Neuropsychological Testing Coalition for Physician Enhancement 2014 Spring

Neuropsychological Testing: Coalition for Physician Enhancement 2014 Spring Meeting

Neuropsychological Testing BETSY WHITE WILLIAMS, PHD MPH Assistant Professor, Rush University Medical Center Clinical Director, Professional Renewal Center

Disclosures Betsy White Williams is the owner and Clinical Director of the Professional Renewal Center in Lawrence, Kansas. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Learning Objectives After participating in this activity learners will be: Learning Objective 1: Discuss how neuropsychological testing differs for physicians vs. the general public. Learning Objective 2: Discuss how to select the proper battery for the referred physicians. Learning Objective 3: Be familiar with neuropsychological issues that could potentially affect a physician’s fitness for duty. Learning Objective 4: Recognize the importance of neuropsychological testing in treatment and return to work planning. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Outline of Talk Case Study Overview of Neuropsychology Brief Review of Studies on Neuropsychological Screening Elements of Neuropsychological Evaluations Cases and Discussion Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Case Study This is a 51 -year-old male diagnostic physician. Reportedly the physician had a history of disruptive behavior in the workplace. This behavior includes a lack of timely charting as well as poor interactions with colleagues and support staff. While these issues are longstanding, this behavior is noted to have worsened both in terms of frequency and intensity. Most recently there have also been two reported instances of diagnostic error. This led to referral for evaluation. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Major Physician Performance Problems Kaigas, T. Assessment of the Performance of Practicing Physicians in Canada. 5 th International Medical Workforce Conference, Sydney 2000 Session 2: Assessment of Doctors’ Performance in Practice - Canada Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Overview of Neuropsychology A field that studies the structure and function of the brain as they relate to specific psychological processes and behaviors. Involves the administration of objective psychological tests and related procedures that are proven sensitive to the effects of brain injury; Involves the integration of statistical and observational findings, and history Considers psychosocial history, personality, medical and physical health history, and mechanisms of brain injury in order to make sense of present mental functioning and clinical presentation; Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Results of Neuropsychological Screening in Underperforming Professionals Turnbull et al. , (2000): Competency referred sample of physicians compared to age and education norms (1. 5 hour screening battery) Perry and Crean (2005): Competency referred compared to normative reference samples (abbreviated neuropsych battery) Turnbull et al. , (2006): Follow up to their 2000 study (1. 5 hour screening battery) Korinek et al (2009): Competency referred compared to normal comparison physicians. (Microcog) Kataria et al (2014): 135 competency referred healthcare practitioners working in NHS referred to NCAS (ACE-R) Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Results of Neuropsychological Screening in Underperforming Professionals Turnbull et al. , (2000): “A significant minority of incompetent physicians have cognitive impairments sufficient to explain both their incompetence and, probably, their failure to improve with remedial CME. Testing physicians for these impairments is important: to detect and treat reversible conditions, to manage irreversible conditions that preclude successful educational intervention, and to facilitate compensation in this instance. Serious consideration should be given to the incorporation of neuropsychological screening in all intensive physician review programs. ” Perry and Crean (2005): “This cohort of physicians is performing lower than expected on tests of intellectual and neuropsychological functioning. Applying a neuropsychological framework to the assessment of physicians may uncover potential cognitive factors that contribute to medical practice errors. ” Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Results of Neuropsychological Screening in Underperforming Professionals Turnbull et al (2006): “A large minority of the physicians who fell significantly below desired levels of competence had cognitive impairment sufficient to explain their lack of competence and their failure to improve with remedial CME”. Korinek et al (2009): “Because there were significant neuropsychological differences between physicians referred for competency evaluations and physicians whose competency was not in question, it is important that neuropsychological screening be included as part of physicians’ competency evaluations. ” Kataria et al (2014): “Our findings highlight the need for increased vigilance and training of responsible officers to recognise performance problems and emphasise the importance of comprehensive assessment. ” Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Microcog Level I Content domains: Attention/Mental Control, Memory, Reasoning/ Calculation, Spatial Processing, and Reaction Time. Level II- Processing speed and accuracy that are not domain specific Information processing speed Information processing accuracy Level III- Global cognitive functioning scores General cognitive processing General processing proficiency (combination of speed and accuracy) Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Microcog Subtest scores Mean=10 SD=3 Index Scores Mean=100 SD=15 Scores are reported as above average, low average, below average General cognitive processing General processing proficiency (combination of speed and accuracy) Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Microcog Normative Sample (n=810) Age range 18 -89 Stratified by Age Gender Race (African American, Hispanic, White) Geographic Region Education Less than high school High school Greater than high school Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Microcog Overview From Korinek et al. , 2009 Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Highway to the Danger Zone Chappelle et al. 2010 Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Overview of Neuropsychology A field that studies the structure and function of the brain as they relate to specific psychological processes and behaviors. Involves the administration of objective psychological tests and related procedures that are proven sensitive to the effects of brain injury; Involves the integration of statistical and observational findings, and history Considers psychosocial history, personality, medical and physical health history, and mechanisms of brain injury in order to make sense of present mental functioning and clinical presentation; Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Overview of Neuropsychology Three Broad Approaches Boston Process Approach Halstead Reitan Battery Luria-Nebraska Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Overview of Neuropsychology Neuropsychological Testing Diagnosis Patient Care Management Planning Treatment What are treatment needs What is treatment efficacy Disease Course Forensic Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Pre-morbid Intellectual Functioning Attention/concentration Learning and Memory Language Visuoconstructional/Visuospatial Functioning Problem solving Executive/Control functions-how behavior is expressed Planning, decision-making, social conduct, flexibility Motor Functioning Sensory Functioning Emotional Functioning Environmental Factors Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

