Independent Medical
Evaluations and Professional Liability
David
L. McCann, M.D.
Legal decisions by the Utah State Courts have significantly decreased
the risk of successful lawsuits against physicians in
Performing
independent medical evaluations is a low profile medical subspecialty which
requires extensive clinical experience and knowledge of medical legal
issues. Third parties often have a need for objectively based
independent medical information to adjudicate claims. Some of
the agencies which request these evaluations include law firms, workers
compensation insurance carriers, disability insurance carriers, or agencies
or organizations which employ persons whose medical conditions may be a
significant factor in the workplace. Physicians who perform
independent medical evaluations in the course of practicing medicine may
believe that they are shielded from lawsuits because they are performing a
service requested by a third party and not providing medical care through a
doctor-patient relationship. The problem in
The case in question
occurred when an employee of a
On September 30th, 2003 the ex-employee, now a
plaintiff, and his attorney filed a medical malpractice lawsuit against me
based on the findings and conclusions of the independent medical evaluation
report.
My standard procedure is to require persons undergoing
independent medical evaluations to sign a "Statement of Conditions for
Independent Medical Evaluation”, which clearly states that the individual’s
visit is for evaluation only, that no doctor/patient relationship will be
established, that no treatment will be provided, and that a written report
will be submitted to the agency requesting the report. As a final step
in performing an independent medical evaluation, the evaluees are provided
with a written question, "Were you satisfied with the way this examination
was performed?" The plaintiff checked “yes” and offered no other
comments.
The complaint alleged that I misrepresented myself as an
"independent medical examiner" and alleged that I had made "fraudulent
statements." It alleged conspiracy between me and the plaintiff's
employing agency. It alleged "libel, slander, negligence, fraud,
racketeering and obstructing justice." It claimed economic damages, as
well as “pain, suffering and inconvenience.” On November 4th, 2003,
given the plaintiff’s allegations of criminal misconduct, I received a
letter from my professional liability carrier stating that the policy had an
exclusion clause for punitive or exemplary damages, and that my policy would
not cover any such claims upheld by the courts. So much for the piece
of mind which came from believing that I was fully covered for malpractice
liability, and that my personal assets were not at risk. On January
16th, 2004 the plaintiff offered to settle the matter for 1.25 million
dollars.
Needless to say, I believed that the allegations were
frivolous without foundation. I have always maintained high standards
for objectivity and my conclusions are based on medical evidence. As
most physicians are aware, or hopefully will become aware of after reading
this article, there is no penalty for filing subjectively based allegations
in a court of law for legal determination by a judge or jury.
My UMIA
appointed defense attorney and I responded by stating that I owed no “legal
duty” to the plaintiff because the report in question was for evaluation
only at the request of the state agency involved; and I did not have a
doctor/patient relationship with the plaintiff as defined by law.
Therefore, I could not be sued for malpractice. In addition, our
defense stated that the lawsuit should be dismissed because the action had
exceeded the two year statute of limitations. We filed a motion for
summary judgment for dismissal of the lawsuit.
On January 27th, 2005
Judge Judith S. Atherton heard the arguments in the Third Judicial District
Court, and on April 25th, 2005 granted our motion for summary judgment and
dismissed the action with prejudice (indicating that the lawsuit could not
be re-filed) on the basis that "defendant David L. McCann, M.D., owed no
legal duty to the plaintiff from which legal action could be commenced; and
that the action was barred by the two statute of limitations.”
As
anticipated, the plaintiff appealed. On November 16th, 2006 a three
judge panel writing for the Utah Court of Appeals determined that after a
thorough review of the legal issues, that "Without the existence of a
physician/patient relationship between McCann and (the plaintiff), the
plaintiff cannot maintain a medical malpractice claim against McCann.
Because (the plaintiff) was not McCann's patient seeking psychiatric
treatment and because the contract for medical services was between McCann
and the (agency), not McCann and (the plaintiff), we conclude that there was
no physician/patient relationship between McCann and the plaintiff.
Therefore, the trial court did not err when held that McCann owed no legal
duty to (the plaintiff) from which a [medical malpractice] action could be
commenced." (Apparently, the Court of Appeals did not believe it
was necessary to address the issue that the claim had exceeded the statute
of limitations).
The plaintiff and his attorney filed a Petition for
Re-hearing by the appellate court. On December 8th, 2006 the Petition
for Re-hearing was denied. As
anticipated, the plaintiff appealed to the Utah State Supreme Court.
On March 16th, 2007 Christine M. Durham, Chief Justice of the Supreme
Court of the State of Utah issued an order denying the plaintiff's request
for a hearing before the Supreme Court, affirming the determinations by the
trial court and the appellate court.
So what can be learned from an
experience such as this? For one, any disgruntled person can file a
lawsuit and you will have to defend against it. When performing an
independent evaluation for third parties, never use the word "patient".
Use words such as "claimant", "evaluee", “individual”, plaintiff, or in
fitness for duty evaluations, perhaps use the term "employee". I would
recommend that any physicians performing independent evaluations be sure
that the evaluees sign a Statement of Conditions such as the one which the
plaintiff signed in this case. The courts cited the statement signed
by the plaintiff as very strong evidence for their favorable determinations.
I think it is also helpful to have evaluees sign a separate statement
immediately after the evaluation as to whether they were pleased with how
the evaluation was conducted. In this case, the plaintiff answered
"yes", he was satisfied. Having that statement helps make subsequent
claims of inappropriate behavior less credible. Another suggestion is
to be sure of your professional ability to sort out objective factors and to
write clearly. When you write, be very careful with the words you use.
The Utah Medical Insurance Association was very supportive in my fight
against this unfounded lawsuit. If you perform independent medical
evaluations, be sure your professional liability carrier will cover you.
The best thing that came out of this seven year process, which created a
very tall stack of documents and cost my malpractice carrier $88,472.70, is
that Utah now has case law that will make it much more difficult for
disgruntled evaluees to file successful lawsuits against independent
examining physicians. The decision may be used by courts in other
states to support favorable decisions for independent medical examiners
elsewhere.
August-September 2011 Bulletin
When Illness Strikes the CEO
Jerrold M. Post, M.D.
“I have always said that if there ever came a day when I could no longer meet my duties and expectations as Apple’s CEO, I would be the first to tell you. Unfortunately that day has come.”
This was the introduction to the brief letter of resignation Steve Jobs, legendary founder of Apple, submitted to the board on 24 August, 2011. Asking to remain as chairman of the board, Jobs recommended that Apple in accordance with its succession plan name Apple’s COO Tim Cook as CEO. Jobs had been on a medical leave of absence since January, a period of unprecedented growth in Apple stock value, at one time exceeding Exxon Mobil as the most valuable corporation, indicating the ability of Apple to thrive without Jobs at the helm, and indicating that he had been able to institutionalize his leadership, and his creative flair within Apple. The stock suffered less than a one per cent drop following this announcement.
This was in contrast to January of 2009, when the stock dropped 7% after the announcement by Jobs that he was taking “medical leave” until at least June. This threw the investor community into turmoil. He invoked personal privacy in not providing details of the illness associated with his gaunt appearance this past summer, which had led to concerns that he had suffered a recurrence of the pancreatic cancer for which he had undergone major surgery in 2004. He denied a recurrence, but his vague descriptions –hormonal imbalance—only intensified the concern. In his e-mail to Apple employees at the time, Jobs asked that “My family and I would deeply appreciate respecting our privacy.” In April, he underwent a liver transplant, returning to work in June as promised.
