“The Black Swan ” - Identifying and
Dealing with the Student Destined for
the Back of the College Quarterly
Masters Teacher Program UBC SMP
Dr. Michael Murray MD CCFP(EM) MHSc CHE
Executive Medical Director Quality and CMIO
Objectives
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Provide a better understanding of disruptive
professional behaviour and the impact of this
behaviour on patient care
Describe how professional behaviour is guided from
legislation to rules and policies
Provide an organizational approach for management
of unprofessional behaviour
Identifying early warning signs in medical students
Discuss what we can do to identify and help trainees
A model of professional behaviour?
Increased public attention to an age old problem
Is the problem the culture in medicine?
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http://www.youtube.com/watch?v=PfH5cC62EWg
In pairs can you talk about this
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Were you ever the recipient of disruptive behaviour?
How did you feel?
How did you deal with it?
Does it still impact you today?
Take 5 minutes
The silver lining
What does disruptive behaviour look like?
Can you think of examples of what you would
consider unprofessional behaviours?
What is disruptive physician behaviour?
http://www.youtube.com/watch?v=HrouVnTXHAQ
0:51
start
Not all behaviours are unprofessional
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healthy criticism offered in good faith with the
intention of improving patient care or facilities,
making a complaint to an outside agency,
or good faith patient advocacy
Many underlying causes of unprofessional and
disruptive behavior
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Substance abuse, mental health illness, psychological
issues;
• chronic or acute family/home problems;
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Perfectionism in the profession ( with inappropriate
responses when things don’t go perfectly),
Narcissism or selfishness;
Poorly controlled anger—especially under
heightened stress
ACPE 2004 Physician Behaviour Survey
Is it one or many?
But, how common is this problem?
How often do you think this behaviour occurs?
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A few times a year
Once a month
Once a week
Once a day
But, how common is this problem?
-what physicians say
But, how common is this problem?
-what nurses say
Physician abuse of nurses is common,
64% of nurses reporting that they experienced some
form of verbal abuse from a physician at least once
every 2 to 3 months
(Diaz & McMillin, 1991)
Why are we now paying attention to
unprofessional behaviour? –impact on culture
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Increasingly, healthcare organizations are devoting
efforts to creating a culture of safety
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Such behaviours destroy the environment for
creating a safety culture
Why are we now paying attention to
unprofessional behaviour?– impact on
communication and teamwork
J Am Coll Surg 2006;203:96–105
Why are we now paying attention to
unprofessional behaviour?– impact on patient
care
17% reported that an adverse event occurred as a
result of disruptive behavior
(Rosenstein &O'Daniel, 2005).
Why are we now paying attention to
unprofessional behaviour? – the CMPA
“There is interest in the healthcare community to
address the issue of disruptive behaviour,” stated Dr.
John Gray, CEO of the CMPA.
“ a lot of money…, your money as CMPA members is
being used to defend physicians… and often
unsuccessfully”
Why are we now paying attention to
unprofessional behaviour? What do physicians
think?
ACPE White Paper May 2011
What tools do we have to guide physician
behaviour?
Why does unprofessional behaviour persist ?
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It is frequently ignored or tolerated
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those responsible for addressing the behavior find it
to be a difficult and unpleasant task
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organizational approaches often prove to be
inadequate to solve the problem
(Leape & Fromson, 2006; Weber, 2004)
How have organizations approached this?
the "fly swatter“ approach,
the "sledgehammer" approach
The result
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reports of subtle intimidation, disrespect, and non
responsiveness to patient needs — the most
common of disruptive behaviors — are ignored or
tolerated
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until patient injury occurs, at which time the most
extreme forms of discipline are undertaken
(Leape & Fromson, 2006).
What should organizations do?
Show commitment
What should organizations do?
Show commitment
Establish a code of conduct
What should organizations do?
Show commitment
Establish a code of conduct
Expeditiously resolve any disruptive behavior
What should organizations do?
Show commitment
Establish a code of conduct
Expeditiously resolve any disruptive behavior
Adopt a staged approach to managing disruptive
behaviour
Vanderbilt University School of Medicine
What does disruptive behaviour look like
in learners? Is there any difference
between medical students and residents?
