Mick Oreskovich, MD Medical Director and CEO of WPHP General and Addiction Psychiatrist

1. WSU College of Veterinary MedicineFebruary 27, 2009“Veterinary Impairment, Recovery, and the Role of WPHP” Mick Oreskovich, MD Medical Director and CEO of WPHP General and Addiction Psychiatrist Clinical Associate Professor of Psychiatry Fellow, American College of Surgeons

2. First, The Veterinarian!

3. How Do They Come To Our Attention? Someone is concerned that they may have a physical or mental condition that may be potentially impairing!

4. Impairment: “INABILITY TO PRACTICE WITH REASONABLE SKILL AND SAFETY”

5. BEHAVIORIALINDICATORS OF IMPAIRMENT: • Irritability • Irresponsibility • Inaccessibility • Inability • Isolation • Incidentals

6. IRRITABILITY • MOOD SWINGS • NEGATIVE ATTITUDE • ARGUMENTATIVE • INAPPROPRIATE ANGER • OVERREACTION TO CRITICISM

7. IRRESPONSIBILITY • SHIFTS WORK LOAD • MANIPULATES SCHEDULE • “HURRY UP-CATCH UP” • HASTY PROCEDURES • SHORT CUTS

8. INACCESSIBILITY • FREQUENT TARDINESS • FREQUENT ABSENCE • “MIA”-MISSING IN ACTION • FREQUENT TRIPS TO BATHROOM • FREQUENT TRIPS TO PARKING LOT • PROLONGED LUNCH BREAKS • UNAVAILABLE WHEN ON-CALL • UNAVAILABLE FOR DISCUSSIONS

9. INABILITY • INADEQUATE ORDERS • INADEQUATE CHARTING • QUALITY • QUANTITY • TIMLINESS • DELAYED BILLING

10. INABILITY • DIFFICULTY WITH DIFFICULT CASES • DEVIATION FROM STND PROTOCOL • DEVIATION FROM DRUG PROCEDURES • UNWITNESSED WASTING • EXCESSIVE AMOUNTS • INSUFFICIENT ANALGESIA • XS SPILLAGE/BREAKAGE

11. ISOLATION • ODD HOURS FOR OFFICE WORK • EATS ALONE • “BEHIND CLOSED DOORS” • AVOIDS • STAFF MEETINGS • CE EVENTS • VETERINARY MEDICAL SOCIETY EVENTS

12. INCIDENTALS • EYES • EARS • NOSE • OTHER

13. TRUE OR FALSE ? Intoxication in a health professional in purely social settings should be ignored since it does not occur during normal working hours ?

14. TRUE OR FALSE ? On the job “A O B” (Alcohol On Breath) is almost always an ominous sign, even noted on a single occasion ?

15. TRUE OR FALSE ? Aberrant workplace behavior caused by chemical dependency should be addressed rapidly because it usually indicates progression beyond early-stage disease ?

16. TRUE OR FALSE ? Normal behavior following aberrant behavior usually means that no significant problem exists ?

17. TRUE OR FALSE ? While several signs of impairment, or a cluster of them, usually suggest trouble, a pattern of aberrant behavior is almost always indicative of actual or potential impairment ?

18. The Washington Physicians Health Program: Is Defined By: • It’s Contract With the Department of Health and • Applicable WACs and Statutes

19. Department of Health Contract “WPHP is the qualified provider for potentially impaired physicians, physician assistants, osteopathic physicians, osteopathic physician assistants, podiatric physicians, dentists, and veterinarians and whose objective is to motivate healthcare practitioners to enter treatment and to recovery from their illnesses, and, in so doing, will serve to minimize the losses and other negative impacts that are caused by these illnesses”

20. WAC 246-160-200 Who must report: • (1) The following persons, entities and businesses must report conduct and conditions as described in WAC 246-16-210: • (a) All license holders under the jurisdiction of a disciplining authority listed in RCW 18.130.040

21. WAC 246-160-200 To report information to the disciplining authority, or an impaired practitioner program, which indicates that the other license holder may not be able to practice his or her profession with reasonable skill and safety to consumers as a result of a mental or physical condition

22. WAC 246-160-200 • License holders voluntarily participating in the approved programs without being referred by the disciplining authority shall not be subject to disciplinary action under RCW 18.130.160 for their substance abuse, and shall not have their participation made known to the disciplining authority, if they meet the requirements of this section and the program in which they are participating.

