How to Handle Lapses in Professionalism- It is not a me, myself and I kind of job

Transcription

1 How to Handle Lapses in Professionalism- It is not a me, myself and I kind of job Dr. Rachel Simmons Boston Medical Center Dr. Craig Noronha Boston Medical Center Dr. Nicole Swallow Penn State/Hershey Medical Center Inez Hudlow Florida State/Tallahassee Medical Center Disclosures No financial conflicts of interest to disclose... we just give these talks in our spare time!

2 Learning Objectives Analyze and discuss examples of lapses in medical professionalism Identify networks, including the Clinical Competency Committee (CCC), involved in handling professionalism cases Describe stepwise approaches to lapses in medical professionalism Agenda Who are we? More importantly, who are you? Background information Cases for small group discussion Report out/large group discussion

3 Who are we? Craig Noronha, MD Associate Program Director Boston University/Boston Medical Center Nicole Swallow, MD Program Director, IM Residency Program Penn State/Hershey Medical Center Rachel Simmons, MD Associate Program Director Boston University/Boston Medical Center Inez Hudlow Getting to know you Are you currently a: Program Director Associate/Assistant Program Director Clerkship Director Program coordinator Program Administrator DIO/Chair Resident or chief resident

4 What is your level of comfort Addressing minor professionalism issues? Very Comfortable Comfortable Somewhat Uncomfortable Very Uncomfortable What is your level of comfort Addressing major professionalism lapses? Very Comfortable Comfortable Somewhat Uncomfortable Very Uncomfortable

5 What is your level of comfort Addressing professionalism issues that require involvement of outside/institutional resources (i.e., Human Resources, Compliance Office)? Very Comfortable Comfortable Somewhat Uncomfortable Very Uncomfortable Medical Professionalism Who to involve in your professionalism discussions?

6 How do you define Professionalism in Medicine? Large group discussion How do you define lapses in Medical Professionalism? I shall not today attempt further to define the kinds of material I understand to be embraced within that shorthand description porn, and perhaps I could never succeed in intelligibly doing so. But I know it when I see it, and the motion picture involved in this case is not that by United States Supreme Court Justice Potter Stewart

7 Elements of a profession Common body of knowledge Commitment to self assessment Professional accountability Altruism Self regulation Mentoring in Academic Medicine. Holly Humphrey ABIM Charter on Professionalism (2002) Primacy of Patient Welfare The principle is based on a dedication to serving the interest of the patient. Altruism contributes to the trust that is central to the physician-patient relationship. Market forces, societal pressures, and administrative exigencies must not compromise this principle.

8 ABIM Charter on Professionalism (2002) Patient Autonomy Physicians must have respect for patient autonomy. Physicians must be honest with their patients and empower them to make informed decisions about their treatment. Patients decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care. ABIM Charter on Professionalism (2002) Social Justice The medical profession must promote justice in the health care system, including the fair distribution of health care resources. Physicians should work actively to eliminate discrimination in health care, whether based on race, gender, socioeconomic status, ethnicity, religion, or any other social category.

9 ACGME Internal Medicine Reporting Milestones Respectful interactions with patients, caregivers, and inter-professional team Accepts Responsibility and Follows through on tasks Exhibits integrity and ethical behavior in professional conduct Responds to each patient s unique characteristics and needs What are the Privileges of being a physician Discuss among your colleagues

10 Privileges of being a physician Patients trust you with their lives and their story Respect from patients, community, and society Comfortable income and job security Power to make changes in individual patient s lives, community, and government Role model for future physicians and other health care providers Work has inherent meaning How are lapses in professionalism handled in a residency program? Chief resident role Program Director role Associate Program Director role Clinical Competency Committee Role (CCC) Attending Role GME/Chief Medical Officer/Possibly Hospital Human Resources/Legal Counsel

11 Evaluation and reporting tools for specific lapses in professionalism Be specific about problem Label behavior not person Provides specific language and society generated milestones to use in discussions with residents Track issues- one major issue vs multiple minor issues that add up over time Remediation? Probation? Remediation Not reportable to outside entities (licensing boards, credentialing) Usually handled at the Program/CCC level Action plan with milestones to meet Consequences outlined for failure to meet milestones Can progress to formal probation Probation Reportable to outside entities DIO/GMEC also should be aware Document, document, document Consequences of repeat offenses/failure to remediate need to be spelled out Can progress to non-renewal/termination

