Impaired Physicians: Helping Good People With Problems Continue to Do A Good Job

1. Impaired Physicians: Helping Good People With Problems Continue to Do A Good Job McGaw Medical Center & Perspectives Housestaff Assistance Program “HAP”

2. What We Will Cover: • Physician Impairment • History of Physician Health • Alcohol and Other Mood Altering Substances • Identification of Addiction in Physicians • McGaw Medical Center Housestaff Assistance Program “HAP”

3. Physician Impairment Defined: • “A physician who is unable, or potentially unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skills, or excessive use or abuse of drugs including alcohol.” AMA “The Sick Physician”, 1973

4. History of Physician Health • 1910 Flexner Report on medical education • State Medical Societies and Legislatures began regulating medical practice • Requiring physicians and surgeons be free of “vice, moral turpitude and the intemperate use of alcohol and drugs”

5. History of Physician Health • 1914 The Harrison’s Narcotics Drug Act • Began process of classifying, regulating and controlling drugs that have the potential for abuse.

6. History of Physician Health • 1920 English Parliament Dangerous Drug Control Act • Registration of addicts as an attempt to control addiction • Nearly 25% of the registered addicts were doctors, dentists, veterinary surgeons or nurses Stimson, Oppenheimer and Stimson, “Drug Abuse in the medical profession”, British Journal of Addiction 79: 395-402

7. History of Physician Health • 1970 Florida “Sick Doctor Statute” • Defined inability to practice medicine with reasonable skill and safety • Revised the grounds for professional discipline under the state’s medical practice act

8. History of Physician Health • 1973 AMA Council on Mental Health – “The Sick Physician” • State Medical Societies establish programs or committees devoted to identifying and helping impaired physicians • AMA develops model legislation to amend state practice acts so that treatment was available instead of punitive disciplinary measures

9. History of Physician Health • 2001 JCAHO Standards • Physician Health - “Medical staff implements a process to identify and manage matters of individual physician health that is separate from the medical staff disciplinary function.” Joint Commission on Accreditation of Healthcare Organizations, Web site, November 2000

10. History of Physician Health: 2001 JCAHO Standards • Physician Health • Design a process that: - provides education about physician health - addresses prevention of physical, psychiatric, or emotional illness - facilitates confidential diagnosis, treatment and rehabilitation of physicians who suffer from a potentially impairing condition Joint Commission on Accreditation of Healthcare Organizations, Web site, November 2000

11. History of Physician Health: 2001 JCAHO Standards • Physician Health • The purpose of the process is: - assistance and rehabilitation, rather than discipline - to aid a physician in retaining or regaining optimal professional functioning, consistent with the protection of patients Joint Commission on Accreditation of Healthcare Organizations, Web site, November 2000

12. Alcohol and Other Mood Altering Substances Use, Abuse and Dependence

13. NIAAA – Safe Levels of Drinking • Two drinks per day for males • One drink per day for females

14. What Is a Drink? • Beer (12 ounces) • Wine cooler (12 ounces) • Wine (5 ounces) • Liquor (1.5 ounces / 80 proof)

15. Substance Abuse – DSM-IV A maladaptive pattern of substance use, as manifested within a 12-month period by one of the following: • Recurrent substance use leading to failure to fulfill major role obligations • Use of substances in situations where it is physically hazardous • Legal problems associated with the use • Continued substance use despite persistent or recurrent social/interpersonal problems

16. Substance Dependence – DSM-IV A maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by three (or more) of the following seven criteria, occurring at any time in the same 12-month period: • Tolerance • Withdrawal • Use of larger amounts or longer than intended

17. Substance Dependence – DSM-IV - Continued • Unsuccessful efforts to cut down or control use • A great deal of time spent obtaining, using or recovering from effects • Important activities are given up • Use is continued despite having recurrent or psychological problems

18. Chemical Dependence Defined A chronic, progressive disease characterized by a repetitive, unpredictable, and inconsistent loss of control or drug use that results in problems for user, his/her family, friends, others

19. Identification of Addiction in Physicians

20. Identification of Addiction in Physicians • Irritability • Irresponsibility • Inaccessibility • Inability • Isolation • Incidentals

21. Identification of Addiction in Physicians • Irritability - Mood swings - Negative attitude - Argumentative - Inappropriate anger - Overreaction to criticism - Altercations with staff, peers, and patients - “Personality change”