23. Practically speaking: • HCPs who have a condition that may be effecting their ability to practice safely • Can get the help they need • Confidentially • Endorsement to return to practice • 90% of WPHP clients are unknown to the disciplinary body

24. MD’s DO’s Dentists Veterinarians Podiatrists Physician Assistants Residents *Washington Physicians Health Program *charged under state law to monitor these practitioners and endorse that they are safe to practice

25. How Do We Do That?

26. PROBLEM HCPs • Chemical Dependency • Mental Illness • Dual Diagnosis • Stress Disorder • Disruptive Behavior • Psychosexual Disorder • Incompetence/Dated • Unethical

27. Not About Impairment: • Sexually Exploitive • Incompetent/Dated • Unethical

28. PROBLEM HCPs • Chemical Dependency PHP • Mental Illness PHP • Dual Diagnosis PHP • Stress Disorder PHP • Disruptive Behavior HOSP,PHP,MQAC • Psychosexual Disorder MQAC • Incompetent/Dated MQAC • Unethical MQAC MQAC

29. We work together….we are partners in protecting the public

30. The Initial Call to 800-552-7236 or www.wphp.org • 17 % Hospital • 20 % Medical Colleague • 09 % Practice Associate • 08 % Spouse • 01 % Lawyer • 12 % Commission/Board • 05 % Other State PHP • 10 % Self • 18 % Other

31. Initial Contact • CATEGORIZE • Chemical Dependency • Psych • Disruptive • Other

32. THRESHOLD • REASONABLE SUSPICION • PROBABLE CAUSE

33. INTERVENTION SITE • 35 % Hospital • 20 % HCP’s office • 28 % WPHP office • 18 % Other • Practice Director’s office • Pastor’s office • Private Doc’s office • Counselor’s office

34. Purpose of the Intervention: • For evaluation?50 % • Directly to treatment?50 %

35. INDEPENDENT EVALUATION • Medical • Psychiatric • Psychological • Addiction • Family Dynamics • Peer Interaction

36. EVALUATION SITE • Local ? 22 % • Out of town? 78 %

37. TRI-DIMENSIONAL TREATMENT • BODY • MIND • SOUL

38. TRI-DIMENSIONAL TX • BODY • DETOXIFICATION • END ORGAN DAMAGE • MIND • COGNITIVE RESTRUCTURING • EMOTIONAL BALANCING • SOUL • SPIRITUAL RESTORATION DURATION: 4 WEEKS-3 MONTHS

39. TYPE OF TREATMENT • 5 % Intensive out-patient • 95 % In-patient

40. CHEMICALLY DEPENDENT CLIENTS ARE PHP ELIGIBLE • SUCCESSFUL COMPLETION OF TX • D/C WITH STAFF APPROVAL

41. C D CONTRACT • Total Abstinence • Behavioral Monitoring • Chemical Monitoring • Worksite Monitoring • Mutual Help Groups DURATION: 5 YEARS

42. TOTAL ABSTINENCE ALCOHOL and any other addictive DRUG

43. BEHAVIORAL MONITORING • Phase I-first 2 years • weekly 90’ face-to-face • professionally facilitated • therapeutic monitoring • Phase II-next 3 years • tapers to monthly face-to-face

44. MONITORING SITES • BELLINGHAM VANCOUVER • EVERETT ELLENSBURG • SEATTLE TRI-CITIES • TACOMA PULLMAN • OLYMPIA SPOKANE

45. CHEMICAL MONITORING • Daily call to 1-800 number • “Color of the day” recording • 12 hour window to urinate • Credentialed laboratory • Witnessed micturition • Chain-of-custody handling • Screening test • Confirmatory analysis

46. WORKSITE MONITORING • FREQUENT CONTACT • PREFERABLY SAME FIELD • NEUTRAL PARTY • UNDERSTANDS CONFIDENTIALITY • APPROVED BY: • Physician • Hospital • WPHP

47. WORKSITE MONITOR REPORT-SIX Is • Irritability • Irresponsibility Yes ? • Inaccessibility • Inability No ? • Isolation • Incidentals How often have you had contact ? Do you want WPHP to call you ?

48. How well does it work? Very, very well!

50. RELAPSED 74/292 = 25 % Over 11 year follow-up!!