Is the CEO of a major public company entitled to personal privacy when he becomes ill? The 2009 episode led to a vigorous debate, with some arguing for rights of privacy, but others, notably the former general counsel of General Electric, Ben Heineman, calling for SEC setting rules on this matter, precisely because the health of the CEO can have major effects on his present and future ability to lead the company. As John Dienhart, professor of professional ethics at Seattle University observed, ”The company has used him and made him a public figure to increase the value of Apple. If you take the good from that, you have to take the bad.”
This question in the political arena was considered by the Presidential Commission on the 25th Amendment (the disability amendment), on which I was honored to serve. It was the consensus that in running for high office, there was an obligation to forgo a certain degree of privacy. This was associated with Senator McCain’s decision to release more than 3,000 pages of medical records during the 2008 campaign, because of expressed concern that McCain had had four operations for serious skin cancer (melanoma) and would be 72 years old when entering the White House. When illness occurs in the White House, it is assuredly not a private matter. And I would suggest, when illness strikes the CEO of a public company, it is also not a private matter.
Despite our wishes to the contrary, leaders are mere mortals, subject to the inevitable ravages of age and illness as the rest of us. Because we want our leaders to be strong, wise and in control, there is a tendency to conceal serious illness. When Woodrow Wilson suffered a severe stoke, his physician, Cary Grayson, reported only that he was suffering from nervous exhaustion, and the degree of impairment was concealed. Only three people had access to the president, his wife, Edith Wilson, Dr. Grayson, and his personal aide, Joseph Tumulty. After Wilson recovered to some degree, his wife remarked, “You men make such a fuss. When Woody was ill, I had no trouble running the country.”
While Franklin Delano Roosevelt’s polio could not be concealed from the public, his serious illness on returning from the Tehran Summit in 1943 during his third term was concealed. Examined by a staff cardiologist Commander Howard Bruenn, Roosevelt was found to be suffering from congestive heart failure, severe hypertension and chronic obstructive pulmonary disease. But Admiral McIntyre, the White House physician, gave a reassuring public statement, that for a man of his age, Roosevelt was in remarkably good health. He was renominated, and elected to a precedent shattering fourth term. Shortly after his inauguration, at the Yalta Summit, he was described by Churchill’s physician, Lord Moran, as having “all the symptoms of hardening of the arteries of the brain in an advanced stage; I give him only a few months to live.” Dubbed ”the sick man of Yalta,” he died shortly thereafter of a massive cerebral hemorrhage.
How cheered we all were after the assassination attempt on Ronald Reagan to see his waving from the window of George Washington University. But in fact he was significantly disabled on his return to the White House. As Bob Woodward reported, “Reagan could only concentrate for a few minutes at a time, then he faded mentally…. The few who were granted access to the president were gravely concerned. This was supposed to be the beginning of the Reagan presidency, but at moments it seemed the end of the Reagan they knew…his aides began to consider that his was going to be a crippled presidency—-that it would at its very beginning devolve into something similar to Woodrow Wilson’s at the end, a caretaker presidency.”
It is eerie the degree to which Hugo Chavez has modeled his career after that of his mentor and model, Fidel Castro, including the severe but unspecified abdominal illness requiring intestinal surgery. In July, 2006, the eighty year old Castro underwent abdominal surgery, and on August 2, 2006, Fidel, looking gaunt, temporarily turned over the reins of power to his brother Raul. Rumors flew throughout Cuba that Castro was on his deathbed. To this day, details concerning the specific diagnosis have not been clarified. Five years after Castro’s surgery, on June 10, 2011 in Havana Chavez underwent abdominal surgery for “a pelvic abscess.” There is good reason to believe the choice of Havana was governed by the ability to control information. But Chavez finally was to acknowledge that his surgery was for a cancerous tumor, although he did not provide details concerning of the nature of the cancer nor the extent of spread, with suggestions ranging from prostate cancer to colon cancer. On July 16 he arrived in Cuba to begin chemotherapy. The compliant Venezuelan congress voted to permit Chavez to continue to lead Venezuela from Cuba while undergoing treatment for his cancer.
For the consummate narcissist, death is unthinkable. Just as Fidel held on to the reins of power until illness finally forced him to stand aside, so too Chavez will not easily yield to illness. Indeed, statements that he intended to run again for president in 2012 have already circulated. The work of Chavez’s Bolivarian revolution is by no means accomplished, but the timetable of Hugo Chavez has been foreshortened. As he simultaneously struggles with the rigors of cancer chemotherapy and struggles to lead his country, the months ahead promise to be a period of immense stress. His decision making and political actions cannot help but be distorted by his own confrontation with his mortality, and exaggerated actions to guarantee his place in Venezuelan history could well occur.
When the leader is ruling while seriously ill, “sitting crowned upon the grave,” it inevitably affects his leadership. It can seriously distort his leadership and decision making. Consider the Shah of Iran, who had crafted a plan to modernize his nation that would require some twenty years. But he did not have twenty years. In 1973, the Shah became ill, lost weight, appeared gaunt, and was suffering from abdominal pain. His physicians, alarmed at his enlarged liver and spleen, called in French physicians who made the diagnosis that he was suffering from lymphocytic leukemia, but that he would have some seven years. 1973 was the year the Shah broke with OPEC, quadrupling the price of oil, leading to a massive influx of oil revenues into Iran which had a poorly prepared infrastructure, leading to a revolution of rising expectations, which destabilized the society, paving the way for Khomeini’s Islamic revolution. Wanting to accomplish his goals for his country before his death, the Shah had superimposed his personal time table on the nation’s time table, and in his terminal urgency had destroyed his legacy.
But confronting one’s own mortality can have constructive effects as well. In a moving essay, Montaigne, at the end of his life, wrote: “Especially at this moment, when I perceive that my life is so brief in time, I try to increase it in weight; I try to arrest the speed of its flight by the speed with which I grasp it, and to compensate for the haste of its ebb by my vigor in using it. The shorter my possession of life, the deeper and fuller I must make it.”
There is every reason to believe this was the case for Steve Jobs. For in 2005, he delivered a moving commencement address at Stanford University, after undergoing surgery for pancreatic cancer. He emphasized the impact of his serious illness on him in a way reminiscent of Montaigne. “Remembering that I’ll be dead soon is the most important thing I’ve ever encountered to help me make the big choices in life. “ Jobs’ leadership of Apple through his period of illness has been quite remarkable. After returning to Apple in August 1997, from August 1997 through December 2010, Apple Stock soared a remarkable 7,272% versus a 67% gain for the S&P 500, suggesting that in his stewardship of Apple, his perception of the brevity of life remaining had led him to all the more vigorous leadership, to make it “deeper and fuller.”
Especially for a strong and charismatic leader, the impact of serious illness upon his leadership can be distorting. When the boardroom becomes the sickroom, leading while ailing inevitably affects the leader. Because of his public role, the leader, whether he is the president of the nation or of a major public company, has obligations to his followers that require forgoing the privacy that the man in the street may seek in coping with serious illness.
………………………………………………………………………………..
Dr. Jerrold Post is co-author (with Robert Robins) of “When Illness Strikes the Leader” and author of “Leaders and their Followers in a Dangerous World.” He is Director of the Political Psychology Program at the George Washington University.
June – July 2011 Bulletin
Daven Morrison
Hello,
We
are a third of the way into 2011 and our planning team is beginning to put
together a program for next year. We have ideas in mind that will take shape
through the summer and begin to be a program by early fall.
