6. The Hippocratic Oath
(4th century BC)
I swear by Apollo, Asclepius, Hygieia, and
Panacea...
...I will not cut for stone, even for patients in
whom the disease is manifest...
Wednesday, March 18, 2009
7. Susruta Samhita, A.D. 300
A physician is to keep his nails
trimmed, his hair short, wear
clean white clothes and shoes and
carry an umbrella and a stick.
Any error in treatment causing
death would earn the physician
severe punishment from the king.
A negligent surgeon would lose
the limb with which he caused
the patient to lose his life.
Wednesday, March 18, 2009
8. In 1847, members of the newly
formed American Medical
Association, meeting in
Philadelphia, adopted the world’s
first national code of professional
ethics in medicine.
Wednesday, March 18, 2009
9. § 3. It is derogatory to the dignity of the profession, to resort to
public advertisements or private cards or handbills, inviting the
attention of individuals affected with particular diseases -publicly
offering advice and medicine to the poor gratis, or promising radical
cures or to publish cases and operations in the daily prints or suffer
such publications to be made ; -to invite, laymen to be present at
operations,-to boast of cures and remedies,-to adduce certificates of
skill and success, or to perform any other similar acts. These are the
ordinary practices of empirics, and are highly reprehensible in a
regular physician.
Wednesday, March 18, 2009
10. *
Principles of Medical Ethics
A physician shall uphold the standards of professionalism, be honest in all professional
interactions, and strive to report physicians deficient in character or competence, or
engaging in fraud or deception, to appropriate entities.
A physician shall respect the law.
A physician shall respect the rights of patients, colleagues, and other health professionals,
and shall safeguard patient confidences and privacy within the constraints of the law.
A physician shall, while caring for a patient, regard responsibility to the patient as
paramount.
Adopted by the AMA's House of Delegates June 17, 2001.
Wednesday, March 18, 2009
11. I will remember that there is art to medicine as well as science, and that
warmth, sympathy, and understanding may outweigh the surgeon's knife or the
chemist's drug.
I will not be ashamed to say quot;I know not,quot; nor will I fail to call in my colleagues
when their skills are needed...
I will remember that I do not treat a fever chart, or a cancerous growth, but a
sick human being...
I will remember that I remain a member of society, with special obligations to 1923-2003
all my fellow human beings...
Wednesday, March 18, 2009
13. Oakland, CA, March 26,
2006 — A neurosurgeon
was wrestled to the floor
by sheriff's deputies outside
the operating room after
he threw a fit because he
had to wait for instruments
to be sterilized. quot;I am a
[expletive] doctor, and I'm
going to do what I want.quot;
Wednesday, March 18, 2009
14. What is disruptive behavior?
• Profane or disrespectful language
• Name-calling
• Sexual comments or innuendo
• Inappropriate touching, sexual or otherwise
• Racial or ethnic jokes
• Outbursts of anger
• Throwing things
• Criticizing other caregivers in front of patients
or staff
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15. • Comments that undermine a patient's trust in
other caregivers or the hospital
• Comments that undermine a caregiver's self-
confidence in caring for patients
• Failure to adequately address safety concerns or
patient care needs expressed by another caregiver
• Intimidating behavior that has the effect of
suppressing input by other members of the
healthcare team
• Deliberate failure to adhere to organizational
policies without evidence to support the
alternative chosen
Wednesday, March 18, 2009
16. What drives disruptive behavior?
• Pressures of the clinical environment
• Health professional shortage
• Increased government oversight
• Intrusive managed care regulations
• Greater liability risks
• No more ‘Captain of the ship’
Wednesday, March 18, 2009
19. Twelve most annoying habits of therapists
1. Being late for appointments
2. Eating in front of a client
3. Yawning frequently in the session
4. T.M.I.
5. Being unreachable
6. Being distractible
Wednesday, March 18, 2009
20. Twelve most annoying habits of therapists
7. Expressing personal preferences
8. Pets
9. Hugging and physical contact
10. Inappropriate displays of wealth or dress
11. Clock watching
12. Excessive note-taking
Wednesday, March 18, 2009
22. •86 percent of nurses and 49 percent of physicians had
witnessed disruptive behavior
•94 percent believe disruptive behavior impacts adverse
events, medical errors, patient safety, patient mortality,
quality of care and patient satisfaction
• 60 percent of the respondents were aware of potential
adverse events
• 17 percent knew of a specific adverse event
• 78 percent of the respondents felt the adverse event
could have been prevented.
Wednesday, March 18, 2009
23. • 40 percent of hospital staff members reported having
been so intimidated by a doctor that they did not
report a possible medication error
• 7 percent said they contributed to a medication
error
• Disrespect is the most common
• Condescending language or intonation (88%),
impatience with questions (87%), and reluctance or
refusal to answer questions or phone calls (79%)
• Strong verbal abuse (48%), threatening body language
(43%), and physical abuse (4%)
Wednesday, March 18, 2009
24. Disruptive behavior problems almost always
involve conflict between a physician and a nurse,
physician's assistant, or other staff member and
rarely occur between physicians.
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25. Why doesn’t the system work?