22. Identification of Addiction in Physicians • Irresponsibility - Shifts Work Load - Manipulates Schedule - ER, OR, On-Call - “Hurry Up – Catch Up” - Hasty rounds - Short cuts

23. Identification of Addiction in Physicians • Inaccessibility - Frequent tardiness - Frequent absence - “MIA” – missing in action - Frequent trips to bathroom, parking lot - Prolonged lunch breaks - Unavailable when on call - Frequent beeper failure - Frequent illness

24. Identification of Addiction in Physicians • Inability - Decreased performance - Inappropriate orders - Inadequate charting - Frequent malpractice action - Frequent “forgetfulness” - Deviation from standard procedures - Drug procedures - Use of excessive amounts - Unwitnessed wasting - Insufficient patient analgesia - Excessive spillage/breakage

25. Identification of Addiction in Physicians • Isolation - Odd Hours for rounds - Volunteers for “Graveyard shift” - Absent from Dr’s Lounge - Eats alone - Avoids - Departmental Meetings - CME Events - Medical Society events

26. Identification of Addiction in Physicians • Incidentals - Disheveled appearance - Tremors - “Green tongue” from mints - Bruises - Needle tracks - Heavy drinking at staff or social functions - Off-duty intoxication

27. Identification of Addiction in Physicians • Incidentals - Runny nose, raspy voice, alcohol on breath - Red, yellow or black and blue eyes - Dilated or constricted pupils - Staff, patient or peer complaints - Slurred speech on phone - Black outs - Subject of hospital gossip (marital problems, DUI, Financial Problems, “party” reputation)

28. Identification of Addiction in Physicians • Other - Unexplained intervals between jobs - Frequent job changes - Frequent relocations - Indefinite references - Unusual medical history

29. Identification of Addiction in Physicians • Prevalence rates - Brewster et al 1986 - No difference than general population - Hughes et al 1992 - Physicians were five times more likely than controls to take sedative and minor tranquilizers without medical supervision - Physicians self prescribing

30. Identification of Addiction in Physicians • Risk Factors - Family history of chemical dependence - Family history of psychiatric disorders - Mood disorders - Certain personality characteristics (overconfidence, sensation-seeking, risk avoidance) - Stress and poor coping skills - Availability of drugs

31. Identification of Addiction in Physicians • Early Detection Difficult - Physicians tend to have negative consequences to physical health, family, community, finances, spiritual, and emotional health - Job performance affected last, therefore disease usually progressed

32. Colleagues “Enable” By: • Believing addiction or mental illness can’t happen to a professional • Making excuses for an impaired colleague’s behavior or performance • Minimizing the obvious effects of alcohol/other drug use in a friend or colleague • Rationalizing changes in a colleague’s performance, behavior or appearance • Covering for a colleague’s errors or omissions • Not using the peer assistance network available • Diagnosing or treating

33. The Good News! • The success rate of health professionals in programs dedicated to staying clean and sober is 95%!

34. McGaw Medical Center Housestaff Assistance Program “HAP”

35. Perspectives1 (800) 456-6327 • Benefit • Voluntary • Confidential • Any Personal Problem • Assessment & Referral • Short-Term Counseling When Indicated • Follow-Up and Monitoring

36. Marital/Family Emotional Stress Eldercare/Aging Parents Addiction Communication Childcare Grief/Loss Legal Financial The HAP Addresses These Problems: Problems ms

37. Problems Call How to Access The HAP • Call Perspectives at 1 (800) 456-6327 to schedule an appointment • Call is answered by receptionist and is transferred to Access Center, staffed by licensed clinicians • Demographic information is collected and in-person or telephonic appointment is scheduled, as appropriate • Assessment is completed • Recommendations are given

38. HAP Flow Chart Counseling • Community Resources • Legal • Financial • Marital/Family • Medical • Psychological • Alcohol/Drug Treatment • Self-Help • Day Care • Elder Care • Other Self-Referral HAP Counselor Assessment Supervisory Referral HAP Short-Term Counseling Follow-Up/Monitoring

39. Counseling Other Services Provided By Perspectives Include: • Wellness workshops • CISD (Critical Incident Stress Debriefing) • Management consultation • Licensed Counselors available for emergencies 24 hours a day, 7 days a week • Perspectives “On Line”

40. Problems Call Summary of the HAP Benefit • Free • Confidential • Benefit provided by employer • For housestaff and family members • Assessment, short-term counseling (when appropriate) and referral services