The Normal Physician

1. The Normal Physician A partially compensated, obsessive-compulsive neurotic with a tendency to depression -Roy W. Menninger

2. “…some level of impairment in residents is a common and predictable sequelae to the time they spend at traditionally ‘catastrophic levels of stress.’..” Levey RE: Acad Med 76:142, 2001

4. Physicians in Crisis • 85% Family life suffers due to emotional demands of job • 58% Have high “emotional exhaustion” • 30% Would change professions • 56% Biggest concern is lack of time with family and friends • 59% Feel guilty that patients’ don’t get enough attention Kam, K; Hippocrates, Jan 1998

5. Things I Wish They Taught in Medical School II • How to Say “I Don’t Know” • How to Say “No” • Inevitability of Ambiguity & Uncertainty • Danger of Self-Medication Pfifferling JH: Res and Staff Phys, 36:85, 1990

6. RECOMMENDATIONS FOR PHYSICIANS I • Regular Source Of Health Care • Seek Help For Mood Disorders, Substance Abuse, And/Or Suicidality • Learn To Recognize Depression And Suicidality In Themselves And Educate Medical Students And Residents To Do Likewise • Become Informed About State And Federal Protections For Confidentiality & Legal Protections For Physicians And Others With Disabilities

7. RECOMMENDATIONS FOR PHYSICIANS II • Physician Health Programs In All States Include Outreach and Education, Guidance Through Evaluation and Treatment, Monitoring, and Advocacy • Routinely Screen All Primary Care Patients For Depression As Recommended By The US Preventive Services Task Force • Screening For Depression In Patients Can Help Physicians Recognize Depression In Themselves • If sued for malpractice, seek as many resources as you can.

8. Illness versus Impairment Short List of Examples Concern is for effect on Patient Care • Less Common Disorders • Seizures • Diabetic Neuropathy • Pain • Parkinson’s Disease • Alzheimer’s Disease • Stroke • Mental Illness • Hyperthyroidism/Hypothyroidism • Common Disorders • Substance Abuse or Dependency • ?Disruptive Behavior? ?Impulse Control?

9. How Addicted Physicians Differ from the Addicted Lay Patient • Presumed above average intelligence. (Perhaps knowledge of addiction.) • Subscribes to defined ethical principles. • Holds public trust and are valuable to society. • Believe they are unique. • Respected by their peers. • Feel pressured to perform. • Enjoy great deal of autonomy. • Are held to a higher standard in many ways by themselves and the public they serve. • Tend to be defined by what they do, know and provide. • Deal with life and death on a daily basis. • Are trained to be in charge, to know what to do in all situations. Diagnosis, Intervention and Treatment Considerations

10. PHP Relative Risk by Specialty

11. Signs and Symptoms to Look for Listed in General Order of Occurrence • Loss of Spiritual Connectedness • Family Relationship Problems * • Disconnection from the Community • Physical Status Changes • Office “Problems” • Hospital “Problems” * • Checkered Professional History and CV *

12. Loss of Spiritual Connectedness • Personal spirituality loss is an early sign. • It stems from the high levels of guilt and shame brought about by the addictive behavior. • Addicts really do have a conscience, but when they keep violating their own ethics, albeit involuntarily, they have to enter denial and rationalization, projection and minimization modes in order for the Id, let alone the Ego, to survive.

13. Family Problems Addiction is a Disease of Relationships • Withdraws from family activities • Spouse becomes caretaker, enabler • Fights become common as spouse attempts to control the abuser’s behavior • Spouse becomes isolated and angry at home, but still attempts to look good for the community • There is always child abuse; always emotional and occasionally physical • Children assume adult roles prematurely • Children may develop antisocial behaviors • Sexual problems emerge (impotence or affairs) • Spouse may start abusing drugs or enter a recovery program

14. Community Problems • Physician isolates; withdraws from clubs, church, hobbies, peers • Exhibits embarrassing behaviors at parties • Receives DUI, has legal problems, exhibits role- discordant behaviors • Behavior is unreliable and unpredictable in social activities • Engages in excessive spending and risk taking behaviors

15. Physical Status Changes • Weight loss, pale skin, constricted/dilated pupils, diaphoresis, tremors, chills • Personal hygiene deteriorates, may always wear long sleeves if abusing intravenously • Clothing and dress habits deteriorate • Multiple physical illnesses and complaints • Writes numerous prescriptions for personal use • Has frequent hospitalizations • Numerous visits to other physicians or dentists • Has multiple accidents or other traumas • Evidence of serious emotional crisis

16. Office Problems • Schedule becomes disorganized and starts progressively later • Is hostile (disruptive) and unreasonable with staff and patients • Spends longer amounts of time behind locked doors • Orders excessive supplies of drugs • Patients complain to office staff about his behavior • Frequently absent from the office for a variety of reasons

