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Chances are you've witnessed behavior
like this at work: A coworker known for his temper
tantrums becomes unreasonably angry at the slightest
provocation. Often he is moody, sometimes verbally
abusive. Office mates have learned to steer clear
of him, but work has started to suffer. Fairly soon
the whole operation begins to feel the effects. Everyone
but him can see he needs help...
...Now, imagine the angry employee
is your doctor. From a potential patient's point of
view, it was probably the last lecture anyone wanted
to hear. But for medical professionals, Dr. Anderson
Spickard, Jr.'s recent lecture seemed to ring true.
"The disruptive physician is the emerging
overwhelming problem for medical and nursing staffs
and administrators," he said at the Clinical Center
Grand Rounds for Clinical Fellows. "My lesson to you
today is, help is effective."
||Dr. Anderson Spickard,
Spickard, a former NIAID clinical associate from
1960 to 1962 who now is medical director at Vanderbilt
University's Center for Professional Health (CPH),
returned to NIH to discuss a delicate topic in the
medical community — impaired physicians, also
known as distressed or disruptive physicians.
CPH offers confidential internal and external programs,
including an in-house wellness committee and three
monthly continuing medical education courses:
- maintaining proper (sexual) boundaries,
- prescribing controlled drugs, and
- distressed physicians.
Since 1999, Spickard reported, 750 physicians have
been referred to CPH by medical boards nationwide
for over-prescribing schedule II narcotics. More than
280 physicians have been required to take the boundaries
class. The first course for disruptive doctors included
12 physicians, with 8 more scheduled to complete the
module. Although dependency and alcohol problems among
physicians account for the majority of cases, he said,
"disruptive" participants are catching up.
"These distressed physicians disrupt the office and
home, ignore their feelings and are on the way to
burnout," Spickard continued.
He said most disruptive doctors have narcissistic
traits, meaning "they have a restricted ability to
express warm and tender emotions, they're overly perfectionistic,
they insist that others submit to their way and they
have excessive devotion to work to the exclusion of
personal and interpersonal relationships.They are
creating such a disturbance in their medical staffs
and hospital staffs that the administrator says, 'You
have got to get help. We can't stand you any longer.'"
The poor behavior ranges from aggressive (swearing,
making threats and pushing) to passive (being chronically
late and providing inadequate chart notes), with passive-aggressive
actions (sending hostile emails and making derogatory
comments about the institution, hospital, etc.) in
"That is an enormous problem — throwing objects
in the surgical theater," Spickard observed, describing
a true case. "Nurses in one of our groups had to draw
straws to see who was going to work with this physician."
his clinical associate days at NIH with
Dr. Jack Bennett, chief of the clinical
mycology section in NIAID's Laboratory of
"I came here today to encourage young people
to become interested in studying, researching
and hopefully leading future physician wellness
For perspective, Spickard provided data from a 2004
physician behavior survey conducted by the American
College of Physician Executives that found such disruptions
occur several times a year for more than 24 percent
of respondents. More than 70 percent report that the
problems "nearly always involve the same physicians
over and over again."
Phase I of CPH's program includes psychiatric and
workplace assessments. Results can suggest problems
of substance abuse or dependency, medical illnesses,
stress related to career choice or skills, or psychiatric
"These people have very short fuses and very little
frustration will throw them off, particularly in the
O.R.," Spickard noted. "These are usually younger
people. They have usually been touted as being the
smartest and the brightest of all, and they think
so. They have no way to control their anger. [However]
the program is not just anger management. This is
the total understanding of how they got that way."
Phase II of the program requires a 3-day CME class,
which combines instructional lectures with role play,
communication strategies and homework.
"I have never seen anything more powerful than to
have two physicians play out another physician's problems,"
Spickard observed. "It is amazing to us that about
30 to 40 percent of the people referred to us don't
understand how bad they are. The role play demonstrates
it in such a vivid way that it breaks through their
denial and they become interested in changing." Class
participants also construct self-assessed psychological
genograms, family tree-like diagrams that help them
trace disruptive personality traits back to behavior
perhaps learned from models in their childhood such
as parents or grandparents. Six monthly follow-up
sessions in small groups, another workplace assessment
and relapse prevention are key components of phase
"Doctors are very lonely," Spickard observed. "They
require a lot of emotional help." Group process addressed
the loneliness, he explained, describing the effectiveness
of 7 or 8 physicians being able to talk about their
needs in a facilitated, safe and confidential environment.
"It's very important, because we were trained to be
lone rangers. We were trained to do it by ourselves."
While the CPH program is getting positive results,
Spickard said more awareness of the disruptive physician
phenomenon by leaders in medicine will help reverse
the growing trend. "The key resistance factor is confidentiality,"
he said, explaining that people will neither admit
they need help nor seek it, if they feel their livelihood
and reputation are at stake. "Residents and faculty
are afraid to get help."
Addressing the stigma, Dr. Mike Bowler of the NIH
Employee Assistance Program described how NIH's formal
effort to help physicians cope began as an alcoholism/substance-abuse
prevention program and how many employees still see
it that way. "So, we have tried to reframe it as a
life transition program," he explained. "With any
kind of life transition, there are stresses and pressures,
and people can be overwhelmed at times. In many ways,
it's kind of normalizing the whole idea of coming
in to talk to someone for help." NIH'ers can learn
more online about the EAP at http://www.nih.gov/od/ors/ds/eap
or by calling (301) 496-3164.
Doctors who ignore their disruptive symptoms may
risk more than their careers, stressed Spickard, who
had begun his lecture by recalling four impaired physicians
— one a personal friend — who committed
suicide while struggling to handle things alone. The
Vanderbilt wellness committee was founded not long
"I came here today to encourage young people to become
interested in studying, researching and hopefully
leading future physician wellness programs," he said.
"Most of us were raised in an atmosphere where to
admit weakness is a sign of failure.I'm telling you
that help is effective. Our course is changing behavior."