William Swiggart, MS, LPC/MHSP
Associate in Medicine
Co-Director
Vanderbilt Center for Professional Health
www.mc.vanderbilt.edu/cph
October 22, 2011
Continuing Medical Education
Courses
Maintaining Proper Boundaries
Prescribing Controlled Drugs
Program for Distressed Physicians
©
©
©
Provide learners with information about
sexual boundaries and sexual misconduct
in medicine, and expose them to a
preventative educational program that
addresses these issues.
1.
2.
3.
4.
Instruct participants on the general definitions,
rules and guidelines around professional
conduct regarding professional boundaries and
sexual misconduct in the medical profession;
make physicians aware of their own
vulnerabilities,
help physicians understand how to prevent
sexual boundary crossings, and
stimulate reflection on current and future
professional practice behaviors.

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List the levels of sexual misconduct.
Define sexual harassment.
Compare and contrast the types of sexual
misconduct as defined by the Federation of
State Medical Boards (FSMB).
Identify three main risk behaviors for sexual
misconduct based on various issues like selfwellness, stress, social behaviors, and medical
cultures.
Identify five behaviors on the slippery slope.
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Identify three preventive measures to avoid sexual
misconduct.
Practice phrases to help define professional
boundaries.
Describe the professional obligations for reporting
sexual misconduct.
Develop an individual action plan to set proper
boundaries in your office.
Hazardous
Affairs
DVD Observation 1 – Sexual Harassment
1. What behaviors did the doctor portray
that resulted in the accusation of sexual
harassment?
2. How did his behavior create a hostile
work environment?
3. What action would you take if you were
his superior/supervisor/department
head?
DVD Observation 2 – Doctor-Patient
1. What type of misconduct occurred?
2. How did Dr. James set himself up for
this sexual boundary crossing?
Late appointments with no chaperone
Business transactions/dual relationships
Excessive physician self-disclosure
Some forms of language use
Personal gifts
Special favors
Flirting, jokes etc.
Grooming behavior
Casual workplace
DVD Observation 3 – Teacher-Student
1. Identify five slippery slope behaviors.
2. How does the power differential
come into play in this scenario?
1. D - In most situations, dating a patient will be
viewed as wrong. Even if the relationship is
mutual and doing well. The power differential
makes dating a patient wrong because the patient
cannot give appropriate informed consent. The
physician will be held accountable.
2. F - Dr K should NOT accept this invitation and should
restate the general policy that doctors cannot date
patients. Dr K is vulnerable and doesn’t know the
intentions of the patient asking. This could be a set
up.
3. A - Correct answer is 2: Sexual impropriety
and sexual violations.
4. B - This is an example of sexual
impropriety. Impropriety is usually
gestures, behaviors or expressions that are
seductive, reflecting lack of respect for the
patient’s privacy. Contrasting impropriety
with violations – violations most often
include physical contact or a behavior
resulting from pressure to perform sexual
acts for favors.
5. C - Grooming is a slippery slope behavior.
It is when patients or others attempt to
adjust your clothing, hair, jewelry, etc.
6. F - None of these options are true. Doctors,
especially psychiatrist, are not supposed to
engage in relationships with patients. There
are other individuals who can show you the
town. Patients can give you information and
advice about your new town but allowing
them to “take you out and show you the town”
is not acceptable and puts you at risk of
being investigated by your medical board.
7. D - Once you prescribe medications to
your partner you entered the doctor-patient
relationship. Thus you are now having a
sexual relationship with your patient. While
giving a small amount may be seen as
reasonable if you were covering this patient
over the weekend, the key point is you
prescribed a controlled substance for a
patient with whom you are engaged in a
sexual relationship.
8. E - All of the above are examples of the
power differential. In each example there is
an obvious hierarchy.
9. A - In every situation, the physician will
always be held responsible for crossing
a sexual boundary and committing an
act of sexual impropriety or violation.
10. A - Sexual violations usually involve a
form of physical contact. Kissing,
intercourse, touching of sexualized
body parts, encouraging masturbation
or exchanging medical care, drugs, etc.
for sexual favors is a sexual violation.
11. C - This question is appropriate for
anyone in an academic teaching facility
where medical students are involved. The
correct answer is C – sexual impropriety.
The patient must give informed consent
for medical students to witness or
perform sensitive genitourinary exams.
12. B - Performing a genital exam without
the use of gloves is considered a sexual
impropriety.
13. C - In this item, clearly joking around
and flirting is certainly risky
unprofessional behavior. But if touch is
involved – boundaries are being
crossed. When individual team
members feel unsafe or that their
rights have been infringed upon due to
repeated acts this becomes a “hostile
or offensive work environment” and is
sexual harassment.
14. C - This is sexual harassment. This is a
very important point – even if the
comment was targeted at another
individual, meaning the recipient was not
the intended target, it is still considered
harassment if that person was offended.
Thus keeping unprofessional specific
comments to oneself is the best course of
action or limit conversations to the
intended party only.
15. A - You must formally discharge a patient;
meaning written documentation. However,
the power differential or the knowledge,
emotions or influence you possess over this
individual may be considered unethical as it
still gives you power over that individual. In
psychiatry – the once a pt always a patient
may hold true as well.
16. E - The best option for this scenario is call
to check on the pt, develop a plan and then
educate the pt on the proper ways to contact
their providers as well as reinforcing the
general rules against using personal emails.
 No: 584
 Gender:
Males 95%
Females 5%
 Age range: 31-80
 Mean age: 49.5 yrs.
 Ethnic Origin: 78% Caucasian; 10%
African Americans, 9% Asian and 4%
Hispanic

