The Problem Physician: Strategies for Improving Care

Javier A. Gonzalez del Rey, M.D., M. Ed.

Cincinnati Children’s Hospital Medical Center

Learning Objectives…

• A systematic approach to identifying causes of inadequate physician performance

• Practical interventions to prevent or change specific behaviors which may interfere with optimal patient care

• Practical skills to handle difficult conversations during the feedback process

Late Majority

Early Majority

Early Adopters

Tradition-alists

Innovators

Adopter Categorization: Speed of Adoption

2% 13% 35% 35% 15%

Some “scary” information…

• Every year approximately 0.5% MDs are disciplined in the USA

• 3 – 5% of MDs present a problem of disruptive behavior

• 10% of MDs will demonstrate significant deficiencies in knowledge or skills as some point in their career

• 10% of MDs restrict their practices for medical illness

Underlying Causes…

• Mental & Behavioral– Substance abuse– Physical Illness– Age related and

disease related cognitive impairment

– Failure to maintain or acquire knowledge and skills

– Anxiety or Depression

• Overwork• Family problems• Dysfunctional

working environment• Personality

Unfortunately…

• “…at least one third of all physicians will experience, at some time in their career, a period during which they have a condition that impairs their ability to practice medicine safely…”

Ann Inern Med 2006;144:107-115

“Professional Competence”

• “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served”

JAMA 2002;287:226-35

“Professional Competence”

• “The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and community being served”

JAMA 2002;287:226-35

What is a Problem Learner?

• A problem learner is a learner with academic performance which is significantly below performance potential because of a specific affective, cognitive, structural, or interpersonal difficulty.

What is a Problem Learner Physician?

• A problem learner is a learner with academic performance which is significantly below performance potential because of a specific affective, cognitive, structural, or interpersonal difficulty.

Lets Review Some “Similarities”…

First…

Current Mix??

• Traditionalists (born 1922-1943)/Silent Generation (1925-1942) 63 million ( 1%)

• Baby Boomers (born 1943-1960)/The Boom Generation (1943-1961) 77 million (30%)

• Xers (born 1960-1980)/Generation X (1962-1981) 44 million (59%)

• Millenials (born 1980-2000 or 1978 and beyond)/Generation Y (1982-1998) 70 million (10%)

TraditionalistsBorn 1925-1945

Baby BoomersBorn 1946-1964

Generation XBorn 1965-1977

MillennialsBorn 1978 or after

Age Span 61 to 81 years old 42 to 60 years old 29 to 41 years old 28 or younger

Traits ConservativeDisciplineRespect for authorityLoyalPatriotic

IdealisticBreak the rulesTime stressedPolitically correct

PragmaticSelf-sufficientSkepticalFlexibleMedia/Info/Tech savvyEntrepreneurial

ConfidentWell-educatedSelf-sufficientTolerantTeam buildersSocially/politically conscious

Defining Events Great depressionWorld War IIKorean WarNew Deal

Cold and Vietnam WarsWoodstockCivil RightsSpace Travel

Collapse of communismMissing kids on milk cartonsComputers in schoolEnergy crisis

Clinton/LewinskySchool shootingsTerrorism on U.S. soilCorporate scandals

Work Is Inevitable Exciting adventure Difficult challenge Make a difference

Work Ethic Loyal/dedicated Driven Balanced Eager but anxious

Employment Goals

Retirement for some Second career Work/life balance Unrealistic

Education A dream Birthright Way to get to an end A given

Technology LP record 8-track & cassettes CD iPod/MP3,computers@home

Communication Face to face Telephone Cellular phone IM/Text messaging

TV Peyton Place Dallas Melrose Place The OC

Sports Joe DiMaggio Joe Namath Michael Jordan Lebron James

Time at Work is defined

Punch clock Visibility Why does it matter if I get it done?

Is it 5 PM? I have a life.

Second…

“Pedagogy”

• Teacher-centered learning where the teacher assumes full responsibility for the learning process by determining the content, timing, and method of instruction.

Pedagogy

“Andragogy”

• Experience

• Need to know

• Self Concept

• Readiness to learn

• Orientation to learning

• Motivation

• Expectations

• Pleasure in learning

Andragogy

“Adult as Learners”

•Respect

•Experience

•Application

•Practice

“Adult as Learners” or “Physicians as Adults” ?