• Fly-swatter approach
• Sledgehammer approach
• Many physicians complain that they
were not informed about problems
with their conduct until they faced
suspension (Leape & Fromson, 2006)
Wednesday, March 18, 2009
26. What needs to be done?
• Universal code of conduct
• Planned implementation
• Compliance monitoring
• Non-retaliation provisions
• Code enforcement
• Flexibility
• Oversight committee
• Preventive strategies
Wednesday, March 18, 2009
27. Code of Conduct
• Professional responsibilities and citizenship
• Commitment to clinical competence and
continuous improvement of care
• Commitment to advancing patient safety
• Commitment to honesty with patients
• Respect for confidentiality
• Professional relationships and behavior
• Maintaining trust by managing conflicts of interest
• Social justice
Wednesday, March 18, 2009
28. 8-SAFE
• Infractions of the code may be reported to
• Hospital administrator
• Chief of staff
• Human Resources
• Medical Affairs
• Safety
• Department Managers
Wednesday, March 18, 2009
29. References
• Rosenstein, A. H., & O'Daniel, M. (2005). Disruptive behavior and clinical outcomes: Perceptions of
nurses and physicians. American Journal of Nursing, 105, 1, 54-64.
• Rosenstein, A. H. (2002). Nurse-physician relationships: Impact on nurse satisfaction and retention.
American Journal of Nursing, 102, 6, 26-34. USA Today. (2006, April 18). p. 5D.
• Weber, D. O. (2004). Poll results: Doctors' disruptive behavior disturbs physician leaders. The Physician
Executive, 30, 4, 6-14.
• Code of conduct for psychologists (APA) http://www.apa.org/ethics/code2002.html
• Institute for Safe Medication Practices (ISMP). (2003). Survey on workplace intimidation. Available at
www.ismp.org.
• Leape, L. L., & Fromson, J. A. (2006). Problem doctors: Is there a system-level solution? Annals of
Internal Medicine, 144, 2, 107-115
• http://psychcentral.com/
• http://www.ama-assn.org/ama/no-index/physician-resources/2498.shtml
Wednesday, March 18, 2009
Dr. House. He’s rude, he’s cynical, he’s addicted to Vicodin. But who cares? He’s a genius, and thats all that matters.
is the most enduring tradition in Western medicine. The oath became the nucleus of all medical ethics. It emphasizes the profundity of the medical covenant, patient dignity, the confidentiality of the transaction, and the physician’s responsibility to guard against abuse or corruption of his knowledge and art.
1964
Loss of facility privileges, limited or lost privileges to practice medicine and even legal proceedings.
Brutal training, pimping
Doctors have traditionally held a position of relative power. Hospitals classify physicians as \"customers.\" Because \"the customer is always right,\" hospitals tolerated a wide variety of aberrant behavior, including resistance to standardization of supplies and equipment, refusal to comply with clinical policies and pathways, and so on. Physicians who generate high revenues for the hospital are often ‘indulged’, which has led to normalization of deviant behavior.
My appointments were at 1:00 p.m., and my therapist used my time EVERY week as her lunch hour, even though my binge eating was a major issue. I had a therapist who fell asleep during every session. It turns out she was actually taking too many pain pills after foot surgery, but I didn’t know that. I would be sharing intimate details of what was bothering me and look up and she would be sawing logs. How rude! Needless to say I stopped seeing her.
I had one therapist who seemed overly concerned with whether I liked her or not. She would frequently ask me if I liked her, how I felt about her, and she would give me small gifts. I was uncomfortable with it all. A lady dressed to the hilt with a load of large metal accessories like belts, earrings and bracelets–she clanked as she moved. Yikes! My therapist had 7 out of these 12 habits.
The study, titled “Disruptive Behavior & Clinical Outcomes: Perceptions of Nurses & Physicians,” was conducted by Alan H. Rosenstein. The study was initiated to assess perceptions of the impact of disruptive behavior on nurse-physician relationships and to determine its effects on patient care. Surveys were distributed to 50 VHA member hospitals in more than 12 states and results from more than 1,500 participants were evaluated.disruptive behavior affects nurses' and physicians' stress levels (94 percent), frustration levels (94 percent), concentration (83 percent), communication (92 percent), collaboration (90 percent), information transfer (87 percent) and workplace relationships (91 percent). Each of these psychological and behavioral variables can directly impact a patient's outcome.
Another survey by the Institute for Safe Medication Practices, a nonprofit organization.
Weber, 2004
many organizations try to rely on physician impairment committees that are designed to deal primarily with impaired physicians. Since most disruptive physicians are not impaired, this is often a poor fit.
1.JCAHO leadership standard now requires that every organization has a code of conduct, and that leaders implement a process for managing disruptive behaviors. Every staff member and physician must be notified of the adoption of the code and should receive a copy of the universal code of conduct together with training about the code and attendant behavioral expectations. Such training should include guidance about what to do in the event that he or she witnesses behavior that violates the code. 4. the organization must clearly spell out its commitment to protect all staff members and physicians against retaliation for reporting of code violations or for participating in investigations of violations. 5. The process should be consistent for both hospital staff and physicians in one key aspect: instances of disruptive behavior that put patients at risk of harm should result in immediate suspension and removal of the perpetrator from the environment in order to protect patients.6. The hospital must make available resources for coaching and mentoring of both employees and physicians when evaluation of the disruptive behavior indicates that this is the most advisable course of action. 7. These include standardized and comprehensive conflict resolution strategies to be used by all members of healthcare team and designed to resolve disagreements before they escalate; standardized communication techniques, such as SBAR, which can greatly reduce the friction. The medical staff standards follow the six core competencies including interpersonal skills and professionalism. good communication and leadership are two of the six core skills taught in medical schools and residency programs.
Physician Wellness committee and Physician Integrity team my be part of the process.
