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Vol. LVII, No. 23
November 18, 2005
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'Physician, Heal Thyself'
Identifying, Helping 'Disruptive' Doctors


On the front page...

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...

Continued...

...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, Jr.

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 between.

"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."

Spickard recalls his clinical associate days at NIH with Dr. Jack Bennett, chief of the clinical mycology section in NIAID's Laboratory of Clinical Investigation.
Says Spickard, "I came here today to encourage young people to become interested in studying, researching and hopefully leading future physician wellness programs."

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 disorders.

"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 III.

"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 afterwards.

"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."