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Malpractice Rx


Physician impairment: When should you report?

Vol. 10, No. 09 / September 2011

Discuss this article at www.facebook.com/CurrentPsychiatry

Dear Dr. Mossman:
Lately, a physician colleague has been arriving late for work. He seemed drunk a couple of times, and he’s been making some careless but minor mistakes. When would I have a duty to report him for suspected impairment? He is a longtime friend, which makes me uncomfortable with the prospect of having to report him.—Submitted by “Dr. Z”

Holding ourselves to ethical guidelines and standards of conduct sometimes is hard, but when we become responsible for our colleagues’ behavior, things can get awkward. Yet the responsibilities of practicing medicine include professional self-regulation.1 Failure to monitor ourselves and each other would put the reputation and integrity of the medical profession at risk—not to mention the safety of our patients. Despite this, many physicians are understandably reluctant to report colleagues who appear impaired.

To decide whether you should report a colleague, you must:

  • know what behaviors constitute impairment
  • understand the duty to report impaired colleagues
  • realize reporting colleagues often creates emotional conflict
  • understand recovery options and resources available for impaired practitioners.

After we examine these matters, we’ll see what Dr. Z should do.

Impairment defined

Physician impairment is a public health issue that affects not just physicians but their families, colleagues, and patients. In this context, “impairment” means a physical, mental, or substance-related disorder that interferes with a physician’s ability to undertake professional activities competently and safely.2

Although many mental conditions can cause impairment, we focus here on substance abuse, a condition that often leads to functional impairment. Physicians develop addictions at rates at least as high as those in the general population.3 Physicians-in- training—including psychiatric residents—are at particularly high risk for developing stress-related problems, depression, and substance misuse.4,5

Occupational demands, self-criticism, and denial of one’s own distress are common failings among physicians,5 as is self-treatment, which may help explain the high rates of substance misuse among physicians.6 Behaviors that suggest a colleague may be abusing substances and experiencing occupational impairment appear in Table 1.7

Table 1

Signs of physician impairment

Deteriorating personal hygiene

Increased absence from professional functions or duties

Emotional lability

Appearing sleep-deprived

Increased professional errors (eg, prescriptions, dictations, clinical judgment)

Not responding to pages or telephone calls

Decreased concern for patient well-being

Citing unexplained ‘personal problems’ to mask deficits in concentration or patient care

Increased patient complaints about quality of care and bedside manner

Many ‘accidental’ injuries (possibly contrived to obtain narcotic prescriptions)

Source: Reference 7

Reporting duties

Doctors and physician health programs have a duty to report impaired colleagues who continue to practice despite reasonable offers of assistance. This obligation appears in professional guidelines (Table 2)2,8 and in laws and regulations governing the practice of medicine. Laws and regulations are similar in spirit across jurisdictions, although the exact wording varies from state to state (Table 3).9-11 Physicians are responsible for being familiar with reporting requirements in states they practice and complying accordingly.

Physicians must follow state guidelines and protocols for reporting a colleague’s impairment. In many situations, an intermediate step—such as notifying a chief of service or a physician health program—might occur before a report of impairment goes to a licensing board. Options for reporting impaired physicians appear in Table 4.2,12

Table 2

Medical associations’ official positions on reporting impairment

American Medical Association (Policy H-275.952)2

‘Physicians have an ethical obligation to report impaired, incompetent, and unethical colleagues.’

Federation of State Medical Boards8

Physician health programs have ‘a primary commitment to [help] state medical boards … protect the public … [These] programs [should] demonstrate an ongoing track record of ensuring safety to the public and reveal deficiencies if they occur.’

Table 3

State medical board rules on reporting physician impairment: 3 examples

State

Rules

California9

California’s Medical Practice Act contains no mandatory reporting requirement. ‘However, … the Board clearly is concerned about physicians who potentially present a danger to their patients. Reporting an impaired colleague to the Medical Board will allow the Board to ensure adequate protections are in place so a colleague who requires assistance will not harm the public. The Board keeps the sources of complaint information confidential.’