12 2 sides to every story- Considerations Have to deal with outside issues as well as lapses in professionalism Just because there are outside issues does not make it right Challenges in Professionalism Small group exercise

13 Small group discussion As you go through each case, consider the associated questions Please break into small groups of 4-5 Discuss and prepare to report out to the large group Case 1

14 Case 2 How would you handle this case? What specifically are the resources at your institution? Mental Health Resources Employee Assistance Program Dr. B Physician Health Services GME Community providers

15 What if there is pushback? Mandate from day 1 is trainee s well being Concern for resident s physical and emotional health for the sake of the trainee, their family, and the patients Parallels to patient care Crisis management versus prevention What do you do to address resident well being? Prevention Dr. B comes to orientation GME is working on seminars for the institution Wellness addressed at all retreats and academic half day Resident lead wellness committee

16 6 D s of unprofessional behavior- potentially reversible causes Depression Deprivation (sleep, food) Distraction (finances, family/so, illness) Disability (neurocognitive, physical) Disordered personality (ADHD, borderline) Drugs (alcohol, narcotics)

17 Case 3 AMA Policy on Social Media 11/9/2010 Encourages Physicians to: Use privacy settings to safeguard personal information and content to the fullest extent possible on social networking sites. Routinely monitor their own Internet presence to ensure that the personal and professional information on their own sites and content posted about them by others, is accurate and appropriate. Maintain appropriate boundaries of the patient-physician relationship when interacting with patients online and ensure patient privacy and confidentiality is maintained. Consider separating personal and professional content online. Recognize that actions online and content posted can negatively affect their reputations among patients and colleagues, and may even have consequences for their medical careers.

18 Annals of Internal Medicine April 16 th, 2013 Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and Federation of State Medical Boards Potential Online Physician Activities Communication with patients using , text, and instant messaging Use of social media sites to gather information about patients Use of online educational resources and related information with patients Physician-produced blogs, micoblogs, and physician posting of comments by others Physician posting of physician personal information on public social media sites Physician use of digital venues for communicating with colleagues about patient care From: Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards Ann Intern Med. 2013;158(8): doi: / Date of download: 3/4/2015 Copyright American College of Physicians. All rights reserved.

19 Excerpt from: For doctors, social media a tricky case- Boston.com April 20 th, 2011 Dr. Alexandra Thran, 48, was fired from the hospital last year and reprimanded by the state medical board last week. The hospital took away her privileges to work in the emergency room for posting information online about a trauma patient. Thran s posting did not include the patient s name, but she wrote enough that others in the community could identify the patient, according to a board filing. Five nurses fired for Facebook postings JENNIFER FINK, RN, BSN JUNE 14, 2010 SCRUBSMAG.COM Five California nurses were recently fired after allegedly discussing patients on Facebook. No patient names, photos or identifying information were included in the posts.

20 Amy Dunbar, OB-GYN, In Hot Water After Posting Comment About Patient On Facebook Huffingtonpost.com 2/6/2013 Case 4

21 Escalation to Outside Entities Involve Human Resources know the policy for physician impairment at your insitution Legal ramifications What if this individual had cared for patients while impaired and had an adverse outcome? External reporting State Board; PHP referral Physician Health Programs

22 How do highlight and reward residents who exemplify high levels of professionalism Kudos on weekly s Maybe box for co-residents to praise peers An end of year/residency award for Professionalism or aspects of professionalism Peers, other health care workers, patients, students 360 evaluations Top Tips 1) Model professional behavior including dress code as a chief resident 2) Do not let prior friendships with residents take precedent over your duties 3) Learn your policies Residency, GME, HR, Hospital wide, Department 4) When handling ANY issues hear both sides of the story before coming to a conclusion 5) Be a good listener 6) Consider other factors 6 Ds 7) Set clear expectations work with the program, department, and hospital leadership 8) Feedback should be timely and specific 9) Label behavior(s) not resident 10) Document issues especially non patient related issues 11) Seek advice from your superiors when there is an unclear answer to the problem 12) Talk early and often with each other, program leadership and CCC 13) Establish clear follow up Twelve tips for addressing medical student and resident physician lapses in professionalism. Rougas S 1, Gentilesco B, Green E, Flores L. Med Teach Feb 10:1-7. [Epub ahead of print]

