1 / 50

The Impaired Physician

The Impaired Physician. Rhiana Fredrickson M.D. Physician Impairment. AMA definition:

jamieharris
Download Presentation

The Impaired Physician

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The Impaired Physician Rhiana Fredrickson M.D.

  2. Physician Impairment • AMA definition: “The inability to practice medicine with reasonable skill and safety to patients by reason of physical or mental illness, including deterioration through the aging process, the loss of motor skills, or the excessive use or abuse of drugs, including alcohol.” AMA Code of Medical Ethics.

  3. Famous Addicted Doctors • Dr. William Halstead, father of modern surgery • Addicted to cocaine, then morphine • Dr. Sigmund Freud, father of psychoanalysis • Addicted to cocaine and tobacco • Early 20th century, prevalence of impaired physicians was reported as 10-40%

  4. Modern Times

  5. Statistics • No large-scale studies have been done in the US since the early 1990s • The last study, a survey of 5,000 doctors, revealed 8% prevalence (general pop = 16%)  unreliable self-report? Schorling, Physician impairment due to substance use disorders. Medscape article, Nov 2009.

  6. Prevalence • >800,000 US physicians (75% male) • 64,000 will develop SUD • 112,000 will experience an Alcohol use disorder • Prescription drug use (BDZs, opioids) is higher in doctors than in general population Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

  7. Statistics • 10-15% of health care professionals will misuse substances at one point in their career • Alcohol – most commonly abused • Opioids and stimulants – next most common • Recreational drugs (marijuana, cocaine) use is less than general population Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

  8. Statistics • Men > women likely to abuse substances • Women tend to choose alcohol over other drugs • Female doctors have higher alcohol abuse rates than general population Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

  9. Statistics – Females Wunsch, et al, 2007. • 125 women and 844 men in PHPs in 4 different states • Female impaired physicians: • Slightly younger (40 vs 44 years old) • More likely to abuse sedative-hypnotics (11% vs 6%) • More likely to have a comorbid psychiatric disorder (42% vs 27%) • Reported more medical (48.7% vs. 34.4%; OR = 1.81) and psychiatric (76.5% vs. 63.9%; OR = 1.84) problems at intake Wunsch et al. Women physicians and addiction, Journal of Addictive Diseases, 26:2, 35-43. 2007.

  10. Statistics – Females • Female impaired physicians: • More likely to report past (51.8% vs. 29.9%; OR = 2.51) or current (11.4% vs. 4.8%; OR = 2.54) suicidal ideation • More likely to have made a suicide attempt whether under the influence or not • More likely to abuse sedative hypnotics than men (11.4 vs. 6.4; OR = 1.87) Wunsch et al. Women physicians and addiction, Journal of Addictive Diseases, 26:2, 35-43. 2007.

  11. Statistics – Females • Female impaired physicians: • Less likely to have family problems, specifically in the marital realm(OR 0.50; 0.32-0.76)and with their children (OR 0.52; 0.28-0.97) • Less likely to have a mandatory referral as a presenting problem at treatment (OR 0.61; 0.39-0.95) and less likely to have had loss of staff privileges (OR 0.46; 0.26-0.83) • No gender differences in employment problems (65.3% vs. 67.5%; ns) or legal problems Wunsch et al. Women physicians and addiction, Journal of Addictive Diseases, 26:2, 35-43. 2007.

  12. Statistics - Specialties • ER Medicine, Psychiatry, Anesthesiology, solo practitioners – 3x as likely than other groups • ER doctors – marijuana (10.5 vs. 4.6%) and cocaine • Psychiatrists – benzodiazepines (26 vs. 11%) • Anesthesiologists – major opioids (less consistent) • Others more likely: nurses, pharmacists, dentists, veterinarians Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 Hughes, et al. Physician substance use by specialty. Journal of Addictive Diseases, vol. 18(2) 1999

  13. Statistics - Specialties • Pediatrics, Pathology, Radiology, OB/Gynecology – least likely to abuse substances Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 Hughes, et al. Physician substance use by specialty. Journal of Addictive Diseases, vol. 18(2) 1999

  14. Statistics - Specialties • Anesthesiologists usually comprise 25% of physicians being treated for addiction • Opioids, 66%; Induction agents, 20%; Benzos, 15% • Alcohol, 12%; Recreational drugs 7%; Inhalational agents 5% • Fentanyl abuse = 95% are either anesthesiologists or surgeons Garcia-Guasch et al. Substance use disorders in anaesthetists. Current Opinion in Anesthesiology. 25: 2, April 2012

