Anita R. Webb, PhD JPS Family Medicine Residency Fort Worth, Texas Impaired Physicians Anita R. Webb, PhD JPS Family Medicine Residency Fort Worth, Texas

Objectives Awareness of Prevalence of physician impairment Treatment options Knowledge Role of colleagues Treatment outcomes

Key Points 1. Impaired physicians present a dilemma. They pose a danger to the public. They need help. They are reluctant to seek help. 2. Colleagues can help resolve this dilemma. 3. Successful treatment options are available.

Examples of Impairment Compared to the general population, what percentage of physicians have: Drug use disorders Alcohol use disorder Depression (see next slide)

PREVALENCE Prevalence is comparable to the general population 6%: drug use 14%: alcohol 13/20%: depression At some point in their careers ~15% of physicians will be impaired

Physician Risk Factors Occupational Hazard Stress Access to addictive substances “Culture of Medicine”

High Risk Specialties Anesthesiology Emergency Medicine Why? Two medical specialties at highest risk for substance use disorder (SUD) Anesthesiology Emergency Medicine Why?

High Risk Jobs These specialties are characterized by High risk medical situations Performance under pressure Different types of personalities? These specialties “tend to attract physicians who are more likely to engage in high-risk behaviors in their personal lives.”

Detection of Impairment At work? At home? Family is more likely to notice symptoms before colleagues

Work Impairment Performance is usually last thing impacted Why? What does that imply about detection?

Should You Intervene? Example: Substance abuse What would you do if you suspect that a colleague’s performance is impaired by a substance use disorder (SUD)? Have you ever been in that situation? What happened?

Colleague’s Role “If a colleague is concerned that a physician has an SUD that is impairing his or her function, “It is that colleague’s ethical duty to “Act immediately to intervene.” Ross SD. Identifying an impaired physician. Virtual Mentor: Ethics Journal of the American Medical Association 2003;5(12).

BARRIERS What is the biggest obstacle with physician SUD? Addicted doctors Are skilled at “covering up” Have high levels of denial Are NOT receptive to colleague interventions So what can you do to help?

AMA “Principles of Medical Ethics” II. A physician shall… Strive to report physicians Deficient in character or competence, Or engaging in fraud and deception, To appropriate entities.

“Appropriate Entities” Who are the appropriate entities?

Reporting a colleague to State board? BARRIER: When a physician is reported to state board Formal disciplinary proceedings are initiated Risk of adverse actions against that physician’s license

Is there a solution? How can you protect both? Patients (the public) Your colleague

Physician Health Programs (PHP) In all states Usually sponsored by state medical societies In cooperation with state board Focus on health and rehabilitation Not disciplinary actions

Offers an Alternative Path An impaired physician has a choice. Can voluntarily accept help through PHP Versus being reported to the state board

Why Use PHP? Legal advantages of PHP Can advocate for physician at Board level Less risk of adverse actions against license

Your Role Report potentially impaired physician to PHP Rather than to the state medical board Can be done anonymously

Advantage Before someone reports that physician to the state board! PHP contacts the impaired physician Before someone reports that physician to the state board!

PHP Services Example: Substance Abuse (SUD) 1. Help to plan an “Intervention” 2. Comprehensive Assessment 3. Appropriate referral for treatment 4. Monitoring after treatment

The “Intervention” Purpose: To overwhelm the physician’s denial Method: Present facts about negative effects of physician’s SUD behavior Confrontation Team Family, peers, friends, supervisors, clergy Each one states impact of physician’s impairment

Treatment: Therapeutic, not punitive SUD: Goal is abstinence More favorable outcomes than general population Treatment and follow-up are more intense Continue random drug testing: Usually 5 years Continue support group Barrier: Expensive

One-Year Relapse Rate 90% for general population 10-25% for physicians “Programs for impaired physicians provide the most comprehensive treatment available.” Merlo LF, Gold MS. Addiction research and treatment. Psych Times 2008;25(7).

Also Address “Intense guilt and shame” “Collateral damage” Family Finances Colleague reactions

EXAMPLE: Texas Rehabilitation Order Effective 9/01/2005 Confidential Non-disciplinary

Texas’ PHP Services Chemical dependency Mental health Behavioral health Sexual misconduct/boundaries Physical illness [and aging issues] Stress management

Nation-Wide: Hospitals New JCAHO requirement: 2001 Physician Well-Being Committees Mandatory at every hospital To identify physician impairment To manage physician impairment

Hospital “Policies/Procedures” Impairment policy applies to whom? All practitioners with privileges at hospital Who is authorized to be a “complainant”? Any employee To whom is the complaint reported? President of the Medical Staff

Investigation Separate from usual staff disciplinary process Confidentiality is maintained Possible actions Assist in finding rehabilitation program Determine if conduct requires outside reporting Re-instatement following rehabilitation Continued monitoring

Summary: Reporting Who is reported? What? Where? When? How? Any impaired practitioner Functional impairment Clinical settings “Immediately” Hospital: Med Staff Pres.

What About Residents? High rates of burnout Factors 1. Tremendous responsibilities 2. Feel they have “very little control” Anger and fatigue increase as internship year progresses

Resident Burnout “Catastrophic level of stress” Situational: Demands of residency Personal: Family, $, time, support system Professional: Career planning,, uncertainty Levey RE. Sources of stress for residents and recommendations for programs to assist them. Acad Med 2001;76:142-150.

Evaluation of Training Model How is the Internship model “good”? How is the model “bad”? How does internship contribute to later physician impairment?

Summary Physician impairment is being recognized and addressed by regulating bodies, medical societies, state boards, and hospitals. The focus is on treatment, not punishment. Resources are available to help impaired physicians. Colleagues have an ethical duty to intervene in a supportive manner.

Key Points 1. Impaired physicians present a dilemma They are a danger to the public. They need help. They are reluctant to seek help. 2. Colleagues can help to resolve this dilemma Direct or report impaired physician to “appropriate entities” for treatment options.

THE END Resource: Classic: Thompson K, Teitelbaum SA. Impaired healthcare provider. UpToDate. www.utdol.com. Accessed July 24, 2009. Classic: AMA Council on Mental Health. The sick physician: impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973;223:684-687.