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CAN A CME COURSE HELP THE DISRUPTIVE PHYSICIAN?

Can you be taught to look before you lip, bite your tongue, button your lip, or things before you speak and get CME for it? You are listening to the ReachMD XM 157, the channel for medical professionals. Welcome to the clinician’s roundtable. I am Dr. Bill Rutenberg your host and with me today is Dr. Charles Samenow. Dr. Samenow is an instructor in the Department of Psychiatry and Behavioral Sciences at the George Washington University School of Medicine and Health Sciences in Washington DC. Dr. Samenow is a psychiatrist specializing in professional health and wellness. His research is focused on addressing professionalism in medical students, physicians, and other professionals. Today, we are discussing a unique CME course offered by the Center for Professional Health at Vanderbilt University aimed in addressing disruptive position behavior.

DR. BILL RUTENBERG:

Welcome Dr. Samenow. It is great to have you with us at the clinician roundtable.

DR. CHARLES SAMENOW:

Thank you. It is good to be here.

DR. BILL RUTENBERG:

I have heard of people wanting to tar and feather disruptive provider, but this is the first time I have heard of offering him or her CME. Why was it chosen to be a CME course.

DR. CHARLES SAMENOW:

Basically, what we noticed were that our state physician health program directors were in a real bond as well as many hospital executives. They would come across individual who had disruptive behaviors in the workplace and there really were no resources for them. They were not candidates to go for 6 months of inpatient residential treatment for drug and alcohol problems because those problems did not exist and many of the things that were in place for the impaired physician simply just did not apply to this individual who was clinically very competent, able to carry out their job, but was reeking havoc all over the workplace and so Vanderbilt had success with two other CME programs around physician behavior. The first one on misprescribing control substances and then the second course was on sexual boundary violations and so we decided to apply the model that we had used with those other physician behaviors towards this really important problem.

DR. BILL RUTENBERG:

How and when did the program get started?

DR. CHARLES SAMENOW:

The program has been existent now for, it must had been about three years that we had experience. Vanderbilt has been doing CME since the late 1990s and had had experience with those other two courses, but in 2004, the course faculty decided to develop a program around disruptive behavior and it was probably predominantly through the feedback they had gotten through their work, they had seen over a 1000 physicians from 50 states and Canada. So, our faculty has been in touch with health professionals, administrators, physician health program executives from around this country and so, through the feedback from that, then collaborating with psychiatry, behavioral medicine, social workers, addictionologist, we really worked to develop a curriculum that could address this problem.

DR. BILL RUTENBERG:

About how many physicians have come through the program in this time?

DR. CHARLES SAMENOW:

I think to date, we have had, I left Vanderbilt a year ago and at that point, we had had almost 40 physicians who had gone through and so I imagine the number is higher at this point.

DR. BILL RUTENBERG:

And how do the physicians get there, do they just set a call up and say I think I need a, you know, CME course?

DR. CHARLES SAMENOW:

We do have a few self referrals, but often times, are most likely source of referral is directly from a healthcare institution, originally many of more from Tennessee, but now again this has expanded nationally. Physician health programs refer and occasionally board licenses refer. We also will have sometimes treatment centers the physician may have drug and alcohol problems and they get successfully treated, but there are still behavioral issues that are identified and so our treatment center will send us a physician.

DR. BILL RUTENBERG:

Having been sent by someone else, do the physicians come in open minded or do you first have to get over that hurdle?

DR. CHARLES SAMENOW:

Most physicians come in very resentful. When you see the first day of our course, it often looks like a funeral. Physicians are guarded, very close, not talking, very paranoid about what will be reported back, <_____> often even legalistic. So, it is a huge challenge.

DR. BILL RUTENBERG:

And how many you are in the course of the given time?

DR. CHARLES SAMENOW:

We try to limit the course to no more than 10, but generally it is, you know, 6 to 8 core in the course, so there is always a small group.

DR. BILL RUTENBERG:

Do you think that model works better, I am just thinking if it was my situation, I would almost rather be one-on-one and not sharing it, but I know as a psychiatrist that some experience I have had in talking to people in groups that it could be very uplifting?

DR. CHARLES SAMENOW:

The small group format is a wonderful format and the reason for this is, the first thing we allow these physicians to do is tell their story and for many of them it is a first chance that they felt that anyone is really even listening to them. By the time they get to us as often, the disciplinary letters have gone out, the threats, you know then put on the defensive. So, they are able to tell their story and they have an audience there who can write because everyone has a story that is similar and so from that moment forward, there is a connection among the group, a cohesion that really helps fit the stage for the rest of the program.

DR. BILL RUTENBERG:

Tell us a little bit about the core program and you said day #1 starts out like a funeral, how many days are involved?

DR. CHARLES SAMENOW:

We do an extensive collateral information from before, so when we get a referral, we do not just take the person automatically. We obviously talk to the physician, but we ask to get information from family members, from their employer, we try to gather information up, want to make sure that the individual is an appropriate referral because we are not setup to do detox. So, this is really a substance abusing physician and that is a different issue. So, we first check for the appropriateness, but then second, we want the information because while the physician has his story or her story, there is often another very complex story out there and so we like to get as much data as possible. So, that is on the fine hand. Then, the program itself is a three-day program, basically full days from morning to afternoon, and we can talk later about each of the individual components, but you know, it is an interactive experiential process involving role playing, assertive training, relaxation techniques, a whole variety of skills, and then it is followed by three booster sessions over a six-month period, in which the physicians actually come back and for a half day, you know sort of share their progress and the change.