  15. Burden and Implications • Chemical dependence is the most disabling illness among physicians • Drug abuse has been directly associated with physician suicide • Accidental death may occur while intoxicated • Patient safety • Substandard care by doctor also affects colleagues • Legal ramifications • Loss of job • Loss of license

  16. Doctors, a special population? • Often limited education regarding addiction • Stressful nature of the job, long hours • Personality traits: • Self-reliance, independence, perseverance, stubbornness  minimize the problem, self-treatment • Intellectual sophistication  hide the problem well • Obsessive-compulsive traits – self-doubt, guilt, excessive sense of responsibility • Idealistic beliefs, perfectionist behavior, and high academic rank

  17. Doctors, a special population? • Access to drugs • Belief that one can effectively self-diagnose and self-medicate, “professional invincibility” • Shame • Denial as a defense is magnified

  18. Doctors, stereotypes and stigma • “Conspiracy of silence” among family members, staff, colleagues • Role reversal (doctor becomes patient) difficult • View that doctors are “immune” to disease • Wounded healer, or case of Dr. Jekyll and Mr. Hyde?

  19. Identifying Doctors in Danger • Family and marital problems occur first • Financial issues, legal issues (DUI) • Work performance is typically not impaired until the more advanced stages • 43% of opioid-using doctors had been using opioids for more than 2 years before detection - Wilson et al. Psychiatrically impaired medical practitioners. Australasian Psychiatry. Vol 17, No 1 . February 2009

  20. Identifying Doctors in Danger Berge et al. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631

  21. Identifying Doctors in Danger Baldisseri. Impaired health care professional. Crit Care Med 2007 Vol. 35, No. 2 (Suppl.)

  22. Intervention “The initial confrontation with the suspected addict in an effort to coerce the individual to submit to a formal chemical dependency evaluation by experts.”– Berge et al.

  23. Intervention • Stressful, delicate, never simple • “Intervention”-style • Never just send them home (high suicide risk) • Suspected acute intoxication – immediate removal of MD, accompany to health care environment, immediate substance testing (=documentation) • Faithful adherence to preexisting institutional policies • Individualized treatment

  24. Merlo et al. Successful treatment of physicians with addictions. Psychiatric Times. Vol. 26 No. 9

  25. Treatment • Addicted doctors receive an intensity, duration, and quality of care that is rarely available to the general population

  26. Treatment • Psychiatric evaluation • R/o comorbid disorders • Screen for cognitive impairment – neuropsych testing if needed • Need for detox? • Programs specializing in physician addiction • Group therapy with addicted physician-peers • Medical Practice Assessment • Connect with other physicians already in recovery

  27. Treatment • Intensive day or residential treatment • Regular contact with a peer (health professional) support group facilitated by a physician • Availability of physician staff to personally conduct assessments, be involved in treatment, and advocate actively for health professional to return to his/her workplace before and during discharge planning. • Availability of neuropsychiatric assessment of cognitive function substantiate ability to return to work. Skipper. Treating the chemically dependent health professional. Journal of Addictive Diseases, Vol. 16(3) 1997

  28. Treatment • Treatment team experienced in setting firm limits boundaries • Personnel capable of addressing continuing care needs post-discharge including: • malpractice insurance, DEA certification, national practitioner databank, hospital medical staff liaison, monitoring, HMO relationships, medication therapy, etc. • Opportunity for extended treatment for those patients who additional time in treatment before returning to work (2-6 program). • Comprehensive Family Program for family and associates. Skipper. Treating the chemically dependent health professional. Journal of Addictive Diseases, Vol. 16(3) 1997

  29. Berge et al. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631

  30. Prognosis Success rates • Doctors have high abstinence rates (74-90%), like airline pilots • Optimal treatment, intensive services, peer support

  31. Prognosis Impaired Practitioners Program, Florida, 1991-96 • 68 physicians (59 males, 7 females), ages 25-63 • 32% IVDU, 12% crack, 7% both • Five-year outcomes based on facilitator reports, physician/psychiatrist evaluations, AA/NA attendance, return to work, negative drug tests • 88% positive outcomes • Coercion equally effective as voluntary treatment Gold et al. Urine testing confirmed 5 year outcomes in impaired physicians. World Psychiatric Association, Florence Italy , Nov 2004

  32. Prognosis 16 US Physician Health Programs, 1995-2001 • 904 doctors, 5 year follow-up • 647 (80.7%) completed treatment • 79% were licensed and back to work • 11% had their licenses revoked • 3.5% retired, 3.5% died • 3.2% unknown status • During 5 years of monitoring, 81% had negative drug/alcohol test results McLellan et al. 5-Year Outcomes in a cohort study of physicians treated for SUDs in the US. BMJ 2008; 337.