17. Hospital Problems • Late rounds, abnormal behaviors, disruptive outbursts • Decreased performance in staff presentations, charting, etc. • Errors in orders increase, overprescribes CS • Hospital staff report their behavior has changed • Malpractice suits increase • ER reports they are unavailable or respond inappropriately or very late to calls • Does not respond to pages • Reluctant to undergo PE or UA • Drinks heavily at staff functions • Volunteers for undesirable shifts

18. Professional History Clues from the CV • Has changed jobs numerous times in last 5 years • Frequent geographic relocations without clear explanations • History of frequent hospitalizations • Complicated and elaborate medical history • Unexplained time lapses between jobs • Submits inappropriate medical references and vague letters of reference • Has been employed in positions not appropriate to qualifications • Professional productivity has declined inconsistent with age

19. NIDA Principles of Drug Addiction Treatment Addiction is a complex but treatable disease that affects brain function and behavior. • No single treatment is appropriate for everyone • Tx needs to be readily available • Meets multiple needs, not just drug use • Must be assessed continually and modified as indicated to meet changing needs • Adequate amount of time in Tx is critical • Counseling/behavior therapies are important elements of Tx • Medications are an important element for many • Co-existing mental disorders must be concurrently treated • Medical detoxification is only the first stage of treatment and by itself does little to change long-term drug use • Treatment does not need to be voluntary to be effective • Monitoring for possible drug use during treatment is necessary • Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases

20. JCAHO Medical Staff Standard 2.6 • Requires Hospitals to Handle Physician Health Separately From Physician Discipline • Educate Physicians and Staff About Physician Impairment • Procedure to Identify Impaired Physicians To Be Referred for Evaluation and Treatment • Many Hospitals Are Turning to State PHPs to Help in This Process

21. History of Diversion Concept • Airline Industry • Railroad Industry • Medical Profession • Variety of Models Association Sponsored Third Party Providers Medical Board Sponsored State Statute Governed • Common Goals • Other Professions • Lay Public Drug Court

22. The New RepublicCorrespondence: What About Physician Health Programs? by Robert L. Dupont and Gregory E. Skipper “We are convinced by the still growing mountain of evidence of the high rates of success for PHPs that there should be a greater focus on early referral prior to overt impairment or overdose, aided by workplace drug testing of physicians (something that is only beginning to occur). And when problems are identified, we think they should be immediately referred to PHPs so they can be properly managed to assure patient safety and good outcomes.”

23. The Road to Recovery Utah Recovery Assistance Program www.dopl.utah.gov (801) 530-6428..Susan Higgs (801) 530-6718..Debbie Harry (801) 530-6106..Charles Walton, M.D.

24. What is URAP? • A confidential structured monitoring program to assist and support the professional who has a problem with substance abuse or dependence or certain behavioral issues. • It is defined by statute as being non-disciplinary, therefore, not reportable to data banks.

25. Criteria for Consideration for Admission • First time offense, no prior disciplinary actions. • No egregious harm can have occurred to other individuals. • No financial or personal gain of any type can have occurred in connection with the problem. • An investigator and a bureau manager must sign off on the admission. (new since 2013)

26. Referral Process • Self (Investigator interview required) • Peers or family or friends • Via investigation by DOPL investigator

27. Referral Source (375 MD from 16 states) Percentage 40 Self Colleague 30 Family Treating MD OPMC Hospital 20 unknown Patient Pharmacy 10 0 Referral Source

28. The Advantages • License will remain in full and good standing. No database report. • Structured monitoring has been shown to effectively double the chances of staying in recovery. • Avoidance of potentially more serious consequences if addiction remains unchecked. • Any investigation will be suspended during the diversion period and closed and permanently sealed if diversionee completes the program successfully.

29. Advocacy • State Medical Boards • Regulatory Agencies • Employers, partners • Malpractice Insurance • Hospitals • Criminal Justice • Other

30. The General Requirements • Completion of formal rehabilitation program • Attendance at weekly aftercare • 12-step meeting attendance • Professional support group attendance • Random urinalysis program participation • Individual counseling and possibly psychiatric care as indicated

31. Conclusions The risk of relapse with substance use was increased in health care Professionals (292 physicians) who used a major opioid or had a coexisting psychiatric illness or a family history of a substance use disorder. The presence of more than 1 of these risk factors and previous relapse further increased the likelihood of relapse. These observations should be considered in monitoring the recovery of health care professionals. JAMA. 2005;293:1453-1460

32. Bottom Line • Addiction kills, rehabilitation works. • Intervening is a profound act of caring. • No one has to “bottom out” before seeking treatment for these difficulties. • The rehabilitation experience is usually viewed as a great gift by those who truly grasp the concepts.