1. Evaluation of the Potentially Impaired Resident/Fellow Michele Kilo, MD Developmental Pediatrician Chief, Section of Developmental and Behavioral Sciences Chair, Medical Staff Health and Wellness Committee

2. Overview The Impaired Resident/Fellow – CMH statistics Diagnoses Overview Case Presentations CMH Process

3. Definition of Impairment Definition by AMA….”the inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness, including alcoholism and drug dependence.” Potential Forms of Impairment:  Classic – substance use & abuse  Mental Illness – Axis I & Axis II  Disruptive Behavior  Medical Issues

4. CMH Resident/Fellow Stats H/W Committee began accepting resident/fellow referrals in 2004 2004 – 2009, 22 total referrals, 3 fellows plus 1 fellow transitioning to medical staff From January 2010, 8 total referrals, 2 fellows

5. Diagnoses Overview Axis IDepression, Anxiety Disorder Obsessive-Compulsive Disorder Axis IIPersonality Disorders Mental Retardation Axis IIIGeneral Medical Conditions Axis IVPsychosocial and Environmental problems Axis VGlobal Assessment of Functioning

6. Diagnoses Overview Axis I disorder symptoms are commonly seen in residency and fellowship and include anxiety and depression. Axis I disorders typically respond to outpatient or inpatient treatment, including psychotherapy, medication (combination of these two often best) or treatment programs.

7. Diagnoses Overview Axis II disorders include personality disorders (narcissistic, histrionic, borderline, paranoid, schizoid and antisocial). Axis II disorders are “hard wired", VERY difficult to treat and are EXTREMELY disruptive to the individuals around the person with this type of disorder.

8. Diagnoses Overview Depression:  Depressed mood  Marked diminished interest or pleasure in previously enjoyed activities  Significant weight loss when not dieting or weight gain  Insomnia or hypersomnia  Excessive or inappropriate worthlessness or guilt  Diminished ability to think or concentrate, indecisiveness  Fatigue, lethargy, apathy  Thoughts of suicide

9. Diagnoses Overview Anxiety:  Excessive anxiety and worry  Restlessness, sleep disturbance, fatigue  Difficulty concentrating or mind going blank  Irritability, quick to display temper  Symptoms not due to medical condition – racing heart, chest pain  Symptoms cause clinically significant distress or impairment in social functioning - isolation

10. Diagnoses Overview Obsessive Compulsive Disorder  Consists of either obsessions or compulsions Obsessions defined as:  Recurrent or persistent thoughts, impulses or images that are experienced as intrusive and inappropriate and cause marked anxiety or distress  The thoughts, impulses or images are not simply excessive worries about real problems  Person attempts to ignore or suppress and/or neutralize such thoughts with other thoughts or actions  Person recognizes the obsessional thoughts, impulses or images as a product of his/her own mind

11. Diagnoses Overview Obsessive Compulsive Disorder (cont’d)  Consists of either obsessions or compulsions Compulsions defined as:  Repetitive behaviors that person feels drive to perform in response to an obsession, or according to rules that must be applied rigidly  Behaviors or mental acts are aimed at preventing/reducing stress or some dreaded event/situation; however, these behaviors or mental acts are either not connected in a realistic way or are clearly excessive

12. Case #1 2 nd year resident/fellow Excellent clinician, superb attending evaluations Extremely dedicated and committed in all h/s does Highly anxious, has strong need to check and re-check work Doesn’t trust colleagues to manage h/h patients

13. Case #1, continued Has great difficulty completing work in timely manner At times, feels paralyzed Believes h/s alone is responsible for difficult outcome and/or death of patients Considering leaving medicine

14. Health and Wellness Committee Process How to make referral, who should refer Timing of referral Michele’s role Introductory interview/assessment Use of obtained information  Consideration of most likely diagnosis  Ascertain acuity  Determine next steps including appropriate evaluation and/or center/provider

15. Case #2 1st year resident/fellow Clinically strong, attending evaluations good until PICU rotation Long-standing issues of biological depression Not currently medicated Increased tearfulness, constant feeling of being overwhelmed Extended family stressors Fleeting thoughts of suicide – no plan

16. Health and Wellness Committee Process How to make referral, who should refer Timing of referral Michele’s role Introductory interview/assessment Use of obtained information  Consideration of most likely diagnosis  Ascertain acuity  Determine next steps including appropriate evaluation and/or center/provider

17. Case #3 3 rd year resident/fellow Bright, good clinician, previously a good team-member Numerous family tragedies occurring within last year Struggling with staying focused at work Cries daily while at work Conflict between need to work and need to support family at home Recent miscarriage

18. Health and Wellness Committee Process How to make referral, who should refer Timing of referral Michele’s role Introductory interview/assessment Use of obtained information  Consideration of most likely diagnosis  Ascertain acuity  Determine next steps including appropriate evaluation and/or center/provider

19. Case #4 3 rd year resident/fellow Clinically okay, not as stellar as h/s believes Very detailed, structured Frequently talks about h/h devotion to program, h/h role/accomplishments to the exclusion of colleagues Not at all a team-player Talks about h/h outstanding productivity or accomplishments but often leaves important tasks incomplete

20. Health and Wellness Committee Process How to make referral, who should refer Timing of referral Michele’s role Introductory interview/assessment Use of obtained information  Consideration of most likely diagnosis  Ascertain acuity  Determine next steps including appropriate evaluation and/or center/provider

21. Health and Wellness Committee Process - continued Follow-up –  All gathered information, whether verbal or in writing is kept confidential  Each individual referred has h/h own file maintained in locked drawer of H/W Chair  Always request resident/fellow signs releases for exchange of information between H/W Chair and evaluating/treating providers  Ongoing monitor of status  Explicit documentation of all interactions

22. Mental Health Costs to Residents/Fellows  HR recommends all trainees choose the Premium Health Plan which has the lowest deductible ($ 1200)  Our job to consistently encourage participation in CMH’s Wellness – Health Basics program First $ 500 paid in full by CMH If health basics check then $ 300 added $ 800 then covered of $ 1200 deductible Trainee only pays $ 400 remaining  Trainees should always complete form for insurance reimbursement even if they pay for service up front In network provider covered 90/10 Out of network provider covered 60/40  NO difference between medical and mental health coverage in CMH contracts

23. Mental Health Costs to Residents/Fellows When H/W Committee recommends comprehensive assessment cost has always been covered by CMH Ongoing treatment, therapy typically covered by individual Always exceptions depending on circumstances H/W Chair interested in “loan” or assistance program for trainees paid for via medical staff budgeted funds

24. Thanks for your interest! Questions/discussion...