What is Typically Assessed Intellectual Functioning A summary and multifaceted concept of general mental capability, reflecting the ability to comprehend, adapt to, and interact with the environment. A composite of several domains. May not reflect some forms of brain injury or disorder. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Components of WAIS-IV Intellectual Functioning Premorbid IQ Current Intellectual Functioning Wechsler Adult Intelligence Scale-IV Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WAIS IV Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Attention and Processing speed Attention and Processing Speed -- The capability to focus and sustain attention in mental activity is reflected in processing speed, simple accuracy in a sustained focus task, divided thinking among tasks, mental manipulation and control, and resistance to internal or external distraction. Digits Forward-immediate memory and rote recall Spatial Span-a visual analog Trail Making Test A: speeded attention, mental tracking and visual search, Cancellation Tasks Continuous Performance Test (CPT) measures sustained and selective attention and impulsivity Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Learning and Memory Working Memory -- closely related to attention ability to keep a limited amount of information active, frequently up-dated, and rapidly accessible for a brief time span. Learning and Memory -- The ability to encode new information, store information in a relational memory system, and retrieve information verbal/auditory spatial/visual Tests include California Verbal Learning Test Rey Auditory Verbal Learning Test Wechsler Memory Test-measures verbal and visual memory Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Language Receptive language is measured in reading and ability to comprehend spoken language. Expressive language is measured in writing and ability to formulate oral communications Boston Naming Test Boston Diagnostic Aphasia Exam Aphasia Screening Test Controlled Oral Word Association Test Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Visuoconstructional/Visuospatial Functioning The ability to receive, interpret, and apply meaning to visual information Block-design tests, Clock-drawing test Copy of a complex figure Line and angle perception ability to mentally manipulate 2 -dimensional and 3 dimensional figures Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Problem solving and Judgment advanced, higher-order information processing where knowledge is assessed and manipulated to find solutions to problems. The ability to make informed and reasoned judgments. problem definition and formulation generation of alternatives decision making, and solution implementation and verification Test Examples include Similarities subtest of the WAIS Wisconsin Card Sorting Test Category Test Tactual Performance Test Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Executive Functioning ability to achieve insight and self-awareness; to reflect on, initiate, evaluate, and regulate (activate and inhibit) thinking and behavior; to think flexibly; and to make decisions integrating judgment and feedback Tests include Trail Making, Part B Category and Letter Fluency Design Fluency Wisconsin Card Sorting Test Porteus Mazes Iowa Gambling Test Delis Kaplan Executive Function System Executive Control Battery Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Motor Functioning Ability to perform gross and fine motor tasks Tests include Grooved Pegboard Finger Tapping Grip Strength Tactual Performance Test Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Sensory and Sensory Perceptual Functioning The ability to detect basic visual, auditory, and tactile sensations is critical to processing information at higher levels. Tests include Right left orientation Finger tip number writing Seashore Rhythm Test Tactual Form Recognition Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Emotional/Personality Functioning Often used to accompany neuropsychological tests to assess personality and emotional status that might lend understanding to reactions to neurofunctional impairment. Tests include MMPI-2 RF MCMI-III, PAI, 16 PF, Neo-PI R Various self report anxiety and depression measures Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