The
immediate past program in April went very well. With an intriguing opening by
our program chair Josh Gibson MD the meeting was off. Dr. Gibson set the stage
for understanding the distress and pain of our current economic crisis and what
impact this environment has had on many people we know as patients, family or
co-workers of our patients.
As
the weekend unfolded we had an interesting collection of different perspectives
and professional backgrounds. From
non-psychiatric experts to psychiatrists deep in experience with psychotherapy,
evaluating threats and other psychiatrists with expertise in organizational
consultation and building EAP organizations, the presentations built on themes
and generated many new insights and new places to begin investigations or start
new and better assessments.
The
topics dug into the workplace challenges of sabotage, threats to employees and
leading an organization while triaging multiple personal professional
challenges the membership from non-psychiatrists. Their added perspective
carried over into the breaks and the evening when we collectively discussed the
movie: Up in the Air. The combination
of people from many different frontlines helped bring new understanding to some
of the pain of people being terminated, working in distressed settings or
dealing with strong negative affects.
Questions
remained from the dialogue:
- When
does a supervisor act with genuine empathy while terminating a co-worker –
is it possible?
- How
does the management team of an organization (individuals not trained in
providing care) fit with those who provide care-giving, particularly
mental health and what do the many insights from the Department of Defense
mean for non-military organizations who have extremely distressed individuals?
- How
does international politics and espionage play a role in mental health and
or bizarre behavior – does it?
- Knowing
how a person slighted by an organization can progress to hostile acts –
are there ways to eliminate or minimize proactively?
- Given
the lessons the Post Office has learned, how can psychiatry help similar
organization given the current climate?
What
comes next in the economy is unpredictable, and thus what will life be like for
our psychiatric patients is also unclear. In general the workplace is
supportive for mental health, but some recent data has argued that being on
unemployment may be better than a job that is highly stressful.
What is fairly clear is there will not be a
rapid rise to salad days on the scale of the middle of the last decade. People who had planned on retirement, others
who had thought they would not be out of work for so long, and others perhaps
even more un appreciated are being asked to do more at work with less
co-workers and no decrease in the demands for work.
It
makes sense that the demand for understanding will continue.
If
you have topics or suggestions for our programs you are free to contact us
either though our website or you can write back to this note.
David E Morrison MD
AOOP
President
April-May
2011 Bulletin
Why I love being a psychiatrist--C. Donald Williams
It’s good to be lucky--to be born in a time and place with opportunity to discover a passion and pursue it. When I was in the 9th grade I was nosing around in the city library and located the “Great Books of the Western World” published by Encyclopedia Britannica. There were 60 volumes in the series, devoted to the subject categories of literature, history, philosophy, and science. It also contained works from 20th century authors; the one that captured my attention was Freud. I remember my first exposure to The Interpretation of Dreams, his discussion of the history of dream interpretation, and then, excitingly his presentation of dreams with their analyses in italics. Now, recalling this first exposure to a Rosetta Stone approach to understanding the meaning of patterns of thought and feeling, I again have an emotional response. The intensity surprises me. It feels fresh and at the same time familiar. I knew it was important to me and that I did not want to lose sight of it. Ever.
Some of you may also have read the March 5, 2011 New York Times piece titled, “Talk doesn’t pay, so psychiatry turns instead to drug therapy.” The article begins, “Alone with his psychiatrist, the patient confided that his newborn had serious health problems, his distraught wife was screaming at him and he had started drinking again. With his life and his second marriage falling apart, the man said he needed help. But the psychiatrist, Dr. Donald Levin, stopped him and said: ‘Hold it. I’m not your therapist. I could adjust your medications, but I don’t think that’s appropriate.’” I think this is inexpressibly sad and is profoundly antithetical to what matters to me.
My lucky times stand out; I went to a college with small classes and superb faculty. I went to my first choice medical school. I took several classes from the psychoanalyst chair of the Department while a medical student before he left and the Department turned strictly to biological psychiatry. I did a child fellowship which made all psychotherapy easier.
It was not all a shining path. The Department developed an anti-analytic bias that was impossible to escape, and I began practice in my community disconnected from the life source of my discipline and felt lost for about 10 years.
Then some more luck. I began doing group therapy, attended the AGPA, became certified, and have an active group as well as individual therapy practice. I began therapy with an analyst and did 10 years of work that reconnected me with me. It wasn’t pretty, but it was necessary and invaluable. I began a 23 year supervision/consultation with a senior analyst which polished the Rosetta Stone and brought the work of analytic psychotherapy into clearer focus. He has been a wonderful mentor and teacher.
The really big piece of luck was joining AOOP in 1994. I liked the atmosphere and the people and kept coming, even though I didn’t see how I was ever going to do corporate consultation or executive coaching in a place like Yakima. Within 3 years I led a workshop encouraged by a former AOOP President and taught courses at the APA annual meetings with Ron Schouten for 5 or more years, which introduced me to creative people in the discipline and opened other doors.
Taking advantage of all I learned about healthy organizations from AOOP I formed an LLC that licensed 3 patents on transdermal pharmaceuticals for the treatment of pain, taking one product through FDA phase 2. We didn’t make a dime, but it was a great ride, and what I had learned about teamwork through my AOOP connection worked for Pharmaceutical Application Associates LLC; we all remained friends, even when it didn’t pan out.
I created a Mission Statement for my practice, which I would never have done without AOOP. It makes a huge difference. I refer to it. I adhere to it.
10 years ago I decided consciously that I would endeavor to always be doing something different and better in my practice compared to the year before. My connection with Ron led to an opportunity to co-author a textbook chapter in 2000, followed by invited papers in peer reviewed journals on an annual basis from since 2006. These require scores of hours, have led to original ideas, and they place me in contact with reviewers and editors that contribute enormously to clarity of concept and accuracy of expression.
In 2008 and again in 2010 I obtained formal training in the MMPI-2/MMPI-2-RF because the psychiatric IME’s I see are inconsistent and lack objective foundation. Using my own practice I have learned that attorney and doctor workers’ comp referrals have essentially identical test characteristics, both in terms of dimensional severity and their diagnoses. This is exciting to me. Because of a paper I wrote for Harvard Rev Psych using this information I developed a friendly relationship with a leading authority on the MMPI-2 and MMPI-2-RF. We are in discussions about writing a paper that will begin to link psychiatry and psychology. In the meantime a 3rd edition of the textbook is coming out with a chapter in which I describe the use of psychological testing in IME’s and to measure progress in treatment.
I approach each treatment consultation, psychotherapy and IME with enthusiasm since they each represent an opportunity to learn. Going to work I feel privileged to be a physician and psychiatrist, to have the opportunity to be creative and bring all I have to offer on whatever challenge appears. I know that the work is important to me, my patients, and to the people I evaluate for other professionals.
I feel lucky almost beyond words. If I were to learn that I had but 24 hours to live, I would be sad to leave life, but I would have no regrets about how I spent the preceding days, weeks, months, and years. I don’t want to lose that. Ever.
C. Donald Williams
March 2011 Bulletin--Interview with Paul Hammer
In this bulletin, Paul Hammer (PH), an Officer in the Marines and Navy and an AOOP Board member, speaks with AOOP President, Daven Morrison (DVN), about his new role as Director of the Centers of Excellence for Psychological Health and Traumatic Brain Injuries (TBI).
DVN: Hello
Paul, Tell me about your current role.
