Managing Disruptive Behavior in Healthcare Professionals

Managing Disruptive Behavior in Healthcare Professionals

Presented by Philip Hemphill, PhD

Managing Disruptive Behavior, Positive Sobriety Institute

Transcript of Presentation:

I appreciate Dan and his staff inviting me up to talk to you guys about this. It’s something I have a passion for and a commitment to, and something that I think our industry has taken a long time to warm up to. And it’s been a bit of a strong alarm when the Joint Commission came out about 10 years ago saying we have to do something about this, we have to have something in place for managing and intervening or it’s going to be considered a sentinel mark on us if we’re surveyed. So I think that was sort of the line in the sand, and from that point forward, I’d like to tell you a little bit about what we’ve done and what I’ve done in my career and share with you some of my experiences.

As a good instructor, Dominic required that I come up with an outline and some objectives. I want to make sure that you guys know that we’ll be covering these topics here, the impact of this behavior on organizations, and how to manage this as best we can.

So a lot of people say . . . Even today, here we are, 2016 about to be 2017, I’m not really clear what this is, what really is this definition [of disruptive behavior] here. And so one of the things I liken it to is a quote by a Supreme Court Justice in 1964, Potter Stewart, who said “I know it when I see it.” Anybody know what Potter Stewart was referring to? Right, pornography. It’s very simple to say that I don’t necessarily have the definition of what pornography is but I know it when I see it, and unfortunately that’s kind of what happens when trying to define disruptive behavior. People are often bystanders of disruptive behavior.

As a matter of fact, my colleague and I started managing these types of behaviors with Alexis Polles. She and I and another one of our colleagues, Austin Smith. Austin had left our group and was working in Manhattan, he’s an industrial organization psychologist. And Alexis and I were doing a workshop, a half-day workshop in New York, on disruptive behavior.

We got Austin to come about halfway through, after one of the breaks, and we gave him a script. We actually had him be disruptive in the lecture. There were about 100 executives in the lecture. He kept going on and on, I tried to “console” him, he yelled a little bit, cursed a little bit. Just stood up and stormed out of the room after about a 3-5 minute exchange with him, trying to calm him down. So then my next slide . . . First, the only reaction from the audience was, “Is that guy for real?” So immediately, there was denial. This isn’t real. What’s happened just now is not real. That didn’t really just happen. We spent the next 30 minutes talking about being a bystander witnessing disruptive behavior. This isn’t an easy topic to define, but I’m sure we can easily say, “I know it when I see it.”

You know, people wear things into treatment all the time. Here’s a T-shirt, “You laugh because I’m different, I laugh because you’re all the same.” So some things I try to bring out, because I just got to grab ahold of that. Some of the information that you’ll hear is the part of some of the work that I’ve done, but it’s very telling when a person feels this sense of omnipotence, that “I’m the focal point here, and everybody else is different.”

I have a tendency to be direct and it has really carried me in my career. I think it’s been to the advantage of the people that I’ve been around, both colleagues and patients that I’ve had the fortune to treat. But like Confucius, I think we have to call things by their real name. I don’t think we need to skate around and say, “Well, this is just a distressed issue.” Sometimes that’s not the case. Sometimes there are other issues; it’s clear what’s going on with the person, and we need to say, “This is disruptive behavior.” We don’t need to come up with some other definition of this.

Now, I like the word “tame” when dealing with disruptive behavior. As a matter of fact, I’ll mention it now, but at the end I’ll give you the citation. One of my colleagues, who’s actually in the management department here at DePaul, Marty Martin, he and I co-authored a book called Taming Disruptive Behavior and it was published by the American College of Physician Executives in 2013. There wasn’t much out there in the industry, so we were able to marshal up some resources, talk about what we’ve done and put that into a book form.

We use the word “tame” because we really are about focusing on moderating something and becoming less harsh or extreme. That’s it. We don’t need to think that taming is domesticating and subduing or repressing or subjugating a person. That’s sort of a negative connotation with holding down. That’s not really the case with the individuals with these behaviors. It’s about helping to make them less harsh and more moderate.

Even though this definition is about 10 years old, I still think it’s one of the better ones that’s out there. When Daniel Rosenstein said that, “It’s inappropriate behavior, confrontation, conflict, ranging from verbal to physical to sexual harassment. And this disruptive behavior causes strong psychological, emotional feelings which adversely affect patient care.” Really, you can’t argue when it’s affecting patient care. Now, you could say, “Well, that’s subjective.” But there is very clear evidence that these behaviors affect patient care.