  33. Prognosis • Importance of Random Urine Testing • 1-800 number an MD calls daily, he/she is randomized to urine test or no test but given at least 1 urine test weekly • Success with urine testing = 96% sobriety • Without urine testing = 64% sobriety Shore et al. The Oregon experience with impaired physicians on probation. JAMA. 1987 Jun 5;257(21):2931-4.

  34. Relapse • Washington PHP 11-year experience • 25% had at least 1 relapse Domino et al. Risk factors for relapse. JAMA. 2005;293:1453-1460

  35. Domino et al. Risk factors for relapse. JAMA. 2005;293:1453-1460

  36. Domino et al. Risk factors for relapse. JAMA. 2005;293:1453-1460

  37. Public Policy and Awareness __________________ The first legal and ethical obligation of a clinic or hospital is to safeguard patients  by removing the physician from practice and counseling the physician to take a leave of absence for treatment. _________________

  38. Public Policy and Awareness • 1958 – FSMB first identified alcohol and drug addiction among doctors as a disciplinary problem • called for a probation and rehabilitation program to be adopted in all states • 1973 – AMA formally recognized physician impairment as a serious problem • “The Sick Physician: Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence”

  39. Public Policy • 1980s • ASAM was established • addiction as a disease without boundaries • Physician health committees formed in all 50 states • 1985 – AAAP was established • 1990 – Federation for State Physician Health Programs

  40. Physician Health Programs • 50 states have established PHPs • Separate from state medical board • Approach is non-punitive, focus on rehabilitation not discipline • Allow a doctor to seek assistance without jeopardizing his or her medical license • Fellowship and support of peers • Individualized treatment contract, typically 5 years DuPont et al. How are addicted physicians treated. Journal of Substance Abuse Treatment 37 (2009) 1–7

  41. Physician Health Programs • Average annual operating budget $538,000 • Range = $21,250–$1.5 million, Median = $270,000 • Sources: licensing boards (50%), participant fees (16%), state medical association (10%), hospital contributions (9%), malpractice companies , (6%), and other (9%) • Do not provide treatment or drug testing (expense born by patients themselves) DuPont et al. How are addicted physicians treated. Journal of Substance Abuse Treatment 37 (2009) 1–7

  42. Physician Health Programs • Admit average of 34 new doctors/year, per program • Range = 0-150, Median = 21 • Average caseload of 138 doctors at any point • Range = 9-541, Median = 86 • Self-referrals (26%), clinical colleagues (20%), state licensing board (21%), hospital medical staff (14%) DuPont et al. How are addicted physicians treated. Journal of Substance Abuse Treatment 37 (2009) 1–7

  43. Berge et al. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631

  44. Public Policy, Legal Aspects • 2002 mandate by Joint Commission on Accreditation of Healthcare Organizations: • All hospitals should have physician wellness programs that are separate from the disciplinary process • State laws vary on drug testing of employees. • California only allows pre-employment testing • Random testing not allowed, unless with good suspicion or post-accident

  45. Public Policy, Legal Aspects • AMA guideline is to report • State Licensing Board usually is last step • First step – talk to the impaired colleague as well as request guidance from hospital’s impaired physician’s program, chief of staff, or regional PHP • Most states have a bypass mechanism (CA Diversion Program, now defunct) that allows foregoing of a report to the state licensing board and instead allows a report to the state’s PHP to satisfy this requirement.

  46. Public Policy Mossman and Farrell. Physician impairment: when should you report? Current Psychiatry, 10:9, p67-69, Sept 2011.

  47. What would you do? • 95% of doctors agreed that they have an ethical obligation to intervene, but only 67% will report appropriately

  48. Points to Ponder • Addiction is a brain disease, not a moral or ethical failure • Low threshold for intervention, not “beyond reasonable doubt”

  49. Points to Ponder ___________________________ “If we don't police ourselves, someone else is going to do it, and they'll do it more harshly than we might. It's a matter of professional pride, as well. I don't want bad doctors to give all doctors a bad name.”  “In the end, we will remember not the words of our enemies, but the silence of our friends.” • Martin Luther King Jr. ___________________________

  50. End. Thank you!

More Related