1. ”A Treating Doc’s View of Treating Docs”
By Zachary A. Kordik, M.D.
IAEAPE Annual Conference – Chicago, IL
October 28, 2016

2. Affiliations Rush University Medical Center
Hazelden Betty Ford Foundation
Foundations Recovery Network
I have received no funding or sponsorship from any commercial entity in regards to this presentation.

3. Objectives
List and describe risks specific to certain high accountability professions and specialties.
Navigate barriers in identifying and recommending appropriate treatment for professionals.
Recognize the need, methods, and resources for professional treatment and advocacy in returning to work.

4. Substance Abuse by Industry
“Substance Use and Substance Use Disorder by Industry”
Published by SAMHSA most recently April 16, 2015
Data collected between 2008 and 2012 by the National Survey on Drug Use and Health (NSDUH)
Combined data from 2008 to 2012 indicate that an annual average of 8.7 percent of full-time workers aged 18 to 64 used alcohol heavily in the past month, 8.6 percent used illicit drugs in the past month, and 9.5 percent were dependent on or abused alcohol or illicit drugs in the past year.

8. Health of the physician
Physician Impairment
When assessing possible impairment of a physician two things must be weighed:
Health of the physician
Vs.
Safety of the public

9. Health of the physician
Physician Impairment
When assessing possible impairment of a physician two things must be weighed:
Health of the physician
Vs.
Safety of the public

10. Health of the physician
Physician Impairment
When assessing possible impairment of a physician two things must be weighed:
Health of the physician
Vs.
Safety of the public
(This is how most media, governments, and the public in general will see this balance.)

11. Definitions Physician Impairment (AMA):
“Any physical, mental, or behavioral disorder that interferes with the physician’s ability to engage safely in professional activities.”

12. Definitions Physician Impairment (AMA):
“Any physical, mental, or behavioral disorder that interferes with the physician’s ability to engage safely in professional activities.”
Can be a result of:
Mental disorder
Physical illness or condition
Substance related disorder

13. Definitions Physician Impairment (AMA):
“Any physical, mental, or behavioral disorder that interferes with the physician’s ability to engage safely in professional activities.”
Can be a result of:
Mental disorder
Physical illness or condition
Substance related disorder
Illness does not, per se, constitute impairment.

14. Definitions Disruptive Physician Behavior (AMA):
“A style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care.”

15. Definitions Disruptive Physician Behavior (AMA):
“A style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care.”
Behavior that is exhibited as a pattern

16. Definitions Disruptive Physician Behavior (AMA):
“A style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care.”
Behavior that is exhibited as a pattern
Can include words, attitudes, and actions

17. Definitions Disruptive Physician Behavior (AMA):
“A style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care.”
Behavior that is exhibited as a pattern
Can include words, attitudes, and actions
Potential to interfere with quality healthcare

18. Definitions Disruptive Physician Behavior (AMA):
“A style of interaction with physicians, hospital personnel, patients, family members, or others that interferes with patient care.”
Behavior that is exhibited as a pattern
Can include words, attitudes, and actions
Potential to interfere with quality healthcare
Is a descriptive label, not a diagnosis

19. Physician Impairment
Estimates suggest that approximately 15% of physicians will be impaired at some point in their careers.

20. Physician Impairment
Estimates suggest that approximately 15% of physicians will be impaired at some point in their careers.
The leading cause of physician impairment is chemical dependence.

21. DSM-IV vs. DSM-V DSM-IV (1994-2013)
Substance d/o divided into two separate diagnoses
Dependence – “dependence syndrome”
Abuse – social and interpersonal consequences of heavy use
Dependence above abuse in a hierarchy
Abuse should not be diagnosed with dependence was present

22. DSM-IV vs. DSM-V

23. DSM Criteria DSM-5: Alcohol/Substance Use Disorders Specifiers:
Mild – presence of 2-3 symptoms
Moderate – presence of 4-5 symptoms
Severe – presence of 6 or more symptoms