And if you ever have a question about whether this is affecting someone psychologically or emotionally, all you need to do is do a quick survey of the work environment that an individual that has been in or exposed to, and people that have been around individuals with disruptive behavior. I personally have made about 50 trips across the United States at different times to put healthcare workers back to work. I would go into departments; I would go into hospitals, meet with chief medical officers, executive teams, and we’d have a series of meetings for anywhere from four to eight hours. And I’d sit down with different stakeholders for a person returning into the workplace. I, personally, witnessed some pretty strong reactions to just seeing the person in the room. So, these things are there. They’re very present.

Now, if I ask you, which of these are crossing the line: the physical confrontation, use of profanity, condescending behavior, intimidation, lack of sexual boundaries or racist remarks? I would hope that most would say, “All of these are really crossing the lines. It’s pretty clear.” However, if you take a step back and look at our society, some of these things aren’t crossing the line. What we’re talking about is a reflection of society in a lot of ways too. We’re essentially having to police ourselves, as professionals, and take the high road as it relates to what is professionalism and how we’re going to manage it in the context of delivering patient care. Some of these are less attended to in our society.

So that colleague, he and Timothy, again, over a decade ago, looked at 16,000 executives and they said that 95% stated that they encountered these behaviors on a regular basis, and about 33% said these are weekly types of behaviors that they’re encountering. One of the things that came from this study as well is that about 5% of the individuals in a healthcare organization take up about 95% of the executive staff’s time in trying to manage this. Now, that right there is evidence that you need to really pay attention and offer some opportunity and intervention for these individuals.

Some of the other behaviors are disrespect and refusal to carry out duties and yelling. We often think, “Oh, disruptive behavior! I mean, that’s physical abuse, throwing items, stuff like that.” That’s really on the low end of what’s really considered disruptive and impactful.

So why do these behaviors go underreported? We saw that just not knowing that there’s a process of reporting, and how most organizations today, as part of their orientation, say that every single staff member has a responsibility. It’s not just, let’s say, physicians in a healthcare system, but it’s everybody who has the possibility of being disruptive in an organization, therefore everybody has a right to say something. So you know, eventually they trickle down to the TSA, and “see one, say something” or “see something, say something” is the mantra. It’s what’s being promoted at least in the healthcare organization.

Some people are afraid of retaliation. If I say something, you’ll know it’s coming from me, and something’s going to happen back. There’s this history, oftentimes, of an organization not responding. Sometimes that’s because the leaders turnover, or there can be some inequality, depending on the status of an individual, the production of an individual, the partnerships that the individual may have with executives in an organization. All of these are variables where people sometimes feel like they don’t really have the opportunity to report.

My colleagues and I came up with a pretty long list here. What we really said is, this is our definition of what destructive behaviors are, and we made like a checklist of some items. We were able to go through it and come up with some real specificity related to this. At the end, I’m going to give you some data on how we validated an instrument for monitoring people post-discharge, when they return and re-enter the workplace. But it entails a number of these items. So people often say, “What do you mean, man? Tell me what you mean by disruptive behavior.” And so I say, “Well, here are some real specific examples.”

• Reads hidden, demeaning or threatening meanings into benign remarks or events. That’s an example of, you know, “What do you mean by that?” or “You’re doing something to sabotage me, my career, my opportunity for a vacation, my opportunity for advancement.” Whatever it is, my financial gain, whatever. That would be an example, reading hidden, demeaning meaning behind something that may be more benign.
• Also, taking advantage of others in order to get what they want or reluctant to delegate tasks. I’ve seen individuals who won’t really refer to other specialties, they want to do it all, they want to read their own radiology reports, they want to do the whole thing because they just don’t trust the system, so to speak. That’s some of the words I hear back.

Obviously, inappropriately expressed hostility.

You could read some of this and say these are some examples, but we can also look. So here we say, “When things go wrong, as they usually will, when your daily road seems all uphill, when funds are low and debts are high, when you try to smile but can only cry, and you really, really feel like you want to quit . . . Don’t turn to me, I don’t give a shit.”