WHAT IS TYPICALLY ASSESSED Clinical Interview What is the individual’s sense of the situation Are there any external stessors Are there any medical conditions that individual is aware of Is there a history of psychiatric illness What is family/psychiatric history Does the client engage in self care activities Is there a history of exposure, previous head trauma, learning difficulties Description of practice situation Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED This can depend on purpose of the evaluation Is it for diagnosis? Is it to document treatment response? Is it to document possible progression of a disease process? Is it to determine implications for functioning? Is it to determine fitness for duty? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED Typically since there are often not serial evaluations of an individual test, interpretation is based on NORMS Norms are data that make it possible to determine the relative standing of an individual who has taken a test. Norm-Referenced Test (NRT) is a type of test, which yields an estimate of the position of the tested individual in a predefined population Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED What is the NORM for doctors? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Assessing high accountability professionals Appropriate Norms Appropriately Challenging Tests Consideration of Elements of Job/Practice Recognition of System Demands and Impact Remember Purpose of Evaluation Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

OTHER IMPORTANT QUESTIONS Again this depends on reason/purpose for evaluation but. What is the ecological validity of tests? Brunswik (1955)-are the findings obtained within a controlled experiment or environment generalizable to what we see in the real world How well do the test results reflect everyday functioning? How well do tests predict outcome or future functioning? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

OTHER IMPORTANT QUESTIONS What is the ecological validity of tests? Franzen and Wilhelm (1996): Veridicality and verisimilitude Veridicality -“the extent to which test results reflect or can predict phenomena in the open environment” Verisimilitude-“the topographical similarity of the data collection method to a task in the free environment” Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Ecological Validity What is the ecological validity of neuropsychological tests? A L Schueneman, J Pickleman, R Hesslein, R J Freeark (1984). Study assessed predictive utility of neuropsychologic tests of nonverbal cognitive and psychomotor abilities in accounting for individual differences in surgical skills Compared their efficiency with those of traditional residency selection criteria. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED OTHER IMPORTANT Q’s 120 general surgery residents underwent neuropsychologic testing and were also rated by attending surgeons on surgical skills exhibited during the course of 1445 surgical procedures. Results of neuropsychological battery yielded three factors (complex visuo-spatial organization, stress tolerance, psychomotor abilities that were unrelated to traditional measures). Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED OTHER IMPORTANT Q’s Neuropsychological test scores show significant positive correlation with the attendings’ ratings. “These tests may provide a useful addition to traditional methods of predicting operative skills” Did a number of studies looking at variables affecting ability patterns in surgeons Found neuropsychological testing helpful when looking at other variables (age and gender) in understanding surgical performance Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED OTHER IMPORTANT Q’s How do we understand failure Do we focus on individual physician? Do we focus on public safety? How do we balance the two? Are we doing evaluation for diagnostic purposes, forensic purposes, or some other purpose? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED OTHER IMPORTANT Q’s What Norms should be used? This is particularly salient when dealing with assessment of older physicians So, is it ok if the performance of a 75 -yearold surgeon is consistent with other 75 -yearolds or does it need to be consistent with that of a 50 year old? Norms used also can vary as a function of the reason the evaluation is being done Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

