1. The Impaired Medical Staff Member Michele Kilo, MD Kathryn Pieper, PhD Stephanie Andrews, LSCSW, LCSW Section of Developmental & Behavioral Sciences

2. The Impaired Medical Staff Member I. Forms of impairment II. Response to impairment III. Process of reporting impairment

3. Definition of Impaired Physician The American Medical Association Council on Mental Health published a report defining physician impairment as “the inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness, including alcoholism and drug dependence.”

4. Forms of Impairment Classic – Substance Use & Abuse Mental Illness – Axis I & Axis II Disruptive Behavior Medical Illness

5. Classic Form of Impairment Substance Use and Abuse: – Overall, the prevalence of substance use disorders in healthcare professionals appears to be about equal to that in the general population (8-14%). – Identification of substance abuse and dependence in healthcare professionals is often very difficult because of extremely strong denial and the “Conspiracy of Silence.”

6. Classic Form of Impairment Substance Use and Abuse: – Healthcare providers tend to have better treatment outcomes. – Patterns of substance use include recreational use, performance-enhancement (seen more in ER physicians) and self-treatment of pain, anxiety and depression (seen more in residents and practicing physicians). – What can this look like?

7. Classic Form of Impairment Substance Use and Abuse by Medical Specialty – highest use: – Anesthesiology- due to access to drugs with high potential for abuse and addiction – Emergency Medicine – higher prevalence in most studies – higher prevalence of marijuana and cocaine use – Psychiatry – higher prevalence in most studies – higher prevalence of benzodiazepine use.

8. Classic Form of Impairment Substance Use and Abuse by Medical Specialty – lowest use: – OB/Gynecology – Pathology – Radiology – Pediatrics

9. Mental Illness A multiaxial system involves an assessment on several axes, each of which refers to a different domain of information that may help the clinician plan treatment and predict outcome. There are five axes included in the DSM-IV multi-axial classification:

10. Mental Illness Axis IClinical Disorders Other Conditions That May Be a Focus of Clinical Attention Axis IIPersonality Disorders Mental Retardation Axis IIIGeneral Medical Conditions Axis IVPsychosocial and Environmental Problems Axis VGlobal Assessment of Functioning

11. Mental Illness Axis I disorders are commonly seen in impaired medical staff include Anxiety Disorder and Depression. Axis I disorders typically respond to outpatient or inpatient treatments, including psychotherapy, medication or treatment programs.

12. Mental Illness Axis II disorders include personality disorders (narcissistic, histrionic, borderline, paranoid, schizoid and antisocial). Axis II disorders are VERY difficult to treat and are EXTREMELY disruptive to the individuals around the person with this type of disorder.

13. Mental Illness Personality disorders develop over a period of many years and are characterized by persistent difficulty in interpersonal relationships. Individuals with this type of disorder view the problems they encounter as SOMEONE ELSE’S fault.

14. Disruptive Behavior May often be associated with a combination of above-mentioned forms of impairment. Overt or subtle intimidating behavior including: – Verbal, physical, emotional, undermining, degrading, demeaning, negative – Can include boundary violations such as sexual and professional boundaries – Other staff refusing to work with this person – Can be extremely subtle

15. Medical Illness Importance of attending to observed impairment in a timely manner If impairment is a newly observed behavior, may be medically induced Greater chance, for all impaired behavior, for a successful recovery the sooner intervention takes place.

16. Response to Impairment By Impaired Medical Staff: – Fear of consequences – Loss of license = loss of identity/potential loss of career – Feelings of “I can take care of myself” – Strong tendency to self-diagnose and treat – Disease understanding does not equal disease acceptance – Shame & embarrassment

17. Response to Impairment By Staff: – Fear of Intimidation by impaired medical staff member – Fear of loss of job if known as whistle blower – Peer pressure to keep “conspiracy of Silence” – After reporting concerns, lack of follow through, feeling of vulnerability

18. Process of Reporting Impairment Ethical obligation to report a physician who may be endangering the lives of others through impairment – result of the 1972 AMA House of Delegates State Impaired Physicians Programs, also known as Physicians Health Programs, are present in all 50 states, as a result of The Disables Doctors Act of 1974.

19. Process of Reporting Impairment The Missouri State Medical Association established the Missouri Physician Health Program (MPHP) in 1985. The MPHP is legally and financially independent of licensure and regulatory agencies, such as the Board of Healing Arts, BNDD and DEA. It has no reporting requirements to the National Practitioner Data Bank.

20. Process of Reporting Impairment MPHP maintains a confidential hotline Physicians who volunteer to participate in the program have the opportunity to arrest the progression of their disease and check their impairment before public exposure, disciplinary action of licensing boards or loss of family relationships, financial resources and clinical privileges occurs.

21. Process of Reporting Impairment As of January 2001, the Joint Commission on Accreditation of Healthcare Organizations has required that all JCAHO accredited hospitals establish a “process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.”

22. CMH Process of Reporting Potential Route of Reporting: – Person themselves, to express your concerns – Section Chief – Department Chair – Any chosen confidant in a position of authority Anyone and everyone can make an anonymous and confidential referral *Please remember this is all confidential

23. Staff Advocacy Process Recently Developing Chaired by Chief Nursing Officer, Cheri Hunt, RN Dr. Kilo a member If concerns about an Allied Health professional staff and/or other employee that may or may not involve patient/parent interactions a referral can be made to the Staff Advocacy Committee Appropriate referrals

24. Conclusion: Physicians helping Physicians Not meant to be a punitive process Goal is for early identification and intervention for greatest opportunity for recovery and return to practice.