Montana10

‘[E]ach licensed physician … shall … report to the board any information … that appears to show that a physician is’ impaired. However, ‘[i]nformation that relates to possible physical or mental impairment connected to [substance misuse or illness] may be reported to’ Montana’s physician rehabilitation program ‘in lieu of reporting directly to the board.’

Ohio11

‘Any Board licensee having knowledge’ that a physician is impaired because of substance misuse ‘is required … to report that information to the Board. … [H]owever, … the [impaired] physician’s colleagues may be excused from reporting the physician’s impairment … if the [impaired] physician has completed treatment with a Board approved treatment provider and maintained uninterrupted sobriety, and violated no other provisions of the Ohio Medical Practice Act.’

Table 4

Options for reporting impaired colleagues

Impairment in hospital-based physicians may be reported to the hospital’s in-house impairment program, the hospital’s chief of staff, or another appropriate supervisor (eg, a chief resident)

Impairment in physicians with office-based practices may be reported to hospitals where they have privileges or to the state’s physician health program

Colleagues who continue to practice despite offers of assistance and referrals for treatment or for whom the above options are not available should be reported to the state licensing board

Source: References 2,12

Overcoming emotional factors

Doctors facing the need to report an impaired colleague often experience emotional conflicts because the impaired is a mentor, supervisor, trainee, friend, or practice partner. Denial, stigmatization, concerns about practice coverage, and fear of retaliation also can contribute to non-reporting. Although we know a colleague’s substance misuse represents a threat to his patients’ welfare and safety,13 reporting a colleague forces us to overcome our allegiance to a fellow practitioner.

Medical professionals should remember, however, that it is always better to identify and treat illnesses early in their course. When early referrals are not made, doctors afflicted by illness often remain without treatment until more severe impairment causes workplace errors. Withholding information about an impaired colleague from supervisors or state medical boards does a disservice to patients and to the colleague. The colleague’s drug or alcohol problems may worsen, and recovery or acquisition of future licenses might become more difficult or impossible. Initial application for medical licensure in 47 states and the District of Columbia inquire about physicians’ recent history of mental health and substance abuse problems, as well as their functional impairment.14 Even renewal of state medical licensure examines applicants’ mental health, physical health, and substance abuse histories.15

Recovery resources

Many institutions and medical board committees have instituted written policies for dealing with workplace addiction.13 An awareness of and sensitivity to physician vulnerability and early detection and prevention of impairment are important.2

At least 39 states have “sick doctor statutes” that permit licensure suspension for physicians who cannot practice medicine safely because of illness or substance use disorders.16 Several states have forms of “immunity”—license protection and preservation—for physicians who seek treatment voluntarily, and some states have legislative provisions that require impaired physicians to get treatment and be monitored so they can keep their licenses.17 In almost every state, medical societies have established physicians’ health committees and treatment programs (Table 5).18

Table 5

Examples of state physician health programs

State

Organization

Contact

Colorado

Colorado Physician Health Program

(303) 860-0122
www.cphp.org

Florida

Professional Resources Network

(800) 888-8776
www.flprn.org

Illinois

Illinois Professional Health Program

(800) 323-8622
www.advocatehealth.com/IPHP

Massachusetts

Physician Health Services, Inc.

(781) 434-7404
www.massmed.org

Minnesota

Health Professionals Services Program

(651) 643-2120
www.hpsp.state.mn.us

Nevada

Nevada Professionals Assistance Program

(702) 521-1398
www.medboard.nv.gov

New York

Committee for Physician Health, Medical Society of the State of New York

(518) 436-4723
www.cphny.org

Ohio

Ohio Physicians Health Program

(614) 841-9690
www.ophp.org

Oregon

Oregon Health Professionals Program

(503) 620-9117
www.oregon.gov/OHA/addiction/health-professionals.shtml

Tennessee

Physicians Health Program, Tennessee Medical Foundation

(615) 467-6411
www.e-tmf.org

Texas

Committee on Physician Health and Rehabilitation, Texas Medical Association

(512) 370-1342
www.texmed.org

Source: Reference 18

Physicians often recover

Physician treatment is unique for several reasons. First, it is rarely voluntary, and because treatment is coerced in some way, physicians are sicker when they enter treatment. They have more social dysfunction, more medical consequences, and simply are more complicated to treat. Still, most treatment programs for impaired professionals report better rates of long-term recovery than those of the general public, perhaps because physicians are monitored intensively and have the strong motivation of not wanting to lose their medical licenses. For example, in a study of 100 alcoholic U.S. doctors followed for 21 years, 73% had recovered. This study and others show a strong relationship between recovery and attending meetings of self-help groups.19