HOW IS TESTING INTERPRETED OTHER IMPORTANT Q’s How do we interpret those whose first language is not English? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Older physicians Is it normal aging or a disease process Given normal aging, do there need to be changes made to the practice? Physicians with various health problems: Cerebrovascular issues Metabolic issues Sleep apnea Post head injury Neurological issues (MS, PD, etc) Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Physicians with Substance Use Disorders Part of Fitness for Duty Evaluation Determining Possible Progression or Improvement in Functioning Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Older physicians Are changes part of normal aging? Is it dementia or “pseudodementia”? Is it another kind of dementia? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Older physicians If no neuropsychological deficits are found (normal aging) are the changes in aging such that changes still need to be made to practice? If neuropsychological deficits are found (disease process) are they sufficient to preclude the safe practice of medicine If neuropsychological deficits are found (disease process) but not sufficient to preclude practice, what changes/safeguards would continue to ensure safe practice? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Physicians with various health problems: Cerebrovascular issues Metabolic issues Sleep apnea Post head injury If deficits are found are they sufficient to preclude the safe practice of medicine If deficits are found (disease process) what are next steps Medical follow up Re-testing, etc Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Physicians with various health problems: Cerebrovascular issues Metabolic issues Sleep apnea Post head injury If deficits are found (disease process) but not sufficient to preclude what changes/safeguards would continue to ensure safe practice? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Physicians with Substance Use Disorders Alcohol and other drugs Are there cognitive changes that will in some way negatively impact ability to participate in recovery program Are there cognitive changes that will or may influence long term recovery Are there cognitive deficits sufficient to preclude the safe practice of medicine? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Physicians with Substance Use Disorders Alcohol and other drugs Are there cognitive deficits that have impacted practice currency Do we expect recovery over time and if so in what area(s) of functioning? When might we anticipate improvement? If deficits are found, but not severe enough to preclude practice what changes/safeguards would continue to ensure safe practice? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Part of Competency Evaluation Are there neuropsychological sequellae that contribute to practice competency issues? Is there a treatable medical condition? How might this impact practice of ability to benefit from CME/CPD? Part of Fitness for Duty Evaluation Are there cognitive deficits sufficient to preclude the safe practice of medicine? Are there cognitive concerns sufficient to warrant competency evaluation? Are deficits suggestive of a treatable medical condition? Do we expect recovery over time and if so in what area(s) of functioning? When might we anticipate improvement? If deficits are found, but not severe enough to preclude practice what changes/safeguards would continue to ensure safe practice? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

OUR DATA? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

CASE STUDY This is a 51 -year-old male diagnostic physician. Reportedly the physician had a history of disruptive behavior in the workplace. This behavior includes a lack of timely charting as well as poor interactions with colleagues and support staff. While these issues are longstanding, this behavior is noted to have worsened both in terms of frequency and intensity. Most recently there have also been two reported instances of diagnostic error. This led to referral for evaluation. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

CASE STUDY History Attended Ivy league undergraduate and medical school Married but estrangement in marriage History of trauma No history previous head injury No history LD or ADHD English first language Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