23 Summary Contact information Craig Noronha Rachel Simmons Nicole Swallow

24 Resources Twelve tips for addressing medical student and resident physician lapses in professionalism.rougas S1, Gentilesco B, Green E, Flores L. Med Teach Feb 10:1-7. Online Medical Professionalism: Patient and Public Relationships: Policy Statement From the American College of Physicians and the Federation of State Medical Boards. Annals of Internal Medicine. 2013;158(8): doi: / Professionalism in the Digital Age Arash Mostaghimi, MD, MPA; and Bradley H. Crotty, MD Annals of Internal Medicine. 2011;154(8): doi: /

25 Medical Professionalism cases APDIM 2016 Skills Conference Case 1 It is October 1 st and intern A is getting comfortable with his intern duties. He is often 5-10 minutes late for sign out rounds and team rounding. He always shows up to team rounds with a cup of coffee that he bought from the cafeteria. The whole team usually waits for him before starting rounds, but given how often it was happening, the resident has resorted to starting rounds without him today. When asked why he was late, he says that he was running late rounding and he had some sick patients. Aside from his clinical work, he also shows up at least 5-10 minutes late for conferences including ambulatory conferences usually with a coffee in hand. He takes good care of his patients and is clinically strong. Intern A is routinely late in filling out his duty hours and handling other credentialing paperwork. He also not respond to reminders to fill out duty hours and usually has to be paged by an APD or PD before he fills them out. The office staff are frustrated with him and want something done. When they asked him to fill out the paperwork, he reports that he is too busy caring for patients. How would you handle this case? Who would you involve in managing this case? Case 2 A senior resident who has been a solid and hard-working resident has started to look more haggard recently. She is quiet by nature but has been less interactive recently with colleagues. One of the APDs who was a ward attending for her as an intern asked her how she was doing in passing. She replied that she was dealing with a lot of things and was in a tough place. Through some investigation you find out that she has been providing good patient care but she has been breaking duty hours by 1-2 hours each day over her last 2 ward rotations. She has been more short tempered and has been noted to get into a few arguments with nursing staff and orthopedics consult team. You have a meeting with her where she reports that she states that she feels sad and stressed. Her grandmother, who she was close to, recently passed away. She was able to attend the funeral, but she feels guilty that she was not to see her before she died. She is also a lot of stress as she cannot figure out if she should apply for a fellowship or work as a hospitalist. What professionalism issues does this case bring up? How do you handle this case? What institutional/local/regional resources are available for a case like this?

26 Case 3 A junior resident in your program has started to have issues on the wards. He is showing up late for rounds and often does not know his patient s well. He always dressed on the casual side as an intern but has now started to appear more haggard appearing. He missed 2 continuity clinics in the last month as he called out sick, both on Monday mornings. His current ward attending came into your office to discuss his performance as he was concerned. The attending feels that the resident is having significant issues including not knowing the patients on the team, disappearing for a few hours a day, and does not seem engaged in the team dynamics or in patient care. He also notes that his personality has changed and he has become more withdrawn. You meet with the resident and he assures you that he is just under a lot of stress at home and that he ll be more attentive to his patients. For several weeks his performance improves. He then misses a random Saturday admitting shift, and was unable to be reached for several hours. When he was located he stated he forgot about the shift and was in a nearby city but unable to present for the rest of his shift. The following Monday you receive a call from his ambulatory attending that when he arrived in clinic that morning she thought she smelled alcohol on his breath, and his eyes were bloodshot. When she asked him about it he blamed it on his mouthwash. She sent him home and called you. You setup an urgent meeting with the resident where he continues to deny having any issues aside from stress outside of work. His father is ill and he has been expected to manage the care planning as he is the only child in the medical profession. You are concerned about the alcohol accusation and specifically ask about drugs or alcohol, which he denies. What can you do in this case as you have suspicions of alcohol/drug abuse but no confirmation? At what point do you mandate a fitness for duty evaluation? Can you mandate this? Can you encourage/mandate him take FMLA until his outside stressors are resolved? What if he comes to work smelling of alcohol again? What is the protocol at your institution to deal with employees under the influence at work? At what point do you need to refer him to the medical board?