PH: I’m the Director of the Defense Centers of
Excellence for Psychological Health and Traumatic Brain Injuries (TBI). Our mission basically is to be an integrator
of information between a number of different entities in psychological health
and TBI. So the idea is to be able to
translate information from the research and academic side into something that
is practical and useful for the military side, to promote research and to
promote good clinical care as well as provide clinical guidance, and that sort
of thing.
DVN: What
are the target goals?
PH: Well, there are a number of different things
we are trying to do. I guess the global
target is that we improve the overall level of care for PTSD; that we develop
and transmit practice guidelines for traumatic brain injury; that we improve
the care system for TBI sequelae, for example, concussions. So, it’s global target: one you never fully
achieve, which is ultimate psychological health and minimal traumatic brain
injury. It’s the unachievable goal in
medicine: total health. What we are
trying to do is to improve the overall level of care and via identifying
research gaps and where we need to look deeper and do more to close those gaps.
DVN: As
these wars are going on and combat is changing and evolving, how do you see the
care changing that you are providing?
PH: I think we have a greater understanding of
the effects of stress on people, and I think there is a greater acknowledgment
of the impact on people’s ability to function and their need to recover when
they come home. I’m hoping that that
impact will be better results and better treatment overall globally for
PTSD.
For
TBI, the biggest thing is developing an understanding of the effects of blast
in the world of concussion. I think we
have a fairly good understanding of impact injuries, which happen in a lot of
professional sports, most notably the NFL, is being looked at now. I tell you what they’ve still got a
long way to go. It’s really interesting
to hear on the sports news when a player has a concussion and they are held out
of the game, there’s still a lot of questioning about that, and a lot of
misunderstanding that the guy looks fine, but the treatment team realizes he’s
got to stay out of the game for a period of time to allow his brain to heal
before he goes back in.
DVN: This
subject really came into the headlines here in Chicago. We had a former safety with the champion
Bears commit suicide believing that something was wrong with his brain. He wanted his brain analyzed. In terms of
what the military is experiencing, the IEDs are still the main thing?
PH: Definitely.
The effect of blasts and understanding it, especially in the role with
traumatic brain injury is important.
That’s a huge area where we are looking at, as well as how to deal with
it easily, developing a system of care in the field so that it’s dealt with
appropriately and you are not medevacking people who don’t need to be
medevacked or you’re not keeping people in fear that actually need higher level
of care. So, it’s the appropriate level
of care.
DVN: So,
tell me: how did you get this role? What
was happening where they said, “Hey, we want Paul Hammer to take on this
responsibility?
PH: I did two tours in Iraq. The first time I had noted that the surgical
teams were collecting data on wounds and mechanisms of injury and types of
treatment for those types of injuries.
It occurred to me: why aren’t we doing this in the psychological health
and behavioral health community? Why are
we just sort of doing our own thing?
So,
when I returned the second time, I was in a position to be able to do and in a
position to be able to support a number of initiatives to assess mental health
among the population coming home. When I
came back I was assigned to a little task force that was sent to Washington, DC
to address the invisible cost of war with psychological health and TBI. So, Washington appropriated a lot of money to
us. There was concern about how we
efficiently, effectively, and appropriately spent this money in order to
address the invisible wounds of war. One
of those projects was heading up the naval center for combat operations stress
control, which I did. I think I was
successful at doing that. Once that occurred,
that led to this job now.
DVN: What
was it that people said that’s a good job, that’s what we’ve been looking for?
PH: I think what we did with NCCOSC in San Diego was to start up a number of programs,
things were designed to practical, concrete things you could do to improve care
for PTSD, start to begin to look at; how are we going to track the data; how
can we promote research projects and research in the military treatment
facilities, etc.
DVN: If I
remember, you had a website too, right that was also intended to be educational
and encouraging people to ask for help, tackle the stigma, etc.
PH: Exactly: www.nccosc.navy.mil So, that led to, “Okay well you did pretty
good with the navy, there are some issues with the defense center of excellence
needing some direction,” so I was asked to take over this job, and here I am,
three or four weeks into it.
DVN: As you
were talking about your current role and I know it relates back to your
previous role too, you said you were learning a lot more about how people
manage stress. Can you share a couple of
thoughts about that and how it relates to soldiers coming back?
PH: One thing is we are learning a lot about the
actual physical effects of stress in changes in the brain, particularly
traumatic stress, changes in the amygdala and hippocampus, but I think what we
are also learning, what we’ve learned is training and educating and focusing
people on managing, and effectively managing the effects of stress is
important, too. I think we are at the
beginning of understanding: how do we, if there is such a thing as resilience
and quality of resilience, how do you promote that or develop that in people. That’s a difficult thing to do.
Ours
are largely anecdotal. We are trying to
figure out how to study it. There are a
number of programs that military services have done to try to make people more
aware. We know part of helping people is
recognizing you can’t go 90 mph, without any sleep, without any water, without
any food, without any rest, and expect to perform at a high level. You can do that for a short burst, but you
can’t do that for long periods of time.
In order to get maximum performance out of people for the longest period
of time, you need to give people downtime.
You need to give them rest and you need to have cycles of intense
activity followed by cycles of rest. It
all works in a cycle. You can’t go
without sleep. At some point, you have
to stop and get some sleep. That works
in a very simple way like with sleep, food, or water, but it also works with
complex things like knowledge work, and effective performance in complex tasks,
and that kind of stuff. The key for most
people is making people aware of the effects of stress and that’s sort of the
beginning is, okay, let’s get aware of where we are. It isn’t naval gazing, oh my gosh I feel so
sorry for myself, because I’m in a stress situation, it’s more akin to
acknowledging it, and then dealing with it, and addressing it effectively. An example I give, and probably everyone has
had when a conversation with somebody on the phone, they are talking, a friend
is getting all worked up and then you’re asking what are you so angry
about? And the friend goes (shouting),
“I’m not angry!” They are not
aware. It’s boiled frog syndrome. You are not aware of where you are until you
are in it or until you are well past the point where you should have done
something about it.
What
it often requires is that you do buddy care.
Leaders are taking the pulse of the unit. People are looking out for their
friends. Where is everybody at? How are we doing? What’s going on? And then doing things to effectively address
what’s going on, which can often be very simple. Take a break.
Go get a drink of water. Do
something different. Do something
else. Talk to them, say “calm
down.” One of the things that was
developed the Critical Incidence Stress Debriefing (CISD) that was developed by
Mitchell, showed that firefighters and
paramedics and emergency services type of people was really not working. The literature shows some mixed reviews
There
isn’t a whole lot of evidence that it works.
There was some concern in some cases it might make it worse. So that we
worked well in defining it but the people who really are traumatized can often
be provoked into disassociating and possibly re-traumatized, so there is some
concern about that. What the idea was
the National Center for PTSD developed a different model that they called
psychological first aid. What the navy
did, and the navy and marine corps did was translate that into sort of
marine-speak or military-speak and they call that combat and operational stress
first aid, which is looking at basic needs and taking care of people,
intervening on the basis of what’s needed, rather than just, “Oh my God,
something terrible happened, everybody gets something.” That’s the kind of thing that has been
developed out of this, and has been promoted, and we’re starting to teach people
how to do it, and how to use it. There
may be some indication that it might be taking root, and this, of course,
requires a lot more study and development.
PH: There is also a concern about chronic high
levels of cortisol causing damage. There
is also a great study that’s currently in the works called the Marine
Resilience Study. And the idea is what
they are doing is taking marine infantry battalions and doing some pretesting
before they go over, they do a number of measures: they take urine and blood
and do startle tests, as well as some paper and pencil psychological
testing. They send them over and they
track what their experience is and then when they come back, like 30 days after
they come back, they run the whole group through and do the same things all
over again. They look at the
differences, and then look at the people that actually develop symptoms versus
what’s their genetic markers, what are the different levels of stress
hormones. There are a lot of things that
they are looking at. It’s an
amazing…it’s a landmark prospective study that you cannot do in a civilian
community. You can’t take a bunch of
people and say, “We’re going to see which of you is going to get raped or
robbed or in a car accident or a natural disaster.” You can’t predict that. But, you do know that a bunch of marines are
going to be going over and they are going to be exposed to traumatic events, so
which of them is resilient, how do they get resilience, and looking at some
sort of concrete markers. There is a lot
that’s happening that we are trying to learn from in this particular conflict.
DVN: The
final question: Tell us about your relative interest in occupational and
organizational psychiatry.
PH: I think I’ve been interested in it for a long
time. Some of the guys who work around
have heard of AOOP and thought about it for a couple of years and then we came
back to it again. I think there is a lot
that we psychiatrists can contribute to the conversation in the workplace
issues that’s a little different than what a psychologist does in terms of organizational
psychology. A lot of that is focused on
testing, screening, and right fits with the right job, and that sort of
thing. I think what…and here’s my
opinion, and I don’t know whether it’s true or not, but I think we often look
more at the effective things like workplace stress or systems on what’s going
on with individuals and producing, contributing to or sometimes even helping
mitigate psycho-pathology. There is a
lot that we can add to the conversation related to people’s mental health, as
it relates to their workplace. The
workplace is really an important part of who somebody is. In the military, it is particularly
important, because identity is a really…identity within the organization,
identity with the organization is huge in the military. I often tell people, , if you go up to a
group of people and you say, you meet somebody at a cocktail party, right, and
you talk to them, one of the questions usually asked: What’s your name? Where are you from? Oh, by the way, what do you do for a
living? People say I’m an accountant or
I’m an executive or I’m a baker or a plumber or whatever it is, but usually
they give a job category, and then they say I work for, and in some cases it
gets kind of vague. I’m an account
executive over at XYZ company. Oh, okay,
but to identify with their job to a certain extent. If you talk to somebody in the service, I’m a
soldier. I’m a marine. I’m a sailor.
That identification is not just identifying the job or identifying who I
am that’s a part of me. It’s the same
thing when I’m a veteran or I’m a former marine, or know I’m not one right now,
but I still have ties and connections to that.
There’s a deep bond there and a deep sense of identity. It’s accentuated in the military where in the
civilian community, not so much, but even so, people still identify with their
organization, who they are. It’s a huge
part of their life. It’s an important
part of who they are, and I think acknowledging how it effects psycho-pathology
and also how psycho-pathology effects their ability to work, that’s an
important thing. That’s really an
important thing. When we ignore that,
and just say, “Well, I don’t want to talk work, let’s talk about your
symptoms,” that may be an important thing that you are really leaving out in
terms on that individual. I’ve always
been interested to that kind of stuff, and I think at the annual meeting the
stuff we talk about is always interesting, and looking at how some of those
issues cut across different sectors of the world, whether it’s in the civilian
community or IME evaluations, in workman’s comp, what they’re like as opposed
to the disability evaluation system in the military, and how that all works,
it’s all fascinating.
DVN: That’s
an important theme of our conference, too, because we’re talking about
disruptions in the workplace and stress in the workplace, the potential losing
your job, I wouldn’t be surprised too if that idea about identity plays an
important role in the resilience you’ve seen.
They’re going to fight through it.
They’re going to see themselves as healthy. They’re going to see themselves getting
through the crisis.
PH: Or, if you don’t identify, is it easier to be
shunted off or cut from the herd, and how quickly do
you cut yourself off, and then you find yourself isolated in difficult or bad
situations. It’s a fascinating
realm. The trouble is it’s not something
that’s real concrete or easy to measure.
When you study it, there’s…it’s sort of like psychoanalysis, there’s a
lot of theory and a lot of discussion, but not much you can hang your hat on
and say that’s the proof right there.
DVN: Now for
something fun. We have been curious about your assignment, so it would be cool
to hear what a typical day is like.
PH: For me, it’s pretty boring. But I’ll tell you one story that might shed a
light. There’s a very important meeting
that I go to that’s chaired by the Deputy Secretary of the VA and the Deputy
Secretary of Defense, and there’s assigned seating and it’s in the wood-paneled
section in the Pentagon. So I go over
there for this meeting, the first one was last week, and I’m looking
around. The Pentagon is like a
maze. It takes a while for you to get to
know the maze, but I find the right place and they have assigned seating. So, I’m looking around the room as I got
there earlier than anybody, so in this back corner, all the way back. There was an alcove, it wasn’t like a
perfectly rectangular conference room, it has a little cut-out section in the
area in the back there. That’s were I
was. I was up against the wall, and then
on the other side of where the wall turned to go back to the regular part of
the conference room, there was a little cart that held coffee and tea and cups,
a coffee cart, and so I’m sitting there waiting and start chatting with people
and then the two Deputy Secretaries come in and then into this meeting, one of
the aids comes in and there wasn’t room for him to sit behind his particular
Secretary, so they move the coffee cart right in front of me. I thought, yeah, that’s how important I am.
DVN: Life
has a way of keeping us all humble, doesn’t it?
PH: You get humble, and then you have to keep
your sense of humor.
January 2010 AOOP Bulletin--Treating the Organization :
David Morrison Reflects
on Four Decades of Organizational Consulting
Steve Heidel MD interviews David Morrison MD
David Morrison, M.D., a psychiatrist, has had a
distinguished career in executive and organizational consulting. He trained at
The Menninger Foundation then directed several departments in Menninger’s
Center for Applied Behavioral Sciences before moving to Chicago and founding
Morrison Associates. I recently spoke
with Dr. Morrison about his career.
Dr. Heidel: When did you first learn about organizational consulting?
Dr. Morrison: When I started my residency at Menninger’s we attended a five day seminar, taught by Harry Levinson, before we went on the wards. The seminar was for executives, modified for residents, to give us an overview of psychiatry. Then Dr. Levinson taught a seminar on organizational consulting. I found it fascinating. He told us we needed to learn about business and I questioned why I would want to do that. He told us many patients have never been dealt with honestly. We spend so much time helping them recover from this. What he liked about business was that if you do not tell it like it is, you fail. Take performance reviews, as an example. One client had a secretary who was awful. None of her boss’s wanted to tell her how bad she was. As a result she continually got adequate or very good performance reviews. At one point she was assigned to work with a new executive who thought she was awful, told her she was a problem, gave her a poor review and terminated her. She filed an EEOC complaint and sued the company for sexual discrimination. As proof that she was right, she cited all of her good performance reviews. She won her case. This whole problem occurred because her previous bosses wanted to be nice and did not want to hurt her feelings.
Dr. Heidel: How has your career evolved?
