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Study examines physician behaviors

Sep. 5, 2013, 9:56 AM

A study of 381 non-Vanderbilt physicians referred to the Vanderbilt Comprehensive Assessment Program (VCAP) in the Department of Psychiatry has shown that those referred for mental health, substance abuse and improper sexual boundary issues are less likely to receive a fit for duty recommendation than those referred for disruptive behavior.
VCAP has been doing fitness-for-duty assessments for professionals in crisis since 2001, recommending appropriate remediation strategies based upon a thorough independent evaluation, to enhance professionalism and restore them to practice.

The program has assessed more than 500 physicians from 37 states and four Canadian provinces.

The study of physicians evaluated between 2001-March 2012 was supported by a grant from the Vanderbilt Institute for Clinical and Translational Research and is available online ahead of publication in General Hospital Psychiatry.

“Ours is a forensic evaluation,” said A.J. Reid Finlayson, M.D., associate professor of Clinical Psychiatry. “We’re not providing treatment for these doctors, but we try to understand their behavior and recommend ways to help them practice safely and more effectively.

“This report is a beginning and we hope to evaluate what we are doing, but acquiring follow-up data can be challenging. To be honest, our subjects aren’t always entirely pleased at first with their reports, but the medical boards, hospitals and clinics that refer practitioners often rely upon independent, comprehensive evaluations to make administrative decisions.”

A multidisciplinary team of specialists in psychiatry, addiction, internal medicine, psychology, neuropsychology, sexual disorders, social work and nursing works closely with the client to explore and understand the issues underlying the behavior that is problematic. Occasionally, subspecialists in other Vanderbilt departments are enlisted for their input on clinical issues.

The outpatient assessment process takes place over two to four days. With consent, the team also gathers additional information about the physician from relevant third parties that may include the physician’s spouse, therapist, family members and colleagues.
“Our goal is to get the complete picture of the doctor as a person. It helps us make a very thorough assessment to determine what they need to change if they plan to improve their ability to practice professionally,” Finlayson said.

After the evaluation, a comprehensive report is generated that includes a diagnosis and recommendations, if appropriate, which are made to improve the health and well-being of the doctor and to enhance their professional practice.

Finlayson said that VCAP referrals most often originate from state physician health programs and are more likely to be middle-aged, white males who received their training in the United States. The single most common reason for referral was disruptive behavior, such as exhibiting threatening, intimidating or demeaning behavior to patients or staff.
“Far from lacking knowledge or skill, disruptive physicians are often well-respected surgeons, internists, gynecologists or other specialists. But their dysfunctional or inappropriate interactions with others around them, often happening under stress, may interfere with the optimal clinical outcome. Our hope, by using a thorough evaluation to tailor appropriate recommendations, is that we can facilitate more effective leadership and professional practice,” Finlayson said.

Program manager Ron Neufeld, a social worker and licensed addiction counselor, said VCAP has seen an increase in the referral of physicians exhibiting disruptive behavior.
In 2008, The Joint Commission, which accredits and certifies more than 20,000 health care organizations and programs in the United States, issued guidelines to create a “culture of safety” in health care organizations. Since then, responsibility for physician conduct has shifted from self-governance by the profession itself toward the institutions where physicians are employed or practice.

This change in the culture of health care delivery and the evolving role of the physician’s role are reflected in curriculum changes at medical schools such as Vanderbilt’s, Finlayson said.

“We’re now teaching doctors to work on teams and promoting the effective leadership skills necessary when stakes are high and things go wrong, as they sometimes do,” he said.
“But the most important finding in our research, so far, is that those physicians who behave badly can often be restored to full practice with appropriate management rather than discarded. So much is invested in training physicians that society cannot afford to discard them if at all possible.”

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