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

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

3. 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.

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

5. 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

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

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

8. 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.”

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

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

11. 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?

12. 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).

13. 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?

14. 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.

15. “Appropriate Entities”
Who are the appropriate entities?

16. 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

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

18. 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

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

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

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

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

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

24. 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

25. 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

26. 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).

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

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

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

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

31. 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

32. 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

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

34. 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

35. 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:

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

37. 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.

38. 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.

39. THE END Resource: Classic:
Thompson K, Teitelbaum SA. Impaired healthcare provider. UpToDate.
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: