Download 03 Williams CPE Final 6 19 14

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. 5th
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, 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
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
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 3dimensional 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 neuro-functional
impairment.
Tests include
MMPI-2 RF
MCMI-III, PAI, 16PF, 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 butWhat 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-year-old
surgeon is consistent with other 75-year-olds 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
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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
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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 whether there 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 C3- C4 level
Presentation by BWWilliams, Ph.D., M.P.H., Professional Renewal Center
to a meeting of the Coalition for Physician Enhancement, (c) BWWilliams
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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, PhD MPH
[email protected]
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