Dr. Morrison: After my residency I was asked to work at Menninger’s. Initially, the program consisted of executive seminars. We began doing executive consultations, which consisted of periodic mental health checks. We sold these by saying periodic physical exams were good, but executives made money by using their mind and personality, not their bodies. The consultations were day long, intense meetings that included psychological testing and interviews with two or three people. This gave the executives a chance to work on their problems. Organizational consulting in those days consisted of seminars. I gave speeches on stress and change. I really wanted to do consultations, not seminars. I did more executive consultations, looking at their strengths and weaknesses. I met with executives on an ongoing basis to help improve their performance. Executives wanted to know the strengths and weaknesses of their subordinates, so I began having meetings with executives and their direct reports. We talked about strengths and weaknesses and what needed to be done. My role was to facilitate an honest conversation in a manner that was constructive and avoided shame. The boss and the subordinates loved it. They had never had such a conversation before. Later, as our team expanded, our process expanded and we added 360 degree feedback to the process. This improved our ability to discuss strengths and weaknesses with the boss. In the late 1990’s a profile of successful CEOs and top Executives was added to the assessment. This allowed executives to be able to compare their results with profiles of highly effective executives and CEOs who had been seen through the years. It also could be modified to allow comparison with other executives in their company. With this information, and input from the organization, our consultants could create a development plan which included things they needed to work on for the next year. The executive would say to his subordinate, “You work on this with Dave over the coming year.” In addition to this I have offered seminars on a variety of topics, including change, leadership, and balancing work and family.
Dr. Heidel: What is it about your career that you find so stimulating?
Dr. Morrison: First, I get to practice the part of psychiatry that I really like, including interviewing, dynamic issues and behavior change. Second, most people are healthy. I am able to build a strong working alliance, things move quickly and I am dealing with both broader and complex problems, such as how people think and interact with each other. Third, I work with people who really make a difference. One executive runs a business with 80,000 employees. The tone he sets and the decisions he makes impact a lot of people. Finally, I meet really exciting people and work on really important things.
Dr. Heidel: Do you have any advice for psychiatrists who are considering organizational consulting as a career?
Dr. Morrison: This work is different than traditional
psychiatry. If you think you may like this kind of work, test it out before
making a full commitment to it. Ask yourself if you really like these people.
If you think all business people are exploiting their customers, you will not
have a good time working with them. Finally, learn to sell your services and
how to do a deal. It is important to understand the essence of what is needed
to work with each person.
Dr. Heidel: Thank you. As always, it has been a pleasure talking with you.
AOOP
Organizational and Occupational Psychiatry E-mail Bulletin--December 2010
Malpractice
coverage and Record Keeping
Julia Read, MD
Malpractice coverage and medical record keeping are dreary topics at best—but especially unwelcome guests during the holidays, I think. A recent experience in Federal Court, however, as a defendant in a defamation case, makes me willing to play the Grinch for a few paragraphs in an otherwise jolly December.
I
would wager that most of us pay our malpractice premiums diligently, but don’t
spend a whole lot of time reading the fine print of our policies to sort out
what is and is not covered. The insurers
assume that we are working primarily as clinicians and are primarily providing
treatment in an office with two comfy chairs and a box of Kleenex. For those of us who do consulting to
organizations or employers, or courts and attorneys, our work may be clinical
and informed by the same principles governing good treatment, but we are not, in
general, providing treatment. We go out
of our way to clarify this in our daily practice, by explaining our role, the
lack of confidentiality and the absence of a treatment relationship to anyone
we interview. In occupational
consultations, most of us require a signed waiver, authorizing our
communication with the evaluee’s employer or insurer at the outset of the
evaluation. These practices may insulate
us from a classic malpractice lawsuit—a claim that we breeched the standard of
care with a patient and that harm resulted from our negligence—but they do not
protect us from an array of other charges and claims.
Most
of us evaluate disaffected individuals who are angry at their employers (and
the evaluators they choose), in a heap of trouble, or desperate for a
particular outcome in a high stakes situation.
We are generally not seen as helpers or advocates. It’s not a big surprise, then, that we are
vulnerable to a variety of legal actions when our consultations yield an
outcome that disappoints (or enrages) the evaluee.
In
my years of practice as a forensic and occupational psychiatrist, I have been
charged with a whole range of behaviors, including Discrimination, Defamation,
Fraud and Tortious Interference with an Employment Contract. My colleagues report a similar
experience. Most of the cases have gone
away, or failed to develop beyond the heartburn-inducing Demand letter.
This
fall, one of these cases failed to ‘go away,’ and I focused for the first time
on the fine print of my malpractice policy.
The case arose from a fitness for duty evaluation I had conducted with
the written consent of an employee for a large company. Unhappy with my report, the employee
initiated a civil lawsuit, alleging that I had engaged in Discrimination, Fraud
and Defamation.
My
malpractice insurer liberally interpreted the language of my policy, agreeing
that my evaluation constituted clinical professional practice and they would
therefore defend me against the charges.
The fine print, however, revealed that my policy excluded coverage if I
were proven to have engaged in unfair trade practices, violated a statute
intentionally, discriminated against someone, engaged in any dishonest or
criminal acts, or disclosed information without authorization. In the event that any of these actions could
be proven, I would be responsible for my legal defense and all costs.
The
risk manager for my insurer told me that her company was more generous than
most in covering my consultation work, noting that many companies would exclude
coverage for anything that was not related to the provision of clinical care.
The
story ended happily for me when the case went to trial and the jury returned a
verdict in my favor. Another civil
lawsuit was recently dismissed.
But
I am left with a few more gray hairs and a persistent anxiety about my
liability coverage. There will be more
creative lawyers and disgruntled evaluees sending me subpoenas in the future,
and I want to be prepared. To that end,
I am talking to underwriters, spelling out the nuts and bolts of my practice
and squinting my way through paragraphs of legalese.
At
the risk of sounding like a flak for Allstate, let my cautionary tale embolden
you to review your own professional liability coverage, ask a bunch of
questions about your own practice vulnerabilities, and cover your nether
regions. Then have yourself that glass
of eggnog and party on.
AOOP
Organizational and Occupational Psychiatry E-mail Bulletin -- November
2010.
Annual
Performance Appraisals: Articles of Faith or Useful Tools
Sandra K
Cohen, MD
Each year from Halloween through the end of January patients who work in medium to large corporations, consulting firms, and law firms spend session after session in psychotherapy discussing performance appraisals. Thirty years ago, more often than not, formal appraisals were scheduled, cancelled, rescheduled and ultimately never done. When appraisals were done, supervisors generally avoided serious criticism or suggestions about how the employee might develop his skills. For many employees the first time they were formally notified of their short-comings was close to the moment they were fired.
Since then, efforts within companies to improve management skills and changes in employment law requiring a paper trail before firing an underperforming employee have led companies to devote significant effort to create well-designed performance appraisals. Over time, modifications of the appraisals have mirrored changes in management theory. Initially appraisals were the responsibility of the supervisor alone. A later addition was the idea of the 360 degree review in which the opinions of subordinates, peers, and sometimes customers, were added to that of the supervisor. More recently, to combat the criticism that rivals and enemies might put forward unrepresentative criticisms in a 360 degree evaluation, a modified 360 has emerged where the employee presents his supervisor with a list (often with six names) of peers, subordinates, senior staff and customers from which the the immediate supervisor chooses a subset of the list to fill out extensive evaluations. Finally, most employers ask the employee himself to do a self-rating, which may be more or less detailed depending on the company.
There is no question that a total avoidance of feedback hurts the employee and the company. However, as these evaluations have become more cumbersome and time consuming, one might ask in what ways the benefits of the process are outweighed by the negatives----and what might these negatives be?