This was some collateral data that we got on an individual that we were doing an assessment on. So the interesting thing is the very first conference that I presented this at was in Orlando, so in an attempt to not traumatize everybody and keep them . . . I didn’t want Disney coming after me. So I put a happy Mickey up there, after I showed this picture here.

Here’s one, “Can’t fix stupid, no whining.” “I put up with so-and-so’s BS for three years and all I got was this T-shirt.” So this was the way the front door to this person’s office was decorated. So, again, very clear evidence. The interesting thing here is that we have a tendency to have our own biases that we bring into this. These last two pictures were actually a female who was disruptive in the workplace. So we have to watch our own biases.

This is what we typically think of . . . this is a picture of “draw your engagement in this process,” and the person is being flooded with emotions, sometimes that’s challenging for people in a decision-making process, so that’s sort of what’s being drawn here. We have the surgeon over here yelling out, the patient bleeding out, you have the circulating staff over here sort of saying, “I don’t really know what’s going on.” And so one of the things I was asked is, who’s the most vulnerable person in this picture? And what do you guys think was the response? That would’ve been a good response, the patient. But unfortunately that was not the response, it was “I’m the most vulnerable person in this picture here, because I’m about to lose this patient . . .” And on and on and on about this particular scenario. This is what we typically think of when we think of disruptive behavior.

So some of these acts are workplace aggression. There’s been a big push in academia to look at disruptive behavior, aggressive behavior on campuses and the entire industry of training and those types of things, of identifying at-risk students and stuff like that. So this is also sort of in HR as well, in that we have to really look at the issues of harassment and workplace bullying and those types of things. And actually, my colleague, Marty Martin, he’s done a lot of publications on workplace bullying and that was his approach to our book.

To what’s really at risk, here. People say, “Well, you know, what are you really talking about, man? You’re like making something bigger than what it really is.” Well, this is clear evidence that there’s legal issues; you certainly hang yourself out there as an organization for legal . . . There’s regulatory risk, there’s accreditation risk, there’s public relations. Somebody goes to the public. We see it today in our physician health programs around the United States, there’s a big public relations issue on, “I can’t believe you’re hiding physicians!” or “You’re not turning them into legal authorities!” and all these types of things. I mean, you just look at the Atlanta Journal Constitution. About a month ago they did a series of articles on sexual boundary violators and physicians, and really said that the physician health programs were aiding and abetting. So that’s a public relations problem for medicine and for healthcare.
You know, there’s morale, too. You have a difficult time retaining employees. You have a difficult time with people not wanting to work with the person. You may be afraid to make a call to that person when they’re on call in the middle of the night for fear of retribution or some type of response, and so patient care is impacted. Financial issues . . . I mean, how much do you think it costs to recruit a nurse here at Northwestern? Ten [thousand dollars]? Probably more like fifty. When you think of the actual costs—get the person in the door, get them up to speed, train them on all of your regulations and all expectations, it takes a period of time for that whole process. And so you add other ancillary staff– you add a physician, that probably doubles as far as the cost to the institution [is concerned]. So, there’s a number, and obviously careers are at risk for people as well.

Here is some more information about the actual cost and the quality of care associated with this. Some of these are just straight out of our book. If you’re in a position of authority, in a position where you can write some policies related to this, these are just some lead-in ways, some language you may want to use, to include what is expected when you come up with your code of conduct. “Here are the expectations.” So you know, you say real specifically, “This is what’s tolerated; this is what’s not tolerated.” You can even use that list of disruptive behaviors.

I mentioned Joint Commission and the sentinel event expectations, and that’s certainly a citation for that. In an organization, when there’s disruption it affects, it creates a hostile environment, it interferes with patient care. Now courts have actually ruled on the side against hospitals and held them accountable for not following through with some of these expectations for patient safety.

This is where a wonderful place like the Positive Sobriety Institute comes into play, with regards to what you do with this, and what is really going on behind the scenes. Is there a health issue? Shouldn’t need to rule that out, that’s certainly something that’s possible. Is this something that can have an identifiable, manageable outcome? Certainly, that is possible, and certainly that is the ideal course of response to disruptive behavior in healthcare. Not to just eradicate and get rid of; it’s about preserving and rehabilitating and monitoring people.

Here are the things that really need to be screened out. Is there an addiction going on? That’s sort of the first thing that can be real evident and real quick to screen. Are there medical stress-related psychiatric and personality issues? And not necessarily in that order, but certainly in a comprehensive way, you can do an assessment on all of those.