CASE STUDY Testing Premorbid Intellectual Functioning – 125 Performance on neuropsych screen: Average Intellectual Functioning: Verbal Comprehension Index: High Average Perceptual Organization Index: Average to Low Average Processing Speed Index: Mild-to-Moderate Impairment Working Memory: Mild-to-Moderate Impairment Attention/concentration: Mild Impairment Learning and Memory: Slow at learning new information Inconsistent recall Good recognition Language: Average Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Testing Visuoconstructional/Visuospatial Functioning: Low Average-to Mild Impairment, slow in completing tasks Problem solving: Low Average to Mild Impairment Executive/Control functions-Mild Impairment Motor Functioning: Average Sensory Functioning: Average Emotional Functioning: elevations for depression, anxiety, trauma Obsessive compulsive and narcissistic traits Environmental Factors: multiple external stressors including marriage, issues of aging parents. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Other Elements of Evaluation Increased alcohol use to “cope” Long history of problematic interactions, staff unwilling to work with physician Psychiatric Evaluation positive for depression, anxiety and trauma Medical Evaluation Sleep apnea Poorly controlled asthma High blood pressure, poorly controlled Diabetes Type II poorly controlled Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Other Elements of Evaluation Increased alcohol use to “cope” Psychiatric Evaluation positive for depression, anxiety and trauma Medical Evaluation Sleep apnea Poorly controlled asthma High blood pressure, poorly controlled Diabetes Type II poorly controlled Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Dispensation Not cleared to return to work Medical follow up and stabilization of medical and psychiatric issues Participation in professionals program Re-testing at 3+ months Significant improvement across areas assessed Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

When can neuropsychological testing be helpful Dr. C is a 62 -year old married left-handed procedural specialist who was referred for a comprehensive multidisciplinary evaluation. Events prompting the referral included that Dr. C was described as gruff and difficult to interact with, especially in the OR suite. Of great concern was that he had a higher than anticipated rate of complications. A recent event that was of great concern was that he let his tech perform aspects of procedures that he had been counseled against previously. This event raised concerns about his cognitive functioning. Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

CASE STUDY History Born and raised in US Educated in US Second marriage, young children from current marriage No History of trauma No history previous head injury No history LD or ADHD English first language Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

CASE STUDY Testing Premorbid Intellectual Functioning – 121 Performance on neuropsych screen: High Average Intellectual Functioning: Verbal Comprehension Index: High Average Perceptual Organization Index: Average to Low Average (slow) Processing Speed Index: Mild-Impairment Working Memory: Average-to-High Average Attention/concentration: High Average Learning and Memory: Average to High Average Language: Average Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Testing Visuoconstructional/Visuospatial Functioning: performance varied as a function of whethere was a motor component Problem solving: High Average Executive Functions-High Average Motor Functioning: Mild to Moderate Impairment dominant hand Sensory Functioning: Mild to Moderate Impairment dominant hand Emotional Functioning: results suggestive of situational anxiety and depression Obsessive compulsive and narcissistic traits Environmental Factors: financial concerns related to having young children Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Other Elements of Evaluation Long history of “gruff behavior” with poor interactions occurring if things were not done exactly as he requested Psychiatric Evaluation positive anxiety related to current situation. Reported chronic neck and back pain Medical and Specialist Evaluations Degenerative changes/problems at the C 3 - C 4 level Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Dispensation Not cleared to return to work secondary to motor issues including weakness, poor speed, strength, fine motor coordination Surgical intervention Retesting post recuperative period Ongoing motor and sensori-motor issues Physician participated in short course of treatment opted to hire junior partner Physician continues to practice but does not do procedures, Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Summary Neuropsychological Testing can be helpful in diagnosis, treatment and return to work planning. It is important that age and education corrected norms are used It is important to understand demands of the physician’s job performance Detailed clinical interviews which include health and substance use histories are also important Serial testing can be of great benefit Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Q and A If you would like newer presentation feel free to contact me: Betsy Williams, Ph. D MPH bwilliams@prckansas. org 785 -842 -9772 Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014

Cases Dr. D What would your diagnosis be? What would your concerns be? What would you recommend? Would you clear physician to return to practice? If what if any practice restrictions/oversight would you recommend? Presentation by BWWilliams, Ph. D. , M. P. H. , Professional Renewal Center to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams not for duplication or distribution without express written consent 19 June 2014