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
Family Practice/GP 28%
Internal Medicine 10%
Med. Specialty 6%
Surgery Specialty 9%
General Surgery 4%
OB/Gyn 7%
Psychiatry 10%
Other 26*
* anesthesiology, neurology, emergency, dentist
 Board
of Medical Examiners
 Physician Health Program
 Treatment Center
 Self Referral
 Complaints
from patients, family
members, nurses
 Affair with patient, office nurse/staff
 Flirting
 Cybersex
Date someone you
supervise such as
office staff, i.e., nurse,
secretary, a resident or
intern.
If someone objects to
your sexual jokes or
flirting assume it is their
problem. You can say
anything you want to.
Prescribe scheduled
drugs or operate on
someone with whom
you are sexually
involved.
Use the hospital or
office computer to
view or download
pornography.
Avoid even the appearance
of professional boundaries
in regards to dress,
language and behavior in
the office.
Make comments about
your patient’s
underclothing, e.g.
“how pretty” or “where
did you buy that?”
Tell stories about your
own sexual life. This
will certainly impress
your patients and make
them feel more at ease
during the breast
exam.
Be present when your
patient is disrobing and
offer to help with those
hard to reach items.
Don’t use a chaperone in
your office. They only
make the patient
uncomfortable.
Accept offers to meet
after-hours from your
patients even if it is
just for coffee or a
meal.
Flood your life with
work, long hours, and
ignore your personal
needs. A lack of
balance between
professional and
personal life are setups for problems.
Disregard your own
emotional life and any
past trauma you may
have experienced which
impacts you today.
Stress, lack of balance
between professional
and personal life are setups for problems.
Ignore state, federal
and professional
guidelines regarding
sexual harassment,
sexual impropriety and
sexual misconduct.
3%
10%
954,224 physicians currently in
practice
Swiggart, W., K. Starr, et al. (2002). Sexual boundaries and physicians: overview
and educational approach to the problem. Sexual Addiction & Compulsivity 9:
139-148.
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Psychiatry once a patient always a patient
Primary Care
Surgeon
Pediatrician patient surrogate
Anesthesiology
Rheumatology ????
 The
physician holds the balance of power over
patients, staff and students.
 Mutual consent is not recognized as a defense
for the physician.
 Patient and physician emotional vulnerabilities
are at the core of boundary violations.
 Self care by the physician is critical to prevent
hazardous romantic relationships.
 Physicians
lack training in the complexity
of sexual boundary misconduct.
 An educational approach can resolve
most of the problem.
 A pre-emptive approach is better than a
post-violation intervention.
 The process is complaint generated.
Courses
N
Ave Age
Sex
Distressed
99
49
Boundaries
710
50
5% F
95% M
Prescribing
828
51
13% F
87% M
Total
11% F 89% M
1637
Distressed
Boundaries
Prescribing
IM subspecialties*
IM/FP
IM/FM
IM/FM
Psychiatry
Psychiatry
OB/GYN
Surgery
Surgery
Surgery
OB/GYN
ER
*(interventionalists)
Last Updated October 2011
Vanderbilt Center
for
Professional Health
Continuing Medical Education Courses
Prescribing Controlled Drugs©
Maintaining Proper Boundaries©
Program for Distressed Physicians©
Give learners an overview of
disruptive/distressed behavior and
provide resources for interventions.
 Joint
Commission requirements
 Examples of disruptive behavior
 Impact of disruptive behavior
 Etiology of disruptive behavior
 Describe an educational approach
 Identify some appropriate resources
“Physicians are often poorly socialized
and enter medical school with inadequate
social skills for practice.”
“There is a growing body of literature
documenting that residency programs do not
prepare resident physicians adequately for
the practice of medicine.”
 Defined
disruptive behavior as a Sentinel
Event
 Recognition that disruptive behavior can:
Foster medical errors
Contribute to poor patient satisfaction
Contribute to preventable adverse outcomes
Increase the cost of care (including malpractice)
Lead to turnover/loss of qualified medical staff
Defined by The Joint Commission as:
“Any unanticipated event in a healthcare
setting resulting in death or serious physical
injury or psychological injury to a person or
persons not related to the natural course of
the patient’s illness.”
Goal of including Disruptive Behavior as a
Sentinel Event:
Reform health care settings to address the
problem
There is a history of tolerance and indifference
Promote a culture of safety
Improve the quality of patient care by improving