So when you’re dealing with substance issues and personality which are often at the basis for a lot of these behaviors, you want to start there at least. These can sometimes be difficult to diagnose. There’s usually a continuum of diagnostic. . . There’s usually multiple personality traits or disorders as well as substance, polysubstance use. These are usually characterized by immature defense mechanisms like denial, and projection of blame and real difficulty accepting feedback. And then treatment is actually pretty expensive and it’s long term. This isn’t just, “Well, we’ll just go away for a weekend course and everything’ll be fine.” There’s a need to maintain engagement over a period of time and some commitment to monitoring.

So here’s my sort of public service announcement for the next five minutes, which is really about why –and I imagine most people in the room are professionals– so I’m going to offer you some pearls that I’ve gleaned over the course of my career, about why professionals aren’t too keen on getting feedback on things, or identifying that this behavior is problematic.

One is we’re accustomed to being in control. We’re accustomed to being able to call the shots, manipulate the rules. We know just how far to go; we know just how far not to step over the line. There’s a little grandiosity to our professionalism. I mean, heck, somebody’s paying to spend time with you, I hope that makes you feel good. I mean try going home, like tonight I’m going to go home, and try to tell my kids to pick up their clothes or “Sit down, time to eat dinner.” I have to go yell at them three times to come to the dinner table. So there’s still some things to resolve back at home for me, I guess.

But intellectually, we have a good defense mechanism with our intellectualism. We’re trained to discount our own feelings. There’s a fear of exposure, really don’t want people to know too much about us. And fear of disapproval by our peers and colleagues. But ultimately that’s who we’re held to the standard of, our peers and colleagues, when it comes to our license.

So you know, being a nice southern gentleman, I like to consider Mark Twain. And he says, “To be good is noble, but to tell others how to be good is even nobler and a lot less trouble.” It’s a lot easier to point the finger and say, “This person’s really bad! And they’re over there, in that corner!” As opposed to thinking that it’s much more like the person who’s working right next to us. It’s a lot easier to say it’s them over there, than to think that it’s somebody close to us, or even us.

Where does this come from? Well, you’re a self-selected group, brightest of the bright. You’re anointed with a lot of authority, years of conditioning, volumes of learning. There’s an illusion that you have the ability to be objective. We all like to think we are, but we bring our own experiences. I’ve selected certain slides for us, examples for us, because I have one hour and I’m going to do my best to articulate those. That’s totally biased, because you hear someone else up here with their experiences, it’ll be there.

How many people have seen the new Alice in Wonderland? Anybody? Yeah. And so the reviews aren’t as good because Johnny Depp’s not starring in it, this next one. And the little kids aren’t the ones that’re being focused on, to me it’s more of an adult theme. But if you really think about it, this idea of going down the rabbit hole is something to ponder, momentarily, in medicine and in training. “In another moment down went Alice after it, never once considering how in the world she was to get out again.”
I’m here to tell you in your public service announcement that you’ve all gone down a rabbit hole. And there’s really no turning back. Through the things that your training, your exposure to the things that took place during your training, your daily exposure, you’ve essentially become a repository of pain and experiences in people’s lives. And there’s no turning back at this point. Now, you could choose to get out of the industry, but it’s like the old third godfather when he says, “Ahh, you keep pulling me right back into the family.” That’s what essentially happens. Because there’s something in you that has chosen this particular field of interest and pursuit.

Now, what I would say is that when you first started this process, and what you’re experiencing today is probably a little different. I often like to ask, “Are you doing the same thing today that you thought you would be doing when you set on this path?” And they say, “Well, maybe. Maybe I didn’t realize what some of the expectations would’ve been of me.” From an altruistic standpoint, hopefully you feel satisfied in your career. But this usually is a deep well, and it’s okay to acknowledge that we’ve gone down this well, and there’s a long picket here, and eventually there is a possibility that it could be pretty traumatizing for some people. Just the idea of the role switch, the role differentiation that’s required to be a professional, maintaining that aura, maintaining that and not really accessing the real self, can be traumatic in and of itself. Because there’s a lost sense of who you really are.

