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Evidence-Based Reviews


Impaired physicians: How to recognize, when to report, and where to refer

Legal and ethical issues complicate intervening when a colleague needs assistance

Vol. 9, No. 6 / June 2010
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From all outward appearances Dr. S, a part-time psychiatrist at an inpatient psychiatric facility and in private practice for 12 years, is living the “perfect life,” with a wife, children, and successful practice.

In retrospect, his drug addiction began insidiously. In college, Dr. S continued to use oxycodone/acetaminophen prescribed for a shoulder injury long after his pain had resolved. He began to use cocaine in residency to help him “get through” the 36-hour call days, and it “helped” him earn the chief resident position because of his heightened energy and concentration. Dr. S’ primary care physician initially prescribed him benzodiazepines for anxiety and to help him sleep. Opiates were prescribed for a musculoskeletal injury. Dr. S obtained prescriptions for these medications from multiple providers. This ultimately escalated to self-prescription using aliases. Dr. S also began to drink heavily each evening.

Dr. S disregards colleagues’ comment about his obvious mood swings, which he attributes to his stressful job and “nagging” wife, despite having a family history of bipolar disorder. He becomes enraged when his wife or friends suggest he seek help. His colleagues whisper behind his back, but for years, no one confronts him about his unpredictable and frequently inappropriate behavior. Eventually, a nurse files a sexual harassment suit against Dr. S, and a patient complains to the medical board that Dr. S exhibited sexually inappropriate behavior during a therapy session.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence.1 Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.1-3

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

  • review substance abuse, cognitive decline, and other causes of impairment
  • address legal and ethical issues involved in reporting a colleague to the state medical board
  • provide resources for physician treatment and assistance.

Physicians and addiction

Chemical dependence is the most frequent disabling illness among physicians,4 and substance abuse is the most common form of impairment that results in discipline by a state medical board.5 An estimated 6% to 8% of physicians abuse drugs, and approximately 14% develop alcohol use disorders; these rates are comparable to those of the general population.5 Psychiatrists, emergency room physicians, and solo practitioners are 3 times more likely to abuse substances than other doctors.6 An obsessive-compulsive personality and other factors may predispose physicians to substance abuse (Table 1).7,8

Alcohol is the most commonly abused substance, followed by opiates, cocaine, and other stimulants.9 Physicians are estimated to use opiates and benzodiazepines at a rate 5 times greater than that of the general public.10,11

An often-hidden problem. Physicians frequently deny substance abuse and many are able to conceal the problem from coworkers, even as their personal lives disintegrate.1,12 Marital and relationship problems may be the first indication of impairment, which gradually spreads to other aspects of their lives (Table 2).1,2,5 A doctor’s professional performance often is the last area to be affected.1,12

Substance abuse in physicians may long go unreported. The clinician’s family may want to protect the physician’s reputation, career, and income. Colleagues may be intimidated, uncertain of their concerns, or fearful for their jobs if they report the physician’s impairment. Patients may be reluctant to report their concerns because they depend on their provider for health care, respect the physician, or deny that a doctor could have a drug or alcohol problem.5

Table 1

Physicians and substance abuse: Predisposing factors

Obsessive-compulsive personality style

Family history of substance use disorders or mental illness

Childhood family problems

Personal mental illness

Sensation-seeking behavior

Denial of personal and social problems

Perfectionism

Idealism

Source: References 7,8

Table 2

Signs of substance abuse

Frequent tardiness and absences

Unexplained disappearances during working hours

Inappropriate behavior

Affective lability or irritability

Interpersonal conflict

Avoidance of peers or supervisors

Keeping odd hours

Disorganization and forgetfulness

Diminished chart completion and work performance

Heavy drinking at social functions

Unexplained changes in weight or energy level

Diminished personal hygiene

Slurred or rapid speech

Frequently dilated pupils or red and watery eyes and a runny nose

Defensiveness, anxiety, apathy, or manipulative behavior

Withdrawal from long-standing relationships

Source: References 1,2,5

Screening for cognitive decline

Many people with cognitive impairment lack insight into their problem and may minimize or deny the degree of their impairment.13 The prevalence of dementia in individuals age ≥65 is 3% to 11%,14 and 18% of physicians are in this age group.15

Ethical, legal, and practical issues arise in determining who, when, and how to screen physicians for cognitive problems. Standard screening exams may not be adequately sensitive for a well-educated physician, and neuropsychological testing may be necessary to detect mild cognitive impairment.13 In addition, the cognitive, visual-spacial, reactivity, reasoning, and calculation skills required for capable medical practice vary among specialties.16

One screening option is a “360-degree review” of information obtained from peers, patients, and non-physician colleagues that the College of Physicians and Surgeons in Alberta, Canada, has incorporated into its Physician’s Achievement Review (PAR) for physicians age ≥65.17 Compiled in a confidential manner and shared with the physician, the 360-degree survey assesses his or her:

  • skill and knowledge
  • psychosocial functioning
  • management skills
  • performance
  • collegiality.

In Alberta, physicians who score in the lower one-third of the survey are assessed with an on-site evaluation by physicians from his or her specialty appointed by the PAR Director of Practice Improvement.