•Respect

•Experience

•Application

•Practice

Third…

Grasha-Riechmann:Student Learning Styles

• Competitive

• Collaborative

• Avoidant

• Participant

• Dependent

• Independent

“Teaching Styles”

• The attitudes, values, and behaviors that teachers display

It would be rare to find a teacher who fits only one of the styles; we all have a Teaching Style Profile which is a blend of different styles with one or two being a little more dominant

THERE IS NO CORRECT OR PREFERRED PROFILE

Flexibility with styles is a sign of a good teacher

Teaching Styles

Expert

Teacher centeredFormal

Authority

Personal

Model

Facilitator

Delegator Learner centered

“Teaching Styles” “Management Styles”

• The attitudes, values, and behaviors that teachers display

It would be rare to find a teacher who fits only one of the styles; we all have a Teaching Style Profile which is a blend of different styles with one or two being a little more dominant

THERE IS NO CORRECT OR PREFERRED PROFILE

Flexibility with styles is a sign of a good teacher

Fourth…

Enhancement of Adult Learning (How to Change Behaviors or Attitudes)

• Informal in a non-threatening environment

• Ability to exert some control over the process

• Mental and physical participation

• Time for assimilation and practice

• Early application

• Practical applications

• Regular evaluation

Essential Criteria

• Validity• Reliability• Practicality

• Formats:– Skills

– Attitude

– Behavior

• Types

Pitfalls

• Failure to evaluate• Not specific• Teacher Bias• “Halo” effect• Reluctance to fail• Third party

Formative Evaluation

• Throughout educational experience

• Learning opportunity for faculty / trainee

• Specific evaluation about performance

• Timely: used during current educational experience

Summative Evaluation

• Occur at the end of the educational experience

• Based on prior feedback / formative evaluations

• Broad assessment of competence to date

• Information used for future educational experience

Annual Summative Evaluation

• Occur at the end of the educational experience

• Based on prior feedback / formative evaluations

• Broad assessment of competence to date

• Information used for future educational experience

Performance Evaluation

Perceptions / Satisfaction

Learning / Competence

Performance / Behavior Change

Patient / Healthcare Outcomes

Return on Investment

In order to critique or improve…

• You must see it

• You must experience it

• You must feel it

• You must participate

• You must get involved

• You must embrace …

Student – Resident – Fellowor

Attending?

• Interpersonal

• Affective

• Structural

• Cognitive

So … First …

Key Driver Analysis for “The Problem Physician” Outcomes Key Drivers Intervention/Change Concepts

90 Days Aim

Objective Performance / Outcome Tool

(“Solid” evaluation process) “This” will happen:

- If meeting expectations - Exceeding expectations - Below expectations

Identification of problem or behavior in question (By the leadership and MD

in question)

Organized process for “resolving” the problem:

- Scheduled meeting - Structure of meeting - Participants / Goals - Follow up process - Reassessment routine - Add hoc participants /

consultants

Structured process for intervention

(“Solid” communication process)

AIM Statement By ________ Dr. _______ will perform clinically, professionally and scholarly at the level expected by our division as defined in our _______ and measured by _________.

Dr. [name] will incorporate or eliminate by 100% this [behavior] or [technique] / [achieve this level or productivity] by [date] assessed / measured by [performance assessment tool]

Understanding of Divisional Goals /

Performance Indicators (By Leadership and MD in

question) Organized process for understanding the problem:

- Review of data or events

- Direct observation - Interviews (peers –

others) - Discussion of facts

with MD in question

The “Welcome” process: - New faculty orientation - Faculty Development - Performance

Evaluation Education - Periodic Self Reviews

Rewards / Consequences

Importance of Beside Teaching and Direct Observation

• Adult learning theory at best

• Allows true assessment of competence

• Best possible feedback

• New insight in communication skills

• Best reinforcement of desired behaviors

• Best opportunity to remedy errors or undesirable habits

Importance of Beside Teaching and Direct

Observation

• Adult learning theory at best

• Allows true assessment of competence

• Best possible feedback

• New insight in communication skills

• Best reinforcement of desired behaviors

• Best opportunity to remedy errors or undesirable habits

So … In Summary…

• Prevent• Plan• Observe• Discuss• Prepare• Contract• Follow up

 “There is nothing more difficult to carry out, nor more doubtful of success,

nor more dangerous to handle, that to institute a

new order of things”

References

Leape LL, & Fromson JA. Problem Doctors: Is there a system solution? Ann Intern Med. 2006;144:107-115.

Epstein RM, & Hundert EM. Defining and assessing professional competence. JAMA. 2002;287:226-35.

References

Neff KE. Understanding and managing physicians with disruptive behavior. In: Ransom SB, Pinsky WW, Tropman JE, eds. Enhancing Physicians Performance: Advanced Principles of Medical Management. Tampa, FL: American College of Physicians Executives; 200:45-72.

Vaughn, L. M., Baker, R. C., & DeWitt, T. G. (1998). The problem learner. Teaching & Learning in Medicine, 10, 217-222.

References

• Cognitive Psychology and Instruction– Roger H. Bruning

– Gregory J. Schraw

– Royce R. Ronning

– Merrill, Columbus, OH, 3rd Edition 1999

• Adult Learning– Peter Sutherland

– Kogan Page, London UK 1998

References

• How to Turn Learners On…without turning them off– Robert F. Mager– CEP, Third Edition, 1997

• Attitudes and Persuasion: Classic and Contemporary Approaches– Richard E. Petty– John T. Cacioppo– Westview Press, 1996