2007 annual conference disruptive professionals raymond m. pomm, m.d. professionals resource network
TRANSCRIPT
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2007 Annual Conference
DISRUPTIVE PROFESSIONALS
Raymond M. Pomm, M.D.
Professionals Resource Network
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
WHAT IT IS NOT...
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
SUBSTANCE RELATED
DISORDERS
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
PSYCHOTIC DISORDERS
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
MAJORDEPRESSIO
N
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
BIPOLAR I / II
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
WHAT IT IS...
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
A Continuum
Dangerous Disruptive
Difficult
Different Lo Disruptive
Hi Disruptive
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Disruptive Professionals
are ultimately...
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
TEAMBUSTERS!
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
The Underlying Issues...
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
PredisposingCharacter
Poor Role Models
Stress
Poor Coping Skills
Disruptive
Incidents
Hospital Culture
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
PERSONALITY
DISORDERS
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
NARCISSISTIC PERSONALITY
DISORDER
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
THIS IS NO ORDINARY PERSON YOU’RE
DEALING WITH!
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
WHAT TO DO...
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
There is no law that says one
cannot be Disruptive
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
The: -Hospital -Group
-Corporation
-Leadership holds the
hammer
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
The steps to validate and protect the hammer:
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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:
Slide 1 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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. Slide 2 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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.
Slide 3 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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;
Slide4 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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;
Slide 5of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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).
Slide 6 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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,
Slide7 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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
Slide 8 of 8
PRN DISRUPTIVE PRACTITIONER
POLICY & PROCEDURE
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Let’s look at Evaluation/Treat
ment/Monitoring Process...
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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2007 Annual Conference
Disruptive Professionals: New Approaches to
Evaluation and ManagementLarry Harmon, PhD
Physicians Development Program
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Who are the Disruptive Docs?• MBAs
• “Good Doc … Bad Talk”
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Clinical Evaluation• Clinical Interview
• Extensive Personal History • Psychological & Cognitive Testing• Criminal Background Checks• Drug Testing• “Workplace Behavior Assessment”
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
P.hysicians + Professionals
U.niversal
L.eadership + Teamwork
S.kills
E.ducation Survey
Workplace Behavioral
Assessment
360° P.U.L.S.E.
Survey
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Workplace Behavioral
Assessment1. Each physician scores self on survey
2. Other physicians and healthcare team members give physician survey feedback
3. Feedback Report is prepared
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
3 Types of Assessments1. Individual - Continued disruptive
pattern despite progressive warnings
2. Small Group or Section (2-10)
• Individual resists
• Protect identity of subject
3. Department or Hospital ProgramAnnual Leadership Feedback Reports
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Conducting an
Individual Workplace Behavioral Assessmen
t
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Phase I:
Assessment Step 1: Referral Letter
Step 2: Physician Orientation
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Dr. Disruptive
Administration
Supervisors
OtherDepts.
Colleagues
Patients**Patient Pulse survey
Nurses+Healthcare StaffSupport
Staff
Step 3. Select “Feedback Groups”
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Dr. Disruptive
Administration
Supervisors
OtherDepts.
Colleagues
Patients**Patient Pulse survey
Nurses+Healthcare Staff
Step 3. Select “Feedback Groups”
SupportStaff
“Validator” Adds Any
Missing Names (Chief of Staff, CEO,
i.e., the “Boss”)
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Step 4. “Self-Rating”
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Motivating/Encouraging Dimensions
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Disruptive/Discouraging Dimensions
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
TO: My Team Members and ColleaguesRE: 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
Step 5.Step 5. Writes Cover Letter Cover Letter
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
1. Mailed / Emailed to Raters
Step 6:Step 6: Send Surveys+Create Report Send Surveys+Create Report
2. Raters Complete Surveys
3. Feedback Report Prepared
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Dr. Disruptive requests your honest and anonymous feedback
Dirk Disruptive, MD
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
“Discourager” or “Disruptive” Feedback Report
LEADERSHIP FEEDBACK REPORT
Physicians P.U.L.S.E. Program P.hysicians U.niversal L.eadership S.kills E.ducation Program
Prepared for
Dr. Disruptive
This report includes feedback from 22 individuals, including your self-rating if you completed one.
