Medicolegal Issues

Physician impairment: When should you report?

Current Psychiatry. 2011 September;10(9):67-71

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.

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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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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

Clinical Point

Occupational demands, self-criticism, and self-treatment may contribute to substance misuse by physicians

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.’