about the colleague, linking it to potential substance abuse (though this turned out not to be the case). This direct conversation prompted the colleague to investigate, leading to a diagnosis of severe sleep apnea of which he was unaware. This highlights that addressing the issue directly, even if difficult, can be effective.
• Offering help and support: Sometimes, a simple offer of help can make a colleague aware that their impairment is noticeable to others, potentially nudging them to seek assistance. This could be as straightforward as saying, "Hey, you look tired. Why don't you rest for 30 minutes and let me see this patient for you?".
• Consulting a colleague or mentor outside the institution: If uncomfortable speaking directly to the impaired colleague, seeking advice from someone removed from the immediate situation can be helpful. They may offer objective advice or have experienced similar situations.
• Reporting to a supervisor or senior department member: If direct conversation isn't feasible or appropriate, or if the impairment poses immediate risk, reporting up the chain of command is an option.
• Utilizing institutional resources: Most institutions have an ombudsman office or an anonymous hotline specifically for reporting concerns like colleague impairment. These resources can help manage the situation appropriately.

While there are requirements to report physicians to licensing boards, these generally apply only when patient harm is imminent or suspected. The ombudsman office or similar institutional resources can often help navigate these reporting requirements.

Support Systems and Professional Accountability

Many states have Physician Health Programs (PHPs) specifically designed to assist impaired physicians. These programs often operate with a no-penalty approach to rehabilitation, allowing physicians to seek help without the immediate fear of losing their license or facing sanctions.

Importantly, the sources note that most PHPs do not report monitored physicians to licensing boards unless the physician is non-compliant with the program or relapses. Privacy protections are also in place to encourage physicians to seek help without fear of misjudgment. Physicians are presumed innocent in these processes, emphasizing support over immediate punitive action.

Ultimately, the sources stress that addressing physician impairment is a shared responsibility of the entire profession. Physicians must hold themselves and their colleagues accountable. If a physician is impaired, they must address it. If a colleague is impaired, action must be taken.

Disruptive Physicians (Video 2)

Introduction

The medical profession, while dedicated to healing and patient care, is not immune to behavioral challenges. Concerns regarding "disruptive physicians" are unfortunately prevalent and warrant significant attention. While some individuals may be known for demanding behavior, the source suggests that such actions, particularly those involving verbal or physical conduct that violates professional norms and interferes with patient care, should be formally labeled as disruptive behavior. Recognizing and addressing this issue is crucial for maintaining a healthy work environment, ensuring quality patient care, and fostering effective collaboration within healthcare teams.

Definition

Disruptive behavior is defined as any behavior, whether verbal or physical, that violates social or professional norms and interferes with patient care with the specific goal of ridiculing or intimidating someone else. This definition highlights three key components: the violation of accepted standards of conduct, the negative impact on patient care processes, and an underlying intent to demean or frighten others.

The range of behaviors that fall under this definition is broad, encompassing actions that are overtly negative and others that are more subtle.

• Obvious Disruptive Behaviors: These are often readily apparent and include actions like yelling at colleagues, engaging in name-calling, unwanted touching, or even throwing things at others.
• Subtle Disruptive Behaviors: These can be less obvious but equally damaging. Examples include repeatedly making demeaning comments about colleagues or patients, telling ethnic or sexist jokes, or using excessive swearing.

These behaviors are problematic because they fundamentally undermine collaboration and interfere with good patient care.

Prevalence of Disruptive Behavior

Despite its negative impact, disruptive behavior is unfortunately common within the medical field. The source indicates that up to 14% of physicians report encountering disruptive behavior on a weekly basis. Furthermore, over 75% of all physicians and nurses have witnessed some form of disruptive behavior. While prevalent, this does not make the behavior acceptable. The source posits that disruptive behavior is part of medicine's "hidden curriculum," a cultural element that should not be passively accepted.

Impacts of Disruptive Behavior

The consequences of disruptive behavior are far-reaching, affecting patients, staff, and the overall functioning of healthcare teams.