January 1, 2007
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Self-Rating
Nursing Staff
PhysicianPeers
Self-RatingNursing StaffPhysician-Peers
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Nursing Staff
Physic-ians
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Findings & Recommendatio
ns• No Disruptive
• Mild
• Moderate
• Serious
• Severe Disrup-
tive Behavior
• No Recommendation
• Anger Mgmt. Videos
• Anger Mgmt. Program• Weekly Group
• Psychotherapy
• Tele-Coaching (month)• Survey Monitoring
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Phase II:
Distance
Education
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Phase III.
Follow-up
“Graduation” requires 4 consecutiveacceptable Feedback Reports
NO RED BEHAVIORS!
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Phase IV:
Group Program or
Treatment
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
3 Types of Assessments1. Individual - Continued disruptive
pattern despite progressive warnings
2. Small Group or Section (2-10)
A. Individual resists
B. Protect identity of subject
3. Department or Hospital ProgramA. Annual Leadership Feedback Reports
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Other Professionals • Immigration and Naturalization
Service (INS)–Law Enforcement–Naturalization Services
• Telephone Marketers• Hospital Executives• Attorneys
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Research Findings
1. 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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
1. COMPLETED PROGRAM BY Facility or PDP STANDARDS 77.19%
Completed by Facility Standards (61.40%)
Completed by Early PDP Standards (15.79%)
2. WITHDRAWAL -- NOT DUE TO DISRUPTIVE BEHAVIOR 10.52%
Facility withdrew Physician (5.26%)
Physician withdrew Self (5.26%)
PDP withdrew (00.00%)
3. EXPELLED -- FOR DISRUPTIVE BEHAVIOR 0.00%
By Facility (00.00%)
By PDP (00.00%)
4. OTHER (INSUFFICIENT INFORMATION) 12.28%
160 Disruptive Physicians Participants
74 Active Physicians / 86 Physicians completers
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Dotted line = Projected values-20
0
20
40
60
80
100
Baseline #1** Follow-up #2* Follow-up #3* Follow-up #4* Follow-up #5*
Leadership Improvement in 282 Physicians(Disruptive vs. Normal and Role-Model) after P.U.L.S.E. Feedback from Raters
NORMALS (N=97)
**At baseline, all groups significantly different at (p) <.01. Baseline 1 vs. follow-up 2 for disruptive physicians: significantly different at (p) < .01.
120.5% Improvement
572% Improvement
ROLE MODELS (N=68)
(3.5 years)
LE
AD
ER
SH
IP IN
DE
X
MOST DISRUPTIVE 25% (N=30)
DISRUPTIVE (N=117)
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Top Improved Behaviors in Disruptives1. Remains approachable even when stressed out
2. Treats team members with respect3. Handles difficult team members effectively4. Is open to suggestions5. Responds to conflict by working out solutions6. Adapts to changing policies, procedures, priorities
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
UnderlyingPrinciple
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
When you see Roadside Radar, what’s the first thing you do?
“Feedback Creates Change!”
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Larry Harmon, PhDDirector, Physicians Development [email protected]
Curious Questions? Concerned Comments?Interesting Ideas?
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2007 Annual Conference
The Neurobiology of Disruptive Behavior
Mick Oreskovich, MDMedical Director and CEO
Washington Physicians Health Program
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Our every thoughtEvery feelingEvery action
Is chemically mediated!
Disruptive behavior is a chemical event in the brain!
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Transference
Countertransference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Inside the middle of the brain is the limbic system and the amygdala:
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
1. How we associate things in the world with emotional responses and process emotional information.
2. Allows us to overrule instinctive responses by connecting the cortex’s memories of things to the emotions they engender.
3. Allows us to respond to fear stimuli.
Amygdala:
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
5-HTTLPR S allele driven amygdalahyper-reactivity to environmental cues
Hariri et al., Science 2002
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
S allele driven amygdala hyper-reactivity
Hariri et al., Science 2002
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Hamann, Nature Neuroscience 2005
5-HTTLPR also effects information processing related to temperament
between the amygdala and the cortex
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
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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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
David T George, MD, Section of Clinical Studies, NIAAA
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Our every thoughtEvery feelingEvery action
Is chemically mediated!
Disruptive behavior is a chemical event in the brain!
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Council on Licensure, Enforcement and RegulationAtlanta, Georgia2007 Annual Conference
Mick Oreskovich, [email protected]
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