the communication and collaboration of health
care teams
 Hospitals
establish a formal Code of
Conduct
 Leadership creates a process for
reporting, evaluating and managing
disruptive behavior
 Educate
all team members about
professionalism
 Hold all team members accountable for
modeling desirable behaviors
 Enforce the code consistently and
equitably
 Non-confrontational intervention
strategies
 Progressive discipline
Disruptive behavior includes, but is not limited to, words or
actions that:
 Prevent or interfere w/an individual’s or group’s work, academic
performance, or ability to achieve intended outcomes (e.g.
intentionally ignoring questions or not returning phone calls or pages
related to matters involving patient care, or publicly criticizing other
members of the team or the institution);
 Create, or have the potential to create, an intimidating, hostile,
offensive, or potentially unsafe work or academic environment (e.g.
verbal abuse, sexual or other harassment, threatening or intimidating
words, or words reasonably interpreted as threatening or
intimidating);
 Threaten personal or group safety, such as aggressive or violent
physical actions;
 Violate Vanderbilt University and/or VUMC policies, including those
related to conflicts of interest and compliance.
Vanderbilt University and Medical Center Policy #HR-027, 2010
57
58
Spectrum of Disruptive
Behaviors
Aggressive
Anger Outbursts
Profane/Disrespectful
Language
Throwing Objects
Demeaning Behavior
Physical Aggression
Sexual Comments or
Harassment
Racial/Ethnic
Jokes
Passive
Passive
Aggressive
Chronically late
Derogatory
comments about
institution,
hospital, group,
etc.
Alcohol and other
drugs
Refusing to do
tasks
Inappropriate or
inadequate chart
notes
Not responding
to call
Dr. A is a 40 year old anesthesiologist
referred for evaluation following several
angry outbursts in his hospital’s OR. The
most egregious (and final) outburst
involved his threatening to shoot one of
his OR staff. Although he reportedly
immediately told staff that he wasn’t
serious about the threat, a complaint was
filed because he was commonly known to
have an extensive gun collection at his
home, and this staff member lived in the
same neighborhood.
Dr. B reported that he was chronically fatigued and
had been working at nearly twice his normal
workload in the three months prior to his
assessment. In addition, he reported several
incidents involving his anger while in
undergraduate school, medical school and
residency. He reported no use of medications, and
no prior treatment for anger management, except
for referral to a psychiatrist over the course of a
semester while in school.
“RN did not call MD about change in patient
condition because he had a history of being
abusive when called. Patient suffered
because of this.”
Rosenstein, A., O’Daniel, M. Impact and Implications of Disruptive Behavior in the Perioperative Arena. J
Am Coll Surg. 2006;203:96-105.
“___ came late to the meeting, then spent
remaining time on a Blackberry… didn’t
listen to the discussion”
“___ doesn’t exactly say anything you could
object to, but always rolls eyes and makes
faces in meetings… not helpful…later
mocks the discussion…disputes wisdom of
decisions”
And Increasingly Common
“___ writes an online Blog with implied
criticisms of some of our units”
“___ (resident) puts feelings about patients
on Facebook - unnamed, but potentially
identifiable”
63
 Perceptions
of inequality when members
of the team compare their contributions
to those of the disruptive member (Kulik &
Ambrose, 1992)
 Some
team members will decrease their
contributions, withdraw (Schroeder et al, 2003;
Pearson & Porath, 2005)
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and
dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
 Team
members may adopt disruptive
person’s negative mood/anger (Dimberg &
Ohman, 1996)
 Lessened
trust among team members
can lead to lessened task performance
(always monitoring disruptive person)...
effects quality and pt safety (Lewicki &
Bunker, 1995; Wageman, 2000)
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and
dysfunctional groups. Research and Organizational Behavior, Volume 27, 175-222.
 High
turnover
Pearson et al, 2000 found that 50% of people
who were targets of disruptive behavior thought
about leaving their jobs
Found that 12% of people actually quit
 These
results indicate a negative effect
on return on investment
Felps, W et al. 2006. How, when, and why bad apples spoil the barrel: negative group members and dysfunctional
groups. Research and Organizational Behavior, Volume 27, 175-222.
Failure to Address Disruptive
Conduct Leads to:

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
disharmony and poor morale1,
staff turnover2,
incomplete and dysfunctional communication1,
heightened financial risk and litigation3,
reduced self-esteem among staff1,
reduced public image of hospital1,
financial cost1,
unhealthy and dysfunctional work environment1,
and potentially poor quality of care1,2,3
1. Piper, 2000
2. Rosenstein, 2002
3. Hickson, 2002
Communication breakdown factored in OR
errors 50% of the time2
 Communication mishaps were associated
with 30% of adverse events in OBGYN3
 Communication failures contributed to
91% of adverse events involving residents4

Gerald B. Hickson, MD
James W. Pichert, PhD
Center for Patient & Professional Advocacy
Vanderbilt University School of Medicine
1. Dayton et al, J Qual & Patient Saf 2007; 33:34-44. 3. White et al, Obstet Gynecol 2005; 105(5 Pt1):1031-1038.
2. Gewande et al, Surgery 2003; 133: 614-621.
4. Lingard et al, Qual Saf Health Care 2004; 13: 330-334

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
fear
confusion or uncertainty
vengeance vs. those who
oppose/oppress them
hurt ego/pride
grief (denial, anger,
bargaining)
apathy
burnout
unhealthy peer pressure





ignorance (expectations,
behav. standards, rules,
protocols, chain of
command, standards of
care)
distrust of leaders
dropout: early retirement
or relocation
errors
disruptive behavior
begets disruptive
behavior
Vanderbilt University and Medical Center Policy #HR-027
Etiologies
Why Might a Medical
Professional Behave in Ways
that are Disruptive?
1. Substance abuse, psych issues
2. Narcissism, perfectionism
3. Spillover of family/home problems
4. Poorly controlled anger (2° emotion)/Snaps
under heightened stress, perhaps due to:
a. Poor clinical/administrative/systems
support
b. Poor mgmt skills, dept out of control
c. Back biters create poor practice
environments
©CPPA, 2008
5. Well, it seems to work pretty well
6. No one addressed it earlier (why? See #5)
7. Family of origin issues—guilt and shame
8.
9.
©CPPA, 2008
The external system
Functional &
nurturing
The internal system
Hospital/Clinic
Physician
Dysfunctional
Good skills
Poor skills
“The Perfect Storm”
"Every system is perfectly
designed to get the results it
gets.”
BW Williams to accompany a talk delivered
at the FSPHP Spring Meeting 2010
Individual Factors
• Predisposing Psychological Factors (1)
 Alcohol and Drug Family History
 Trauma History
 Religious Fundamentalism
 Familial High Achievement, lack of skills regarding conflict
and negotiation and other family of origin patterns
• Personality Traits (2)
 Narcissism
 Obsessive/Compulsive
• Physician Burnout (3)
• Clinical Skills Satisfactory or Above Average (4)
1.
3.
Valliant, 1972
Spickard and Gabbe, 2002
2.
4.
Gabbard, 1985
Papadakis, 2004, 2005
Institutional Factors (1)
Scapegoats
System Reinforces Behavior
Individual Pathology may over-shadow
institutional pathology
Williams and Williams, 2004
Methods to Address
Behavioral Problems
Mr. Bangsiding felt (and wrongly so) that a little chat
would be enough to stop Bob’s disruptive behavior.
 The
role of a comprehensive evaluation
 The importance of consequences
 Educational programs
 Feedback from colleagues, patients, staff,
etc.
 Monitoring and accountability
 External resources
 APA
guidelines for Fitness for Duty
Evaluations
 Multidisciplinary: 1-5 days
Medical
Psychiatric evaluation
Psychological testing
Psychosocial including genogram
Addiction screening
Collateral information
 Comprehensive report with
recommendations
 Monitoring
contracts need to be flexible
 360 evaluations are imperative for
monitoring and to see how the
professional is progressing
 Not all can be helped or saved
 Intensive small group CME with
monitoring works for many
Components:
 Phone
interview
 Three-day CME course (47.5 AMA PRA
Category 1 Credits ™)
 Teach Specific tools/skills - e.g., grounding
skills, Alter, communication strategies
 Three follow-up sessions with the core group
over the next six months; importance of
group process
“ This means you feel so stressed that you become
emotionally and physically overwhelmed…”
“Pounding heart, sweaty hands, and shallow
breathing.”
“When you’re in this state of mind…you are not
capable of hearing new information or accepting
influence.”
*John M. Gottman, Ph.D. The Relationship Cure, Crown Publishers, New York, 2001, 74-78.
GROUNDING
 Categories
exercise
 Judge versus describe
 Mindfulness with all senses
 Breathe
SELF-TEST: FLOODING
1.
At times, when I get angry I feel confused.
Yes
No
2.
My discussions get far too heated.
Yes
No
3.
I have a hard time calming down when I discuss disagreements.
Yes
No
4.
I’m worried that I will say something I will regret.
Yes
No
5.
I get far more upset than is necessary.
Yes
No
6.
After a conflict I want to keep away or isolate for a while.
Yes No
7.
There’s no need to raise my voice the way I do in a discussion.
Yes
No
8.
It really is overwhelming when a conflict gets going.
Yes
No
9.
I can’t think straight when I get so negative.
Yes
No
10.
I think, “Why can’t we talk things out logically?”
Yes
No
John M. Gottman, All Rights Reserved (revised 11/17/03)
11.
My negative moods come out of nowhere.
Yes
No
12.
When my temper gets going there is no stopping it.
Yes
No
13.
I feel cold and empty after a conflict.
Yes
No
14.
When there is so much negativity I have difficulty focusing
my thoughts.
Yes
No
15.
Small issues suddenly become big ones for no apparent reason.
Yes
No
16.
I can never seem to soothe myself after a conflict.
Yes
No
17.
Sometimes I think that my moods are just crazy.
Yes
No
18.
Things get out of hand quickly in discussions.
Yes
No
19.
20.
My feelings are very easily hurt
When I get negative, stopping it is like trying to stop an
oncoming truck.
Yes
No
Yes
No
21.
My negativity drags me down.
Yes
No
22.
I feel disorganized by all this negative emotion.
Yes
No
23.
I can never tell when a blowup is going to happen.
Yes
No
24.
When I have a conflict it takes a very long time before I feel
at ease again.
Yes
No
Flooding - Scoring
Scoring: If you answered “yes” to more than eight statements, this is a strong
sign that you are prone to feeling flooded during conflict. Because this state
can be harmful to you, it’s important to let others know how you are feeling.
The antidote to flooding is to practice soothing yourself.
There are four secrets of soothing yourself: breathing, relaxation, heaviness,
and warmth. The first secret is to get control of your breathing. When you are
getting flooded, you will find yourself either holding your breath a lot or
breathing shallowly. Change your breathing so it is even and you take deep
regular breaths. Take your time inhaling and exhaling. The second secret is to
find areas of tension in your body and first tense and then relax these muscle
groups. First, examine your face, particularly your forehead and jaw, then your
neck, shoulders, arms, and back. Let the tension flow out and start feeling
heavy. The secret is to meditate, focusing your attention on one calming vision
or idea. It can be a very specific place you go to that was once a very
comforting place, like a forest or a beach. Imagine this place as vividly as you
can as you calm yourself down. The fourth part is to imagine the body part
becoming warm.
John M. Gottman, All Rights Reserved (revised 11/17/03)
 Describe
an incident you are concerned about.
 Who was there?
 Pick someone to play you.
 A powerful cathartic exercise viewing their
behavior from multiple points of view.
 Example.
When asking for something,
use the acronym – DRAN
Describe
Reinforce
Assert
Negotiate
 Describe
the other person’s behavior
objectively
 Use concrete terms
 Describe a specified time, place &
frequency of action
 Describe the action, not the “motive”
 Recognize
the other person’s past efforts
 Express
your feelings
 Express them calmly
 State feelings in a positive manner
 Direct yourself to the offending behavior,
not the entire person’s character
 Ask explicitly for change in the other
person’s behavior
 Request
a small change at first
 Take into account whether the person
can meet you needs or goals
 Specify behaviors you are willing to
change
 Make consequences explicit
 Reward positive changes