I mentioned our book, Taming Disruptive Behavior. There weren’t any books out there. There were a number of journal articles on disruptive behavior when we got the proposition, the opportunity. So, we had to sort of prove why we thought this book was important in the industry. We went around and looked at other books. The most similar book that we could find was called, The No-Asshole Rule. Anybody ever heard of that book? Alright, so Dan has. So, please don’t answer, what do you think the industry is that that book was written for? Academia. It was written for university academia. So, saying that our role models sometimes can be disruptive in the training process. And so, unfortunately, we didn’t want to take that approach, that’s a very pejorative way, to say somebody’s an asshole, that’s really disrespectful. We obviously said this is behavior that needs to be managed, that needs to be intervened on, and not necessarily the individual.

Part of the challenge of being a professional comes from all these competing needs: the relationships you’re trying to develop, your family, your work, your sense of self, your performance. All of these are oftentimes compromised when it comes to balance. So these are areas of exploration when it comes to understanding a person with disruptive behavior. Just a few more slides, and I’m going to move on from this for time purposes. I believe Dominic will . . . do you post these on your website or do we send them to people for information purposes? Okay, yes, thank you. So if there’s a few slides that I go through, you can certainly go back and read them.

This is very similar to what I’ve been speaking of regarding the educated individual and that we’re self-selected. Now, think about this, are you preoccupied with details and lists and perfectionism? I hope so, to a certain degree. Do you constrict your affect? I hope so, to a certain degree. Do you like to be recognized? Only by superiors, but yeah. Do you have fantasies of unlimited success? Hopefully somewhat, but not unlimited. Some expectations of favorable treatment? Do you like relationships? Do you hopefully have a more stable image? But you have to watch that these can sort of easily flow over into actual diagnostic criteria. All this exists in a continuum. These very skills that drive you through your professional training, that land you in your seats can go beyond, sometimes.

Just a quick word about boundaries as well, because this is very disruptive in that the relationship and some of the losses that people have had related to boundary violations from a professional standpoint. There’s obviously careers, licensing, life goals issues. There’s a fiduciary relationship, when a person is entrusted with the welfare of another. And there can be ruptures; there can be problems, subtle erosions if there’s shared issues, if there’s similarities in any of these particular areas. Doesn’t mean you can’t work with that individual. It just means you should have an increased awareness of this.

The one word that I think is the most dangerous is thinking that you have a “special” relationship with your patient. Now, granted, I’ll tell you you’re special all day long, hopefully Dan tells you you’re special every day, if you’re in his department here, because that’s really important. But at the same time, that attuned personal relationship, while that’s unique, it is not special. It is interchangeable with any of us in this room. We really have to accept that, accept our limitations. And if you go beyond that, that can be very dangerous, because then you start making concessions and start making decisions that can air in a dangerous light. This is the role that patients would place you in, and these are some potential problems with some of the training that I’ve mentioned.

So if you have this case, let’s review here: so an individual with very specific service within a group, high generator, producer, public figure, involved in outside activity with numerous staff, conflict with a specific staff member, some history of similar conflicts, question about substance use, administration has had a difficult time holding the person accountable due to turnover and the personality of the administrators and the family’s engagement in the community. So maybe like, in the same country club, or some other social or spiritual community activity. And then really, the person has had some recent life cycle stressors. This would be a very typical profile. This is not unique for a person that may present with disruptive behavior.

So the first thing is to look at the by-laws and make sure you have something in place. If you don’t have those, those really have to be in place within your organization to say, “This is the limit. This is the response that we have as an organization.” Now, some people may need assessment, localized or specialized, it doesn’t really matter. They may just need a brief evaluation by professionals, and that’s where hopefully a place like this would come into play for someone. Some people just need some monitoring after that, just some supportive monitoring after an assessment’s done, and that’s the extent of it. However, some people may need more intense out-patient and then perhaps more intense therapy like the organization here.

And then, ultimately, we really only saw about 2%, maybe 3%, retirement in practice, and probably about 5% was suspension or revocation of license. So less than 10% of the people that I’ve seen in our organization out of about 2000, needed that type of intervention. We’re talking about a very small, select group that needed that. Now that’s important, because that means it’s a lot of work that we have to put forward to assist a person, and to help them and guide them. We encourage people to look at the culture in an organization: working in teams, perhaps doing some on-going education, and having access to incident reports.