Alternately, physicians age ≥65 could be required to undergo annual or biannual neuropsychological testing to screen for mild cognitive impairment or other evidence of cognitive decline. In the United States, any screening requirement must be structured to comply with the Age Discrimination in Employment Act.18

If a physician shows evidence of cognitive impairment, the state medical board should initiate closer scrutiny and modify or revoke privileges if indicated. Remediation programs designed to assist impaired physicians may not be effective for those with cognitive impairment because the decline in cognitive functioning associated with illnesses such as Alzheimer’s disease often is progressive.13

‘Disruptive’ physicians

Mental illnesses such as personality or affective disorders, interpersonal problems within or outside the workplace, or other stressors could lead a physician to disrupt the workplace or patient care. Numerous programs have been established across the United States to help evaluate and treat disruptive physicians. Remediation programs can help identify and offer education for “dyscompetent” physicians (see Related Resources).13

To report, or not to report

In a national survey of physicians, only 45% of respondents indicated that they had notified the state licensing board of a colleague they felt was impaired or incompetent, yet almost all (96%) indicated that these individuals should be reported.19 Any duty to report requires, at minimum, that the physician be affected by an illness that impairs his or her cognition, concentration, rapid decision making, and ability to handle emergencies or perform work functions safely.20

Shouten20 cautions that someone who is considering filing a report because of fear of liability if they don’t should balance this concern against potential liability for breaching confidentiality. If there is evidence of an imminent risk or serious harm to the physician or patients, you may be legally required to breach confidentiality. Some states require licensed health practitioners to report acts of professional misconduct, unless the information is obtained solely from directly treating the physician. These requirements apply only within the state, and only to that state’s licensees.20-22

An ethical requirement to report also must be balanced against the obligation to maintain confidentiality. Ethics are largely a matter of individual standards, and individuals’ perceived ethical duties vary.

If you are considering reporting an impaired colleague, learn the laws in your state. If the physician is from another jurisdiction, the law provides little definitive guidance. Shouten recommends focusing on clinical outcomes for the doctor and his or her patients rather than on legal liability.20

Physician health programs

Nationwide directories of physician health programs are available from the Federation of State Physician Health Programs and the Federation of State Medical Boards (see Related Resources). Some programs are affiliated with state licensing boards, some are branches of state medical societies, and some are independent. These programs provide confidential treatment and assistance to practitioners experiencing substance or alcohol abuse, mental illness, or disruptive behavior. Some institutions may offer physicians an employee assistance program.

State medical societies may provide information about accessing a physician health program. Programs sponsored by medical societies almost always are independent of state licensing boards. This arrangement allows physicians to seek help without fear of punishment or censure or revocation of their license. Noncompliance with a physician health program, however, likely will result in being reported to the medical board.

Physician health programs typically employ a rehabilitative approach. Punitive measures such as reporting physicians to the medical board usually are not pursued unless the individual does not comply with treatment and monitoring guidelines. A physician who abuses substances, for example, may be required to complete a residential treatment program, attend support group meetings such as 12-step programs, participate in individual therapy, and undergo random screening for alcohol and illicit drug use.5

Abstinence is the goal of treating clinicians who abuse substances. Physicians have better outcomes than the general population, with reported abstinence rates of 70% to 90% for those who complete treatment;23,24 75% to 85% of physicians who complete rehabilitation and comply with close monitoring and follow-up care are able to return to work.24,25 Acceptance of recovery as a lifelong process, monitoring, and self-vigilance often are necessary to achieve and maintain abstinence.5

Risk factors for relapse include:

  • denial of illness
  • poor stress-coping and relationship skills
  • social and professional isolation
  • inability to accept feedback
  • complacency and overconfidence
  • failure to attend support group meetings
  • dysfunctional family dynamics
  • feelings of self-pity, blame, and guilt.5

Treating an impaired colleague. Reid26 recommends that psychiatrists should not evaluate or treat a self-referred, potentially impaired physician unless the relationship is strictly clinical. A physician may withhold symptoms, behaviors, or problems because his or her license, malpractice case, or career are at stake.

Advise a physician who requests evaluation or treatment related to license concerns or any legal matter to seek legal counsel. Working with such physician/patients only upon referral by a lawyer, licensing board, or physicians’ health committee provides treating psychiatrists with a clear professional role, allowing them to focus solely on the physician/patient’s treatment needs.

CASE CONTINUED: Extensive help, then success

The medical director of the hospital where Dr. S works refers him to his state’s impaired physician program. After investigating the complaints by the nurse and patient, the medical board suspends Dr. S’ license and requires him to enter a substance abuse treatment program. He completes an intensive residential program for impaired physicians and achieves sobriety from drugs and alcohol. His mood disorder is successfully treated with medications and psychotherapy. The medical board requires Dr. S to have a chaperone present for all visits with patients and submit random urine drug screens once his license is provisionally restored. The medical board also requires Dr. S to undergo ongoing psychiatric care and medication monitoring. He remains abstinent from alcohol and drugs, complies with the medical board’s requirements, and enjoys a productive practice and improved relationship with his family.

Continued...
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