If the physician is returned to the institution to
practice, it is necessary to ensure that the behavior
does not recur.
There is a significant level of recidivism
As high as 20% among “severe offenders” (Grant and
Alfred 2007)

Prior behavioral issues are a significant risk factor for
later disruption (Papadakis, Arnold, et. al. 2008)
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010
A
monitoring system that is under
development measures these issues using
a 360◦ survey.
 Early data show the survey to be well
tolerated and demonstrates face validity.
 The survey was developed to facilitate
integration with institutional systems.
BW Williams to accompany a talk delivered at the FSPHP Spring Meeting 2010

It is not enough to have good motives; others
respond to our behavior.

Physicians are often not given essential
feedback about their behavior.

The Team Behavior Survey (TBS) is designed to
provide feedback from those we work with.
© Swiggart, Williams, and Williams
 Communication
 Concern
for patients and families
 Accessibility and timeliness
 Work environment
 Ethical behavior
 Interpersonal behavior & respect for others
 Focus on medical tasks
 Ability to work with other members of the
medical team

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


Courses
Coaches,
counselors
Comprehensive
Evaluation
360° Evaluations
Risk Managers
Physician Wellness
Treatment Centers







Office of General Counsel
State BME
Professional Societies
QI Officers
EAP
Others
State Physician Health
Program
1.
2.
3.
There is a need to develop standard, model
policies for hospitals.
Information needs to be widely distributed to
hospitals and medical practices that this is
treatable, saves money, prevents malpractice
suits, and that early intervention is best.
Medical student and resident training cultivates
many of the disruptive behaviors as they learn
from their mentor’s behavior.
 Disruptive
behavior is a patient safety issue.
 State PHPs can be an extremely valuable
resource for both physicians and institutions.
 An objective, comprehensive assessment is
invaluable.
 It is important to understand the system’s
issues related to an individual’s behavior.
 Resources are available.
Please visit our website
http://www.mc.vanderbilt.edu