UC San Diego PACE PROGRAM Fitness for Duty Program Peter Boal, B.S. Associate Director UC San Diego PACE Program

Objectives Review the PACE FFD Program’s: History Processes Evaluations completed to date Discuss challenges faced and goals for the future

How Our FFD Program Came To Be Robust health screening has always been part of the PACE competency assessment The first 250 (or so) competency assessments included a complete neuropsychological evaluation and H&P exam Eventually deemed excessive (and possibly cruel and unusual punishment) Last 1300 (or so) competency assessments have included the MicroCog, self-report forms (PHQ-9, UCSD Family Medicine adult health history questionnaire), and a complete H&P Currently ~ 6-7% of competency assessments result in failure due to impairment (about 5-6 per year)

Magical* Mac ‘N Cheese *NOT laced with cannabis

How Our FFD Program Came To Be Heightened triglyceride levels from Mac ‘n Cheese lunch in February 2011 triggered an epiphany: The rise in inquiries about impairment was likely correlated to the fact that physicians as a group were aging We had done many FFDEs over the years, but had not really considered them as such Our experience assessing physician competence allows us to contextualize FFDEs to the physician’s practice in ways few other programs could As part of the UC San Diego Health System, we had all the resources necessary to conduct FFDEs We need to start a Fitness for Duty Program. NOW

PACE FFD Program Processes First Step: establish whether evaluation will be FFD only or combined with competency Second Step: Determine who will receive results and whether agreement between UCSD and a hospital/medical group is needed Third Step: Obtain background information from referring agency and physician: Information requested from referring agency: Reason(s) for referral in writing Timeline of events Job description if available and/or list of privileges Any additional relevant information

PACE FFD Program Processes Information requested from physician: Personal health records Intake form Adult Health Questionnaire Patient Health Questionnaire (PHQ-9) CV Root cause analysis

PACE FFD Program Processes Fourth Step: Review background information to determine scope of FFDE Only core component is background forms physician submits and an interview with Dave Bazzo, MD, FFD Program Director All other components are selected based on background information received If physician is a proceduralist, we will try to include functional simulation of skills at UCSD’s Simulation Center Fifth Step: Schedule FFD evaluation

PACE FFD Program Processes Sixth Step: Review results and assign final grade Clearly fit for all aspects of duty Fit for some duties, but not others (fit with accommodations) Unfit for duty 7th and Final Step: write final report summarizing all aspects of FFDE

Overview of FFDEs to Date First PACE FFD Evaluation – July 2011 Total FFDEs to date = 24 (22 participants*) *1 participant has been evaluated 3 times 12 of 24 were combined with competency assessment Year # of Physicians 2011 5 2012 9 2013 3 2014 7

Overview of 24 FFDEs to date Referred By N Hospital/medical group 19 Physician state health program 2 Medical Board 2 Self referral 1

Where our FFD participants are from WEST = 17 MIDWEST = 4 NORTHEAST = 3

Who are our participants? 17 Male and 7 Female Average age of group = 54 Oldest = 75 Youngest = 32 Average age of male physicians = 58 Average age of female physicians = 45

Who are our participants? SPECIALTY # Of Physicians Internal Med/GI 3 Radiology 3 Ob/Gyn 3 Critical Care* 3 Anesthesiology 2 Ophthalmology 2 Neurosurgery 2 Interventional Cardiology 1 Family Medicine 1 Vascular Surgery 1 Pediatrics 1 Emergency Medicine 1 Burn Surgery 1

Reasons for Referral Area of Concern # Of physicians Cognitive 10 Psychiatric 3 Behavioral 7 Neurologic 5 Medical 2 Competence 12 Substance Abuse 4 Boundaries 2

FFD Elements Used and Their Frequency Component N Percentage Interview w/Program Director 19 79% Neuropsychological Evaluation 18 75% Physical Health Exam 15 63% Procedural Skills Simulation 12 50% Psychiatric Evaluation 13 54% Neurologic Evaluation 8 33% Behavioral Evaluation 7 29% Tox Screen 1 4%

Results 24 evaluations total 12 participants received a combined competence and fitness for duty evaluation 12 participants (totaling 9 FFDEs) received a fitness for duty evaluation only Final Grade N % Avg Age Clearly Fit 5 20.8% 56.4 Fit with accommodations 11 45.8% 55.5 Unfit 4 16.7% 54.0 Pending 3 12.5% 44.7 Incomplete 1 4.2% 59.0

Results Continued Competency Evaluation Results 12 Competence Evaluations performed Final Grade N Avg Age Clear Pass 5 55.0 Pass with minor recs 0 N/A Pass with major recs 4 56.3 Fail 1 70.0 Incomplete* 2 67.0 *further competence eval requested, but not completed

Challenges Obtaining job cards and privileges Obtaining medical records Using simulation to measure functional abilities Report writing Average report is 15-20 pages in length Hard to write enough without saying too much

Future Goals Further utilize simulation for evaluation of procedural functional abilities Hone final reports

Questions

Thank You UC San Diego Center for the future of surgery