One of my colleagues is the head of the Ontario Physician Health program, his name is Michael Kaufmann, and he recently came up with this whole idea of the organization needing more civility. A lot of people have said, “These aren’t about individuals, these are about organizations!” And don’t get me wrong, organizations are a lot easier to blame. We can point fingers. I’m not saying that every organization has the best functionality, but when you see a person going from organization to organization with the same pattern of behavior, that’s not about an organization. Having a really good history related to a person’s work history is really important.

And so, from just an organizational standpoint and an individual, which is really about looking at the values. And so much today in our society, our institutions have been given the responsibility of providing values to people. Plenty of those values are being respectful, being aware, this sort of positive psychology and the idea of having better self-awareness, being able to communicate, taking good care of one’s self and balance, and being responsible, taking accountability, being responsible when we make decisions and they affect other people. Those are some of the principles related to civility that Michael Kaufman came up with. So, more on responsibility. The federation of state medical boards has some information on boundary issues and disruptive behavior.

We don’t want to always just talk about the negatives, right? We also want to frame this as, what are some positive things people are doing? So that’s really important. Don’t just get stuck with the negative.
In a four-step model, which is really identifying the hazards, the behavior, looking at the risk, controlling the risk, and monitoring, evaluating, and reviewing the individual. That’s really the overarching intervention that takes place.

Some of you may be tasked with being leaders. I would challenge that any professional is tasked with being a leader. And so, as a leader, these are just some tips for being a good leader, and so maybe that you don’t sit silently, like that room of 125 people did in that presentation when we had that disruptive person. That’s part of being a leader, that you step forward, and you sort of rely on your strengths as a leader. And so, providing these types of skills and managing them is part of the professional code of conduct. So being a part of all the levels of the staff, recognizing everybody’s role in the process here, looking at the entire organization.

Now this is what, unfortunately, I’ve seen a lot of leaders do in my career, and going into organizations I’ve witnessed this: hoping that disruptive behavior will just work itself out. You know, it’s just going to take care of itself. And not really taking that first step, because I know what’s going to follow, right? What’s going to happen after I take that first step? That’s the big step. I just don’t want to. I can’t tell you how many telephone consults I’ve had in my career where people just want to talk about the issue. They just want to talk to me and talk and talk and talk, and essentially try to get me to sanction what they’re doing, which is nothing. Okay? And inevitably, it’s like, “You have to take a step. This is the next step for you.” And then I don’t hear back from them, and then a month later I hear from someone else about this person, or something like that. So that’s not completely uncommon.

So, trying to prove that the staff member is incompetent. For example, I’ll see that this person has 400 delinquent medical records. Well, we’ve got to deal with that, I can understand that. So we may have a temporary suspension, or maybe they’ll get their pay check withheld until they complete their medical records, [laughs] I don’t know how the organization deals with it.

But some people will look to performance to try to get rid of people, as opposed to dealing with the behavior that’s at hand, to try to have some intervention. I already covered the using pejorative language, that’s not okay. And then, just using the by-laws and not really dealing with the person.
You could see some people giving special treatment to certain people. Let’s mention that. Trying to conceal the problem from the board, that’s real dangerous, that can blow up in a person’s face and affect their own career. This is my favorite, number 8. “Let’s bring in some external consultants to turn this whole matter over to them.” So what does that do? Well that abdicates any authority, it abdicates any possibility that this is going to happen again, and that you can even manage this situation. Now, while bringing in some external observation is helpful, but not really to deal with it, just to empower the present staff to deal with it. And then lastly, believing that this is forever. That’s not true. I’ve seen people change. I’m committed to that, and that’s why I’m standing here. That’s why I tied my shoes today, and I came over here to give you a talk about it, because I believe that change is definitely a part of it.

So, just some competencies for physician leaders. We didn’t leave the board members out! We said, “Hey, board members can be disruptive, too.” So we’ve got the dominator, they control the agenda; the non-contributor, they just suffer from presentism, so like they’re there, but they don’t participate; the ghost, they come and go, they disappear like they’re not really there; the empire builder, they’ve got their self-interest; the disruptor, diverts the attention away from the strategy; the person that’s boring, they just go on and on about the same old thing; they usually sit next to the dinosaur, the dinosaur’s invested in the past, “Let me tell you how it’s been around here, and this is how it’s going to be, and this is how it’s never going to change.” A representative is an advocate on behalf of others, not the organization.
If you’re a leader, be prepared, be a good listener, respect the boundaries if you’re in a working group, identify your conflicts of interest. It’s okay to disagree with the position but not the individual and, finally, take responsibility. I’ve seen a number of executives’ careers be derailed, these are just some of the ways that I’ve witnessed this. And so it doesn’t just go to the individual providing care, this can go at any level, this can affect any person, so their behavior can become unmanageable.