In the many companies that ask employees to recommend who should be asked to fill out an appraisal, anxiety builds over whom an employee will ask and who in turn, will ask them for an evaluation. Can one say no to being an evaluator, without seeming like a poor team player or raising the question of whether one is avoiding giving negative feedback? Can one limit the number of appraisals one does for non-subordinates? With most such appraisals taking an average of 45 minutes, co-workers considered to be fair are often asked to do a disproportionate number of evaluations. Once it is known who is evaluating whom, employees worry about how honest to be, especially when despite apparent anonymity, the examples given may make it clear who has done the evaluation. This is particularly stressful in evaluating senior management, which might include one’s supervisor’s supervisor. Generally it is easy to write a good appraisal, although evaluators agonize over the need to come up with some negatives, as well as concrete suggestions for areas of improvement, so that the appraisal will appear thoughtful, intelligent, fair and balanced. The longer the evaluation, generally, the more rushed and burdened the respondent feels.
The self-evaluation raises its own difficulty. Employees know that they need to highlight their accomplishments, but at the same time try to guess which areas for improvement their supervisor wants to see. Many feel overwhelmed by the gamesmanship they feel this requires. As the deadline approaches and evaluations remain undone, anxiety is mixed with anger and guilt as many begin to rush through the evaluations trying to find the easiest, but perhaps not most representative examples to put in the appraisals. Once the first round of evaluations are turned in, supervisors need to merge these with their own appraisals. Supervisors with many direct reports are particularly stressed by this job, while generally also quite anxious about what will be said about them. Once the evaluations are carefully collated, what is next? Some companies make sure that manager and subordinate spend a significant time discussing the findings. Yet despite all the effort behind these appraisals, managers at many other companies continue to avoid scheduling sessions or leave inadequate time for discussion with their subordinates. Having spent so much time working on the evaluation process, employees frequently feel short-changed at the end.
Employees tell me that the most useful observations in their appraisals are the answers to the simplest questions: In the coming year 1) what should this employee continue to do, 2) what should the employee stop doing; and 3) what should this employee begin to do?
After years of listening to patient’s anxieties, anger and disappointment with the appraisal process, I was fascinated to read Lucy Kellaway’s commentary in The Financial Times, entitled “It’s Time to Sack Job Appraisals” (Financial Times, July 11, 2010,http://www.ft.com/cms/s/0/a72a8ca6-8b8e-11df-ab4d-00144feab49a,_i_email=y.html) note: to access this link you will have to register at the site.
Her “modest proposal” is to do away with appraisals all together and substitute timely comments to subordinates about the quality of their work.
"Over the past 30 years, I have been appraised three dozen times – as banker, journalist and non-executive director. I’ve lived through the craze for long, complicated forms. I’ve also survived the informal fashion in which appraisals are called “career chats” and where a bogus air of equality prevails. I’ve done appraisals across a table, on a sofa, even over a meal. I’ve had them à deux and à trois – with a facilitator in tow."
"But never have I learnt anything about myself as a result. I have never set any target that I subsequently hit. Instead I always feel as if I am playing a particularly dismal game of charades, with three disadvantages over the traditional parlour game. There is no dressing-up box; there is no correct answer to guess and it isn’t remotely fun. The norm is a harrowing hour’s conversation during which you are forced to swallow an indigestible mix of praise and criticism referring to long-ago events, which leaves you demotivated and confused on the most basic question: am I doing a good job? The resulting form is then put on file, making you feel vaguely paranoid, even though you know from experience how much attention will be subsequently paid to it: none whatsoever."
Kellaway understands that this proposal will be met with shock; she writes:
"I have a friend in a large company who spends an entire month each year appraising her team. She says the system has been “improved” so that she no longer sorts people into “exceptional performers”, “good performers” and so on. Instead she works through a list of mysterious attributes – such as “leverages mastery” and “innovates holistically” – choosing three strengths and one development need (or weakness, as it was formerly known) for each."
"She admits that this system – which applies to almost 100,000 people worldwide – is utterly idiotic. But when I suggest it be scrapped she looks shocked. “Out of the question,” she says. “That would be interpreted as us saying we don’t care about developing people.”
Kellaway’s column was occasioned by the publication of Get Rid of the Performance Review!: How Companies Can Stop Intimidating, Start Managing--and Focus on What Really Matters by UCLA Business School professor Samuel Culbert and Lawrence Rout (Business Plus, 2010). Although I found the first few chapters decrying traditional performance reviews overly strident, the later chapters detailing Culbert’s recommendations for alternative methods of evaluation are well worth reading. I was pleased to see that his suggestions closely echoed the three questions above that my patients had found useful. Charmingly, Culbert admits that his plan also may be performed in a rote, dutiful manner which would make it as useless as the more traditional evaluation (although perhaps less time-consuming.) He argues that for any plan to work, manager and subordinate must share the goal of improving performance. One can argue that different work settings and different industries deserve performance appraisals reflecting the mission of these settings. It seemed that many of Culbert’s clients are relatively young, tech companies which most likely have cultures quite different from the companies for whom current appraisals were developed. Despite this caveat, Culbert offers managers a cogent critique of the status quo, as well as a strategy for improved assessment and management.
Where does this leave an occupational psychiatrist? Short of complete reform, how can we help our patients make the most of a flawed system? By December and January, the appraisals are in and each patient responds as befits their personality. Some are angry and defensive, others passive. Many of the most perfectionistic dwell on every negative, no matter how minor, and fail to hear any of the positive feedback. Others are enraged that bonuses, salary raises, and job security may not mirror positive or negative evaluations. Overt or covert messages to the employee that he would do well to look elsewhere for a career may be missed or over-read. Psychotherapy and psychoanalysis invites us to look at intrapsychic conflict, but it also invites us to explore aspects of the psyche which impede successful management of external reality. Although current economic conditions may make employees hesitant about leaving their current jobs, the yearly appraisal is a good time for each employee to consider whether his current job meets his personal and career goals. Even if job change might be a few years away, awareness of a desired career path may help the individual choose work and educational experiences that will facilitate pursuing that path in the long run.
September
2010
Dear Colleagues,
This month's Bulletin addresses team work in practicing medicine and in
particular as we practice psychiatry. Dr. Pflanz notes general and
specific concerns about how some psychiatrists exhibit a professional
bias that undermines teamwork and collaboration.
Over the years, I’ve heard many psychiatry colleagues talk about the advantages
to employers of hiring psychiatrists for occupational and organizational work.
To my ear, these discussions often emphasized the intrinsic superiority of
psychiatrists rather than any distinct value psychiatric training might bring
to the work. Unfortunately, the tone was often one of professional arrogance
that either implicitly or explicitly disparaged our fellow mental health
professions. My reaction to these remarks was strongly negative because I felt
they were harmful to the overall image of psychiatrists.
This issue came roaring back for me this past month. In reaction to the
recent Army Health Promotion Risk Reduction Suicide Prevention Report’s
recommendation for the hiring of more mental health counselors, one civilian
psychiatrist used an e-mail forum to call for an APA publicity initiative
emphasizing the importance of psychiatry in dealing with psychiatric issues
over other behavioral health professionals. The tone of the message clearly
suggested other behavioral health professionals were less capable.
In the Air Force, the basic unit of operation for mental health is a
psychiatrist, clinical psychologist, and clinical worker. The staff make-up may
vary somewhat from location to location, but we get used to working closely
with other mental health disciplines. Each discipline brings different
strengths to the team. In general, I’ve seen far more variation in the quality
of providers within each profession than between professions. I’ve worked with
skilled psychologists and social workers that I’d take over your average
psychiatrist any day and quite a few that could hold their own against most
psychiatrists that I know. In the end, it is the context that determines which
profession has the most to offer in a given situation. In many circumstances,
any trained military mental health professional will suffice and, in some
cases, all three professions are needed.