• Impact on Patient Care: Disruptive behavior directly interferes with good patient care. In Emergency Room settings, studies have shown that 70% to 80% of errors are related to dysfunctional interpersonal interactions. A toxic environment created by disruptive behavior makes it unsafe for individuals to speak up and question clinical decisions, potentially leading to errors and harming patients.
• Impact on Morale and Trust: Disruptive actions have an obvious negative impact on the morale of patients and staff. The source provides an example where witnessing an attending yell at a nurse created discomfort for both the nurse and family members present. Such incidents can erode trust within the team.
• Impact on Learning: Disruptive behavior can significantly affect the learning environment, particularly for residents and students. The source's author recounts feeling so anxious about potentially being the target of an attending's anger that they were hesitant to ask questions about patient care, fearing further upsetting the attending. This chilling effect hinders education, and the necessary open dialogue required for complex patient management.
• Impact on Collaboration and Team Dynamics: These interactions can create and reinforce hierarchical and siloed structures of care, making it less likely that people will work effectively together. When individuals are fearful or reluctant to communicate openly due to the risk of encountering disruptive behavior, teamwork suffers.

Underlying Causes and Context

While some individuals may have a reputation for being demanding, disruptive behavior can often be a signal that something deeper is occurring. The source suggests that bad behavior is sometimes a sign that a colleague is experiencing underlying physical, mental, or emotional stressors.

The anecdote about the attending whose house had just burned down illustrates how personal stressors can manifest as outbursts at work. The author's own reflection on snapping at someone post-call or making negative assumptions about technicians due to fatigue also points to internal states influencing behavior. Disruptive behavior can also be masking impairment. Recognizing that there may be a backstory often helps with identifying the underlying causes. Sometimes, disruptive behavior might stem from an assumption that other people do not care as much about the patient or are being lazy. Being aware of one's own response to stress and recognizing when one might act disruptively due to personal issues is important.

Disruption Beyond the Negative: "Too Positive" Behavior

Interestingly, disruptive behavior isn't solely characterized by overtly negative actions like yelling or name-calling. The source notes that it is also possible to be disruptive by being "too positive". This might sound counterintuitive, but it refers to individuals who constantly talk or jump in with answers, preventing others from participating or thinking. An example given is a smart medical student who repeatedly answered questions posed to fellow students, causing tension on the team.

While seemingly eager, this behavior prevents other colleagues from having the space to think, potentially make mistakes from which to learn, or have their own opinions heard. This type of disruption can also occur in operating rooms or during procedures when someone is constantly talking or asking questions, not realizing others are concentrating or are shy about speaking up. Addressing this can be challenging as one doesn't want to discourage participation, but it is necessary for effective team function. Potential ways to address this type of behavior include stating a need for quiet concentration or redirecting questions to others.

Addressing Disruptive Behavior

When witnessing or experiencing disruptive behavior, several approaches can be taken, depending on the nature of the behavior and the individual involved.

• Ensure Personal Safety: The first and most crucial step is to make sure that you are going to be safe in speaking out. If there is any doubt about safety, other options should be considered.
• Anonymous Reporting: If direct confrontation feels unsafe or inappropriate, anonymous hotlines for reporting incidents are available. Additionally, speaking with a program or residency director can be a way to address issues involving residents or attendings, as they can often handle these concerns anonymously and help prevent retaliation.
• Utilize Institutional Resources: Institutions typically have established mechanisms for handling disruptive behavior, particularly those involving unwanted sexual advances or comments based on protected characteristics such as sex, gender identity, race, or ethnicity, which are explicitly identified as disruptive behaviors. Federal requirements under Title IX statutes mandate that institutions address such concerns. Resources like a center for professionalism or the office of the ombudsman can approach individuals to make them aware of their behavior and its impact on others.
• Direct Communication (When Appropriate and Safe): The source suggests that if one feels comfortable and safe doing so, speaking with the person directly often works best. Sometimes, a simple chat can make the individual realize the impact of their behavior, such as recognizing that a perceived encouraging gesture like a pat on the arm might be felt as an unwelcome physical advance by someone else.

It is also important to realize when you are being affected by others' behavior and might need to say something to them. Recognizing the potential underlying stressors or impairment behind a colleague's behavior can help in understanding the situation, although this context does not negate the need to address the disruptive behavior itself.

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