27 Case 4 A junior resident posts on Facebook about her experience with one patient on a recent ward rotation. No patient identifiers were used in the initial post. There were multiple subsequent posts by the resident along with comments from fellow residents which added to the description of the patient admission. Nursing staff brought the issue up with the administration as they felt HIPAA had been compromised as many providers were able to tell who the patient was from the string of conversation. The junior also uses Facebook to complain about other services such as I hate orthopedic residents, they forget all their medicine, dump on medicine, and fight all the consults we put in. What lapses in professionalism do you identify in this case? What is appropriate to post on sites like Facebook? How would you approach this case? Case 5 The chief residents are contacted regarding one of the junior residents who has had issues in the clinic. He has not been responding to pages from the clinic or EMR sent messages which has frustrated the clinic staff. He was sent a message about a form for housing that one patient delivered to the clinic. He has gotten feedback from his clinic preceptors that he needs to be more responsive. However, in a few weeks another issue comes up. After multiple pages and messages in the EMR, he finally responded the administrator who handles the clinic forms with a rude and obnoxious saying that the patient was crazy. He has also had issues where he has blocked some admissions with some questionable interpretations of the admitting rules. He has a general impression within the residency of being lazy and too casual at times. He does provide good care of his patients. After a string of complaints, a letter of concern is drafted by the CCC and the resident is called into to meet with his advisor. He refuses to take the letter of concern stating that all the reported instances were not his fault for various reasons. The advisor feels strongly that he is not responding to feedback. He also does not feel that he has any issues with communication skills. After discussion with him you assess that he is not burned out and does not have other underlying issues such as depression, drug use etc. How do you manage this case? How would you fill out his reporting milestones? If he was applying for a fellowship, what if anything would put in his letter regarding professionalism? If you are called by an attending who is evaluating him as an applicant for a job or fellowship position, how would you describe him?

28 EXTRA CASES Resident A is a 2 nd year resident who was invited to a co-intern s wedding in the spring. The Wedding happens to fall on a weekend when she is working on the wards. Resident A has already used her two personal days to hang out with friends. She has tried to get coverage for the wedding days but could not find someone to cover her. On the Friday before the wedding, she pages the chief residents and tells them that she is horribly sick and will need coverage for the next few days. Emergency coverage is called in and another resident covers for Resident A. Resident A attends the wedding including the prewedding rehearsal dinner. Resident A posts pictures of herself at the wedding and at the rehearsal dinner on Facebook and twitter. Several other co-residents are also at the wedding and tag her in pictures they take on Facebook and Instagram. You see these posts online and the resident that was called in to cover for Resident A is also aware of these posts. An intern on a ward team is having issues with worsening of his asthma. The intern does not have a primary care doctor in his current city but has been to the emergency department for a needle stick exposure. He asks his junior resident for a few prescriptions including a prednisone burst and albuterol refill. The resident has not cared for the intern in his clinic or other clinical setting. However, the ward team is busy and the junior resident feels that it is easier to write the prescriptions as opposed to the intern setting up a primary care doctor appointment. The Junior resident access the EMR and writes the prescriptions for the intern. Intern B is well known for his love of technology. He has the latest tablets and smartphone. During rounds he often looks up clinical questions that come up during rounds. Intern B also uses his phone to text his friends during team rounds when the medical student or his co-intern is presenting. He has even texted at times while in a patient room. These texts are almost always unrelated to patient care. He also texts constantly during large conferences and small group (10-12 people) conferences A few medical students have approached you as a chief residents to discuss an issue with all the residents on the ward team. The resident and 2 interns on the team are all applying for specialty fellowships. One day during some down time the residents asked the students what they wanted to do for careers. One of the students voiced an interest in primary care was told you are too smart to go into primary care. Another student expressed a possible interest in general surgery and was told in response surgeons are and work way too hard. The team also makes jokes about other services such as the emergency department and psychiatry services.

29 Intern D is a hard working intern and prides herself in excellent patient care. She has issues maintaining duty hours. She has worked more than 80 hours on multiple rotations and almost never has 10 hours off between shifts. She feels it is difficult to leave work before all the work is done. She feels that it is her duty to complete all the assigned work. However, she has started to burn out and the lack of sleep has started to affect her. She has noted that she forgets to do things or small details in patient care. It is 6 PM and she is about to leave for the day, when her patient tells the nurse she has a headache. She reports that her headache is the worst headache of her life. Intern D and her resident evaluate the patient and order a STAT CT. The CT is performed and reveals a sub-arachnoid hemorrhage. Neurosurgery and neuro-interventional radiology are both consulted. Eventually the patient is transferred to neurosurgery for a planned urgent surgery. She leaves the hospital, after midnight, once the patient is stabilized and transferred. Intern D comes back to work at 6:30 in the morning. Her Attending tells her good job when he hears about the work she did the night before. When filling out her duty hours, she realizes that she spent less than 10 hours between shifts. She felt bad about having her resident or co-intern cover for her. She thinks about lying about her duty hours.