Don’t get me wrong – there are clearly instances when a commander (or employer)
is best served by a psychiatrist. Our unique expertise often comes into play
when biological issues are involved, when pharmacotherapy is a question, or in
more complex or serious psychiatric diagnoses, like psychoses. Psychiatrists clearly
have vast experience in assessing psychiatric illness brought to the workplace
by the employee or psychiatric illness that results from work, as well as work
factors that stimulate or interfere with healthy behavior, functioning or
development. Our medical school training emphasizes a systems approach to human
physiology and pathology. Psychiatry training teaches the understanding of
human behavior. Both of these perspectives lend themselves readily to
consultation to organizations, which are simply systems composed of
individuals.
As I mentioned, there are certainly times when a case calls for a psychiatrist
and not a psychologist or social worker. However, the number of cases to which
this applies is less common than some psychiatrists would like to think. The
quality of the psychiatry workforce is not so uniformly strong nor is the
quality of other mental health professionals so predictably low. Most cases can
be handled by a well-trained occupational psychiatrist, psychologist, or social
worker, with the distinguishing trait being skills and experience, not
profession. I have seen this truth play out on Air Force bases every day of my
career.
Why is this topic important in an occupational psychiatry forum? In consulting
to employers, professional arrogance undermines our credibility. Failing to
respect our fellow mental health disciplines reveals ugly biases and can cause
employers to question our judgment and recommendations. They may wonder if our
professional arrogance extends to other non-medical professions, such as their
own. Medicine in general requires collaborative work and this is especially
true in organizational and occupational psychiatry. The cornerstone of
collaborative work is respect for all members of the team. Even as we in AOOP celebrate
the value of our profession, let us also respect and trust the contributions of
our fellow professions.
More
about Dr. Pflanz:
Steven Pflanz is a Lieutenant Colonel in the United States Air Force and
is currently serving as Chief of the Medical staff at F. E. Warren AFB in
Wyoming. Steve has many experiences common to those who are passionate about
Occupational and Organizational psychiatry: evaluations for returning to
work, fitness for duty, improving an organization's mental health and
leading an organization as a psychiatrist. He is the immediate Past
President of AOOP and a current board member.
What has impressed me about Steve is that he has not only evaluated those
who can use lethal force (e.g., with a rifle) but also whether or not they
are fit to have access to nuclear weapons. He has also been the chief of a
suicide prevention program which has been heralded for its success.
If you choose to join us this April 16-17, you will meet Steve who is
always an active participant and colleague. I have always enjoyed his
contributions and hope you will come join us this spring.
August 2010
This month’s message from the Academy comes from a board member, our
Vice President: Greg Couser.
Here are his observations on the workplace:
Fiddlesticks! I have to admit sometimes
slightly worse expletives than this
come to mind when I'm having a particularly bad day. But in the
workplace,
as both a physician and a leader, I suppose I need to behave. This
probably
means I need to keep my frontal lobe in check and keep my curse words to
myself.
However, would it be so bad if I blew up every once
in awhile, at least to
get the attention of others around me? I could spice things up and keep
other people guessing so I don't become too predictable. After all, slot
machines work on a variable ratio schedule. You're never sure when
they're
going to pay, so you keep playing. I'm wondering if a selective breech of
etiquette on my part might serve a similar purpose and pay every once in
awhile.
The editors of the Harvard Business Review were wondering the same thing in
their June 14 article, Should leaders ever swear? You can access this
article at
http://blogs.hbr.org/hbr/hbreditors/2010/06/do_good_leaders_swear.html
<http://blogs.hbr.org/hbr/hbreditors/2010/06/do_good_leaders_swear.html>
.
As organizational and occupational psychiatrists, we're interested in
nuances of leaders' behaviors. Leaders turn to us for advice about what
to
do and what to say. And so the somewhat provocative question,
"Should
leaders ever swear?" is quite relevant to our field.
And if you've ever attended an AOOP meeting, you know these aren't the
typical boring didactic lectures. A simple question like this could spark
an hour-long spirited conversation with rather diverse opinions, many even
backed by literature and case examples. I am looking forward to such
discussion on April 16 and 17, 2011, at the University Club in Chicago, and
I hope to see you there.
So here's my opinion about leaders swe----Drat! My pager just went off.
Gotta go.
Greg Couser, MD, MPH
July
2010
As a
management consultant in the early 1990s, it seemed vaccinations might be
required to protect against the apparent plague of motivational posters that
seemed to pop up at every client site.
These
posters still adorn the
walls at some businesses, well-intentioned and probably mostly ignored at this
point. You remember them, right? The distinctive typography, all
capitalized with the first and last letter in a larger font size. Photo
inspiration via the majesty of nature. Determination - a photo of a little
sapling next to a big pine tree with the quote "It is the size of one's
will which will determine success." Achievement - a picture of
a man on top of a mountain juxtaposed with the Teddy Roosevelt quote, "It
is hard to fail,
but it is worse never to have tried to succeed." As I recall, there
were an inordinate number of trees and mountains.
Turns out they may have been onto something.
The goal of motivational posters, it would seem, is to subliminally inspire by
priming the brains of employees with positive affect.
Guess what?
There's evidence that priming (both positive and negative) makes a
difference in teamwork and organizational behavior that employees and managers
aren't consciously aware of.
These ideas are touched upon in a great review article you might have missed
from last summer (published in the August 2009 Research in Organizational
Behavior - aren't all psychiatrists at the beach that month?) titled
"Implicit affect in organizations" by Sigal Barsade (at Wharton
School of Business), Lakshmi Ramarajan (Harvard Business School) and Drew
Westen (Emory University).
The authors
discuss the reasons why we should be paying
attention, in effect, to the emotional unconscious (not in a strictly
Freudian sense) and provide a solid review of the neuroscience evidence for
implicit affect in its varying forms.
If your institution lacks direct access to the journal, here's a link:
http://www.sciencedirect.com/science?_ob=ArticleListURL&_method=list&_Articl
eListID=1379787236&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=
10&md5=24e4777e6a5b3265525cfd3b5f3b15d5
What does this mean for occupational and organizational psychiatrists?
The implications are both broad and deep. We know our patients and
clients are not always reliable narrators of what's happening for them, but the
evidence cited in this article can help us discuss with them how action on
unconscious emotion naturally happens and how to avoid being pulled down
preconceived, unconscious roads that lead to neither individual nor
organizational well-being.
-- Josh Gibson, M.D.
June
2010
As
Psychiatrists we want our patients’ work to be fulfilling. Yet the work
place can be tough to navigate, promoting mental health most of the time but
also with the potential to cause psychiatric symptoms.
Consider the following link to better understanding what your patients go
through:
The comments
section voices what many patients are thinking about their boss, the performance
appraisal process and their organization. You may hear echoes as you listen to
your patients or ask about their work life.
What
does this mean for Occupational Psychiatry? As is true for any human endeavor,
the challenge of delivering effective feedback in the workplace will never be
perfected, but it is worth working to maximize its potential for individual and
organizational benefit. We—the Academy of Organizational and Occupational
Psychiatry--are an organization that thrives on dialogue and feedback.
President,
Academy of Organizational and Occupational Psychiatry