As leaders, I hope that you’ve developed a feedback system, or you’re open for that, maybe even a blind spy coach. You know, look at the hiring practices in your organization and try to identify people early on that may have a potential for disruptive behavior, and continuously engage into the reflection.

Here’s a little story about four people named everybody, somebody, anybody and nobody. There was an important job to be done, and everybody was sure that somebody would do it. Anybody could’ve done it, but nobody did it. Somebody got angry about it because it was everybody’s job, everybody thought that anybody could do it, but nobody realized that everybody would do it. It ended up that everybody blamed somebody when nobody did what anybody could’ve done. And so it’s really about those spaces in-between, and who’s willing to step out into that space, and take some action, and be there.

Here’s the instrument that we developed that helps monitor people over the course of time. We looked at about 500 surveys. This is just how we sort of validated our instrument and used it over the course of time, anywhere from zero to two years that we were monitoring people. Initially, I mean this took about five years to develop, we started out with about 75 items. You saw how detailed we were on our treatment planning list of items. Well, we had to slowly pare that down because it was one too many items, they were overlapping each other. So, we thought we got it down to about 38 items, and so we believed and hypothesized that we have five factors going on here with disruptive behavior.
We have:

• aggression
• interpersonal difficulties
• sexual inappropriateness
• self-regulation and
• general disruptive behavior

So, what we really saw was that instead of five, we slowly saw that three were making the biggest contribution, they were accounting for a little bit over 50% of the variants of the instrument. Then, we saw that even the third one, the correlation was so low that it essentially needed to be dropped off as well. So much for our five components here.

It really came down to two factors that were reliable. And so we thought that we would look at interpersonal aggression. So for personal and interpersonal aggression, it was pretty clear that this was disruptive behavior. If they had high on their professionalism which is the second factor, these yellow…

So we had the blue and the yellow. So we said that that’s definitely showing disruptive behavior. So those are really the two factors.

And then we had a number of critical items, so that if a person’s just endorsed one of these, like “I think about quitting or transferring to a different job because of the ratee. So if somebody identified that, that they were ready to leave, then that was a critical item that we needed to pay attention to. If someone reported that the ratee was touched, touches or looks at one or more patients, co-workers in an inappropriate, sexy, suggestive manner, we need to pay attention to that. We don’t need multiple items.

Making sexual remarks inappropriately, or jokes that make others uncomfortable. Performs unnecessary examinations on male or female patients. And lastly, demonstrating lax boundaries when prescribing controlled substances, giving out samples or storing samples of the controlled substances. Those items are what we call critical items. We use this to monitor people over the course of time, anywhere from zero to five years. We found it to be very effective.

So here’s the title of the book, and the American College of Physician Executives, you can get it on Amazon or anything like that. I actually think I brought a couple of copies last time I visited you guys here. It’s really a how-to. This book is really written for physician executives who really don’t have a lot of behavioral health training, to be honest. So it was a sort of go-to for them to look at real quickly when they’re intervening, some strategies of what they can do with individuals.

“I used to have superhuman powers, but my therapist took them away.” Now this is a different patient that wore this T-shirt into treatment, but it certainly feels like there’s a humbling experience that occurs through their change process. Somebody said we do not deal much in fact when we are contemplating ourselves. That was Mark Twain. We really do have a difficult time having an accurate assessment of ourselves. Don’t fool yourself to thinking that you really know yourself. It’s really important, heck, I saw Descartes Deli downstairs, “I think, therefore I am” Really and truly, he or she thinks I am, therefore I am. We really do rely on feedback. Those of you that have been nodding very nicely, that’s been very validating, I’ve been making better eye contact with you. Those who’re just sleeping after taking that meal in, I’m not looking at you, okay.

The way I see it, the way you see it, and the way it really is. So I think that I did a pretty good job here, today. Maybe that’s my grandiosity speaking, but I’ll just take that. And I think you probably see it a little different, and it’s probably somewhere in-between and hopefully somebody’s managing that. So, we have about five minutes for questions, and I’ll leave my contact information up there as well.