What should Dr. Z do?

Dr. Z is a member of a professional community that has an ethical obligation to police itself and to report observations that suggest impairment. His colleague’s suspected substance use disorder could interfere with his ability to function and pose a risk to patient welfare and safety.

Although reporting a colleague is unpleasant, impaired physicians often recover, and the data support optimism about returning to clinical practice for physicians who get appropriate treatment. In this case, Dr. Z’s reporting of his concerns about impairment would help uphold the integrity of the medical profession and would offer his colleague the potential benefits of treatment and recovery programs.

Related Resources

  • Bright RP, Krahn L. Impaired physicians: How to recognize, when to report, and where to refer. Current Psychiatry. 2010;9(6):11-20.
  • DuPont RL, McLellan AT, White WL, et al. Setting the standard for recovery: Physicians’ Health Programs. J Subst Abuse Treat. 2009;36(2):159-171.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

References

1. Ernhart CB, Scarr S, Geneson DF. On being a whistleblower: the Needleman case Ethics Behav. 1993;3(1):73-93.

2. American Medical Association. Policies related to physician health. Available at: http://www.ama-assn.org/resources/doc/physician-health/policies-physicain-health.pdf. Accessed June 19, 2011.

3. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.

4. Broquet KE, Rockey PH. Teaching residents and program directors about physician impairment. Acad Psychiatry. 2004;28(3):221-225.

5. Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA. 2001;286(23):3007-3014.

6. Firth-Cozens J. Improving the health of psychiatrists. Adv Psychiatr Treat. 2007;13(3):161-168.

7. McGovern MP, Angres DH, Leon S. Characteristics of physicians presenting for assessment at a behavioral health center. J Addict Dis. 2000;19(2):59-73.

8. Federation of State Medical Boards of the United States. Policy on physician impairment. Available at: http://www.csam-asam.org/pdf/misc/FSMB2011.pdf. Accessed June 8, 2011.

9. Medical Board of California. Complaint process - frequently asked questions. Available at: http://www.medbd.ca.gov/consumer/complaint_info_questions_process.html. Accessed June 8, 2011.

10. Montana Code Ann § 37-3-401 (2005)

11. State Medical Board of Ohio. Policies and positions: licensure of chemically impaired resident physicians. Available at: http://www.med.ohio.gov/positionpapers/resident.htm. Accessed June 19, 2011.

12. American Medical Association. Code of medical ethics, opinion 9.031. Reporting impaired, incompetent, or unethical colleagues. Available at: http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion9031.page. Accessed June 19, 2011.

13. Hulse G, Sim MG, Khong E. Management of the impaired doctor. Aust Fam Physician. 2004;33(9):703-707.

14. Sansone RA, Wiederman MW, Sansone LA. Physician mental health and substance abuse. What are state medical licensure applications asking? Arch Fam Med. 1999;8(5):448-451.

15. Hansen TE, Goetz RR, Bloom JD, et al. Changes in questions about psychiatric illness asked on medical licensure applications between 1993 and 1996. Psychiatr Serv. 1998;49(2):202-206.

16. Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322(1):31-36.

17. Verghese A. Physicians and addiction. N Engl J Med. 2002;346(20):1510-1511.

18. Federation of State Physicians Health Programs. Available at: http://www.fsphp.org. Accessed June 8, 2011.

19. Lloyd G. One hundred alcoholic doctors: a 21-year follow-up. Alcohol Alcohol. 2002;37(4):370-374

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