24. DSM Criteria DSM-5: Alcohol/Substance Use Disorders
If full criteria for substance use disorder were previously met:
In early remission – no criteria* met for 3-12 months
In sustained remission – no criteria* for > 12 months
*with the exception of “craving, or a strong desire to use”

25. Chemical Dependency
Alcohol is the most commonly abused substance among physicians
Alcohol use disorders are no more common among physicians than similarly matched controls

26. Chemical Dependency
Alcohol is the most commonly abused substance among physicians
Alcohol use disorders are no more common among physicians than similarly matched controls
Physicians have higher rates of abuse of prescription drugs
Physician misuse of benzodiazepines and opioids are up to 5X higher than in age matched populations

27. Chemical Dependency
Possible reasons for higher rates of physician Rx drug abuse:

28. Chemical Dependency
Possible reasons for higher rates of physician Rx drug abuse:
Easy access to these prescriptions/drugs

29. Chemical Dependency
Possible reasons for higher rates of physician Rx drug abuse:
Easy access to these prescriptions/drugs
Familiarity with prescription drugs

30. Chemical Dependency
Possible reasons for higher rates of physician Rx drug abuse:
Easy access to these prescriptions/drugs
Familiarity with prescription drugs
Overconfidence about drug use

31. Chemical Dependency
Substances being abused by physicians in treatment: Drug of Abuse Percent Alcohol 39.5 Opioids 33.9 Cocaine 11.9 Sedatives 3.7 Marijuana 2.8 Inhalants 1.8 Amphetamines 1.8 Other 4.6

32. Chemical Dependency
Specialty Percent

33. Chemical Dependency
Specialty Percent Anesthesiology

34. Chemical Dependency
Specialty Percent Anesthesiology ER

35. Chemical Dependency
Specialty* Percent Anesthesiology 21 ER 18 Surgery 6 Family Medicine 6 OB/GYN 6 Radiology 6 Pathology 6 Neurology 3 Psychiatry 3 *Percentage of total number of 109 physicians in treatment

36. Mental Illness Comorbidities
Physician substance abuse is associated with increased risk of suicide.

37. Mental Illness Comorbidities
Physician substance abuse is associated with increased risk of suicide.
Suicide rates are 40% higher in male physicians than age- matched peers.

38. Mental Illness Comorbidities
Physician substance abuse is associated with increased risk of suicide.
Suicide rates are 40% higher in male physicians than age- matched peers.
Suicide rates are 130% higher in female physicians than age- matched peers.

39. Mental Illness Comorbidities
Physician substance abuse is associated with increased risk of suicide.
Suicide rates are 40% higher in male physicians than age- matched peers.
Suicide rates are 130% higher in female physicians than age- matched peers.
Mental health problems that began before medical school may worsen during training.

40. Identifying Physician Impairment
Colleagues must play a role in the identification of impaired physicians.

41. Identifying Physician Impairment
Colleagues must play a role in the identification of impaired physicians.
AMA Code of Medical Ethics – informs physicians they have an ethical obligation to report impaired, incompetent, and unethical colleagues.

42. Identifying Physician Impairment
Colleagues must play a role in the identification of impaired physicians.
AMA Code of Medical Ethics – informs physicians they have an ethical obligation to report impaired, incompetent, and unethical colleagues.
Many states allow for this to be done anonymously.

43. Treatment for Impaired Physician

44. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment

45. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Self-recognition

46. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Self-recognition
Friends, family, or colleagues

47. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Self-recognition
Friends, family, or colleagues
Employer/Supervisor

48. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Self-recognition
Friends, family, or colleagues
Employer/Supervisor
EAP

49. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Self-recognition
Friends, family, or colleagues
Employer/Supervisor
EAP
Medical board

50. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Self-recognition
Friends, family, or colleagues
Employer/Supervisor
EAP
Medical board
Legal entity

51. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment

52. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Detoxificaton - treatment for withdrawal

53. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Detoxificaton - treatment for withdrawal
Professionals treatment program – PHP/IOP: 6-8 weeks
Group therapy and support
Individual counseling
Education
MAT – Medication Assisted Treatment

54. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Detoxificaton - treatment for withdrawal
Professionals treatment program – PHP/IOP: 6-8 weeks
Group therapy and support
Individual counseling
Education
MAT – Medication Assisted Treatment
Consider sober living residence

55. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Step 3: Aftercare

56. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Step 3: Aftercare
Caduceus contract – requirements of aftercare for advocacy

57. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Step 3: Aftercare
Caduceus contract – requirements of aftercare for advocacy
Continuing care group – weekly for 1-2 years

58. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Step 3: Aftercare
Caduceus contract – requirements of aftercare for advocacy
Continuing care group – weekly for 1-2 years
Monitoring – random urine screens for 2-5 years

59. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Step 3: Aftercare
Caduceus contract – requirements of aftercare for advocacy
Continuing care group – weekly for 1-2 years
Monitoring – random urine screens for 2-5 years
Return to work – determine when, how, in what role, and with any restrictions

60. Treatment for Impaired Physician
Step 1: Recognition of impairment and referral for treatment
Step 2: Treatment
Step 3: Aftercare
Caduceus contract – requirements of aftercare for advocacy
Continuing care group – weekly for 1-2 years
Monitoring – random urine screens for 2-5 years
Return to work – determine when, how, in what role, and with any restrictions
May include specific requirements of employer or medical board

61. To Report or Not To Report…
Does an impaired physician have to report to the Board?

62. To Report or Not To Report…
Does an impaired physician have to report to the Board?
Yes, will likely eventually have to report to the Board.

63. To Report or Not To Report…
Does an impaired physician have to report to the Board?
Yes, will likely eventually have to report to the Board.
A better question is…

64. To Report or Not To Report…
Does an impaired physician have to report to the Board?
Yes, will likely eventually have to report to the Board.
A better question is…
When should an impaired physician report to the Board?

65. To Report or Not To Report…
Does an impaired physician have to report to the Board?
Yes, will likely eventually have to report to the Board.
A better question is…
When should an impaired physician report to the Board?
As a rule, it is always better for a physician to self-report rather than to be reported.

66. To Report or Not To Report…
Does an impaired physician have to report to the Board?
Yes, will likely eventually have to report to the Board.
A better question is…
When should an impaired physician report to the Board?
As a rule, it is always better for a physician to self-report rather than to be reported.
It is usually favorable to have advocacy established prior to reporting.

67. Treatment for Impaired Physician
The function of a treatment plan is rehabilitative and not punitive.

68. Treatment for Impaired Physician
The function of a treatment plan is rehabilitative and not punitive.
Confidentiality and anonymity should be maintained for impaired physicians during and after treatment.

69. Treatment for Impaired Physician
The function of a treatment plan is rehabilitative and not punitive.
Confidentiality and anonymity should be maintained for impaired physicians during and after treatment.
Many states achieve this through state Physician Health Programs (PHP).

70. Treatment for Impaired Physician
The function of a treatment plan is rehabilitative and not punitive.
Confidentiality and anonymity should be maintained for impaired physicians during and after treatment.
Many states achieve this through state Physician Health Programs (PHP).
Physician Health Programs are not directly associated with state medical boards.

71. Professional Health Programs
Purpose:
To assist, guide, and advocate for participants, so they can attain and maintain overall wellness while safely practicing in their chosen profession.
A PHP addresses any physical, emotional, and/or behavioral problem that might interfere with their ability to live meaningful and satisfying professional and personal lives.

72. Professional Health Programs
Services:
Confidential screening and referral
Consultation and guidance
Support and monitoring
Accountability thru documentation of compliance
Substance use disorders, mental/behavioral health problems, disruptive behavior, stress related problems, boundary disorders, physical illness

73. Professional Health Programs
Confidentiality:
Confidentiality is one of the core commitments!
PHP’s can only release information with the explicit authorization of the participant.

74. Professional Health Programs
Confidentiality:
Confidentiality is one of the core commitments!
PHP’s can only release information with the explicit authorization of the participant.
Authority:
Most PHP’s have NO disciplinary role or authority.
PHP activities are solely related to advocacy, education, wellness, and support.

75. Thank You!
Thank you for your
time and attention.
Questions???