Can you think of examples of what you would
consider unprofessional behaviours in medical
students and residents?
In pairs take 5 minutes to discuss this
Can we identify the student destined for the
back of the College Quarterly?
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maybe
Can we identify medical students at risk?
Can we identify medical students at risk?
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A case–control study
investigating the association of disciplinary
action against practicing physicians with prior
unprofessional behavior in medical school.
Can we identify medical students at risk?
Disciplinary action by a medical board was strongly
associated with:
• prior unprofessional behavior in medical school
(odds ratio, 3.0; 95 % CI)
• with low scores on the Medical College Admission
Test and poor grades in the first two years of
medical school
Can we identify medical students at risk?
Examples of unprofessional behavior exhibited
while in medical school:
• irresponsibility,
• diminished capacity for self-improvement,
• poor initiative,
What are these behaviours?
Examples of irresponsibility were:
• unreliable attendance at clinic and
• not following up on activities related to patient care
What are these behaviours?
Examples of diminished capacity for selfimprovement were:
• failure to accept constructive criticism,
• argumentativeness, and
• display of a poor attitude
What are these behaviours?
Poor initiative was characterized by
• a lack of motivation or enthusiasm or by
• passivity
What are other behaviours?
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impaired relationships with students, residents, faculty,
and nurses
unprofessional behavior associated with being anxious,
insecure, or nervous
Are residents different?
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Are residents disruptive behaviours different than
physician disruptive behaviours?
Can we identify trainees at risk?
There may be better identification of unprofessional
behavior in medical school that can best be
identified with the use of multidimensional
assessments :
• 360-degree multisource feedback — i.e., from peers,
patients, and coworkers
Can we help trainees at risk?
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Standardized instruments should be implemented
that assess the personal qualities of medical
school applicants and that predict early medical
school performance
Can we help trainees at risk?
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Improved systems of evaluation are needed to
monitor the development of professional
behavior and to document deficiencies
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Professionalism can and must be taught and
modeled.
Can we help trainees at risk?
Providing students and residents with
feedback that is guided by evidence may motivate
and direct remediation strategies
What are the implications for learners?
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For many of us, this is behavior we may have
experienced, and for others learned from abusive
instructors in medical school and residency training
Advice for teachers
“Model the behaviour that you want to inspire”
Questions?
Case study
A medical student leaves a conference to attend her weekly clinic. As she enters the clinic, she observes an “event” involving an upper‐level resident, the clinic receptionist, and a family. The family later reports the event to the medical center’s patient advocate or ombudsman. According to their complaint: The doctor my mom was to see entered the clinic acting agitated . . . talked down to the girl at the desk: ‘Answer my questions immediately with a yes or no . . . don’t need any extra conversation. . . . I’m here to see one of my patients.’ Receptionist replied, ‘it’s not a previous patient, but a new patient to be seen.’ Dr. became even more upset . . . “Sensing the doctor was in a hurry, I said we’re ready to be seen. Dr. whirled toward me, made a T sign with his hands and barked, ‘Time out! It’s not your turn to talk!’ Turning back to the receptionist, he demanded, ‘Who scheduled me a new patient today?’ “Dr. yelled in my direction so the whole area could hear, ‘You didn’t do anything wrong. The staff did! . . . I don’t see new clinic patients on Wednesdays . . . it will be months before you can be seen in my clinic.’ “Then he turned and left us standing there. I don’t think that was very professional.”
Case study
In this event the medical student ( but could be a peer resident or physician leader)
has several choices.
It is helpful to consider certain factors about each choice, namely (1) why a student
(or peer resident or physician leader) might choose it (the potential “pros”), and (2)
the down-side challenges associated with that choice (the potential “cons”).
1. Continue walking by;
2. Informally investigate by speaking with the resident before taking any action;
3. Approach the parties and offer assistance;
4. After deciding to help the patient or not, approach the resident directly and
indicate that his behavior is inappropriate regardless of the event(s) that precipitated
it;
5. After deciding to help the patient or not, follow up with the resident later in
private; or
6. Report the witnessed event to the attending or residency director.
Case study
Using this scenario what would you advise the
observer if they are:
1. A medical student
2. A resident
3. A house staff