DR. BILL RUTENBERG:

I would like to welcome those who are just joining us at the clinician’s roundtable on ReachMD XM 157, the channel for medical professionals. I am Dr. Bill Rutenberg and with me today is Dr. Charles Samenow from George Washington University Medical Center. We are discussing a unique CME course for distressed physician.

Is there any additional monitoring system that takes place back where they are working?

DR. CHARLES SAMENOW:

There is. We use a 360-degree tool, assessment tool and this is something that they fill out, supervisors fill out, colleagues fill out, and then sometimes even their staff people who are underneath them fill out. So, you have people above them, below them, at their level and themselves, all reflecting on their behavior and the tool that we use to evaluate a variety of domains of their behavior and it allows for them and their staff and their colleagues and supervisors to say, you know, these are areas where this individual is good and these are areas where this individual needs some pretty major improvement, and so they come in with that and then afterwards, the same individuals are asked to complete that form and that feedback is provided to the physician.

DR. BILL RUTENBERG:

Has any type of a profile of the disruptive physician emerged from this?

DR. CHARLES SAMENOW:

Again, we do not do a lot of gathering of psychological data and testing data. So, I cannot be very scientific in our profile, but we tend to see just observationally. The typical physician is generally mid aged or average age is around 45 years old, most are males who get preferred to our program, though there are females and we think that females are underreported. Our physicians tend to be from a variety of medical specialties, almost all specialties have been represented, but the more invasive one is surgery, invasive cardiology, those specialists tend to be more representative.

DR. BILL RUTENBERG:

Do you think it is because they are under more stress and what they do on a day-to-day basis?

DR. CHARLES SAMENOW:

That plays a very large role and because the physicians who are most likely to get undetected are the ones with aggressive behaviors and so under stressful situations, people tend to act out and, you know, throw things or say things that they did not mean and those are the things that come to clinical attention the most.

DR. BILL RUTENBERG:

I really enjoy theatre as one of my avocations, I am used to playing roles. Can you take someone who is distressed or disruptive physician and say okay, here is how you are going to act whether you really feel this way or not, here is your role, here is the part you play in the hospital and can they do it?

DR. CHARLES SAMENOW:

I think we do something even better. Instead of directing the physician, we let the physician see themselves. They get to direct the scene of their own behavior and watch that scene play. Right there, with the other course participants, we say setup the operating room, have someone play you, have someone play the nurses, have someone play the patient and have them play your behavior and they watch their behavior unfold in front of their eyes as they directed it.

DR. BILL RUTENBERG:

No, you got their profile from the data you had gathered previously?

DR. CHARLES SAMENOW:

We got their profile, so we know they are not being completely accurate, but we let the physician create scene, take the moment right before you got identified as having to come here, give us an example of you at your most, this is how, and I have seen orthopedic surgeons on the floor bowling after watching the performance of their behavior and so you know it is a stat. This is obviously not a magic pill that then we have wonderful transformation but by allowing them to gain the insight of the effect that they are having on others that starts what we hope is a process of change.

DR. BILL RUTENBERG:

That is really great. Now, just to take you to the next step, do you let them do take 2 and redirect the scene as it should have been?

DR. CHARLES SAMENOW:

We try to do that. We try to have them come up with better ways of communicating and if it is not directly in the role play, we do have some, you know, very specific skill sets that we treat them, assertive communication, listening or selective listening, being able to sort of take time out, flooding as an important concept that we focus on the idea that any of us get our buttons pushed, we also will get emotionally flooded we cannot turn it off, how to deal with that in a more productive manner. So, we do some direct skill set training as well.

DR. BILL RUTENBERG:

Can you give us the greatest success story you personally experienced in terms of somebody coming through the program?

DR. CHARLES SAMENOW:

I have to be very careful about confidentiality and so without specifics, I can simply say that we have a variety of testimonials and individuals who have months afterwards come back and said this program really is what changed it for me, you know, and it was the ability to one, find other people out there who are experiencing this to recognize I was not alone, but two, to be able to really learn about me, the buttons that I have to get pushed, how they get pushed, how I handle them, and we have seen some individuals make some very big changes. The best changes we see are those individuals who recognize the role they play, you know, we had a guy who was working at three different facilities and he realized that at two of them he was doing great, but one of them, he was a real problem and so he, you know, said you know it, I do not need to work there anymore and so he made a choice that was able to, you know, enhance the way he performed as a physician.

DR. BILL RUTENBERG:

Someone in the audience wants more information, how would they contact the program or who should they contact?

DR. CHARLES SAMENOW:

We have a web site at Vanderbilt, www.mc.vanderbilt.edu/cph, that is a center for professional house, that is our web site or you can just Google, the center for professional health at Vanderbilt and we have a variety of listing of all of our CME programs and then many of our research publications that have come from those programs.

DR. BILL RUTENBERG:

I would like to thank, Dr. Charles Samenow, who has been my guest for this fascinating discussion of a unique CME program at Vanderbilt University for the distressed physicians. Thank you for joining us at the clinician's roundtable on ReachMD XM 157, the channel for medical professionals.

I am Dr. Bill Rutenberg, and I leave you with the words of Sharon Anthony Bower. The basic difference between being assertive and being aggressive is how our words and behavior affect the rights and wellbeing of others. I invite you to listen to our on-demand library on www.reachmd.com. Register with promo code radio and receive six months of free streaming audio. If you have comments or suggestions, call us at 888-MDXM-157. Thank you again for listening and until next time, I wish you good day and good health.

This is Dr. Robert Klitzman with Columbia University in New York City and you are listening to ReachMD XM 157, the channel for medical professionals.