Saving Troubled Physicians

1. Saving Troubled Physicians Lester A Picker Edited Dr. Sandra Oliver

2. Impaired physicians • AMA definition: Any physical, mental, or behavioral disorder that interferes with the ability to engage safely in professional activities.

3. TBME grounds for denial or disciplinary action 164:051 (4): unable to practice medicine with reasonable skill and safety to patients because of: (A) illness; (B) drunkenness;(C) excessive use of drugs, narcotics, chemicals, or another substance; or (D) a mental or physical condition; 164:052 (4) uses alcohol or drugs in an intemperate manner that, in the board’s opinion, could endanger a patient’s life;

4. National Incidence(ama-assn.org) • “Punitive actions against physicians by medical board, including license suspensions, revocations, and probations, increased by 35% over the past decade.” In 2002 there were 4,875 medical board disciplinary actions for all causes • The percentage of impaired physicians is at 10-15 percent of all working physicians.

5. Texas Statistics(TSBME.Texas.State.Tx.Us) • TSMBE issued a total of 256 disciplinary decisions in 2004 • 40,373 physicians are in active practice in the state in 2004

6. Roots of the problem • Prescribing over the Internet and the wide availability of recreational drugs have contributed to problems of some physicians. • Chemical dependency is the leading cause of physician impairment with a lifetime prevalence of approximately 10-15%, which is similar to that of the general population.

7. Roots of the problem • Rates of clinical depression among medical interns are reportedly between 27 and 30%. (Martin,1986) • Frank and Dingle (1999) reported that 19.5% of 4501 practicing U.S. female physicians admit to history of depression

8. Roots of the problem • The very personality factors that enable a physician to endure the rigors of medical training may also work against the physician once an impairment begins. Strong egos, issues of control and fears of being wrong or embarrassed propel impaired physicians toward the brink of self destruction before seeking help.

9. Roots of the problem • Mansky (1996) found that anesthesiologists and emergency room doctors are 3 times more likely to abuse substances than the general population of physicians. Both fields entail high-risk situations and performance under pressure. Hence, both tend to attract physicians who are more likely to engage in high-risk behaviors in their personal lives.

10. Signs of Substance Use Disorder Work-related symptoms: • Late to appointments; increased absences; unknown whereabouts • Unusual rounding times, either very early or very late • Increase in patient complaints • Increased secrecy • Decrease in quality of care; careless medical decisions • Incorrect charting or writing of prescriptions • Decrease in productivity or efficiency • Increased conflicts with colleagues • Increased irritability and aggression • Smell of alcohol; overt intoxication; needle marks • Erratic job history http://www.ama-assn.org/ama/pub/category/11711.html

11. Signs of Substance Use Disorder Problems at home: • Withdrawal from family, friends, and community • Legal trouble (ie, driving while under the influence) • Increase in accidents • Increase in medical problems and number of doctor’s visits • Increased aggression, agitation, and overt conflict • Financial difficulties • Deterioration of personal hygiene • Emotional disturbances such as depression, anxiety, and mood instability http://www.ama-assn.org/ama/pub/category/11711.html

12. Intervention • Contact a Physicians Health Program, in Texas: Committee on Physician Health and Rehabilitation at TMA. • If an impaired physician voluntarily seeks treatment and monitoring, the PHP can then advocate for the physician before the state medical board. If, however, physicians are initially reported to the state medical board before any involvement with a PHP, they are then required to have a formal disciplinary relationship with the board and are in greater danger of license suspension and revocation. http://www.ama-assn.org/ama/pub/category/11711.html

13. TMA Committee on Physician Health and Rehabilitation • PHR promotes the health and well being of physicians as well as the treatment and rehabilitation of those who have become impaired for whatever reason.  It is the responsibility of all members of the medical profession to ensure that the practice of medicine is conducted using the highest moral, ethical and scientific standards. • The function of the PHR committee is two-fold:  1) to ensure safe patient care by identifying physicians whose practice is impaired and 2) to advocate for the physician while maintaining confidentiality and the highest ethical standards. • As advocates, the committee helps with intervention, referral for evaluation and treatment, if necessary, monitoring upon return from treatment, and education for physicians, family members and support staff regarding possible impairments. • 24-Hour Hotline [(800) 880-1640]

14. Process of PHR • If after the initial investigation the evidence indicates that the physician is impaired, referral should be made to an outside provider/agency for evaluation, diagnosis and treatment.  • It is important to note that the PHR is in no position to make the diagnosis and require treatment of this physician.  It’s role is purely facilitation of such evaluation, diagnosis and treatment by competent, outside providers/agencies.

15. Case studyhttp://www.texmed.org/cme/phn/jcaho/jcaho_course.htm • A surgery resident was taken to his hospital emergency room unconscious.  Medical and neurologic workup found no basis for this lapse of consciousness.  In fact, the resident had experimented with Fentanyl, overdosed and was found by his wife who arranged the transfer to the emergency department. • Approximately three years later, the same physician was under suspicion at the hospital for possible drug abuse.  Urine drug screens were being obtained although no psychiatric/substance abuse evaluation had been arranged.  A positive urine for stimulants was quickly explained away by the physician and accepted by the hospital.  No formal physicians health committee existed in this hospital.  Subsequently, a serious, adverse patient event occurred while this physician was on duty and a suspension and more rigorous investigation indicated a high probability of ongoing drug abuse.  The physician agreed to an intensive inpatient substance abuse program where his denial was effectively resolved and a successful recovery ensued. • This case illustrates the importance of having an organized process to thoroughly evaluate, assess, and refer any physician who presents with a possible substance abuse problem.  The incident of unconsciousness during his residency was not appropriately investigated and could have cost the physician his life, but did lead to further impairment and adverse clinical results.

16. Intervention • Impaired physicians are far more likely to commit suicide than their peers. • Intervening early and rigorously following up is essential to rehabilitation and may even save the physician’s life.

17. Goal of Treatment • Abstinence is always the final goal if the physician hopes to return topracticing medicine. • No other option is suitable in light of the physician’s level of responsibility for the lives of his or her patients http://www.ama-assn.org/ama/pub/category/11711.html

18. Treatmenthttp://www.ama-assn.org/ama/pub/category/11711.html • Treatment of an impaired physician might consist of any or all of the following options: • Detoxification/medical stabilization: This is for patients in active withdrawal or who have concurrent medical issues. • Inpatient residential setting: These programs typically specialize in treating impaired physicians. Maximum confidentiality and privacy are the standards. • Rehabilitation: This occurs in an outpatient setting. Ongoing treatment includes group psychotherapy, individual psychotherapy, 12-step programs such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), relapse prevention, psychotropic stabilization, and alternative therapies such as yoga, meditation, relaxation training, and exercise

19. Monitor • Perhaps the most important safeguard for patients and a successful recovery process is adequate monitoring.  • Most PHRs monitor addicted physicians for 5 years.  • Elements of aftercare plan may include the monitoring of bodily fluids (ie, toxicology screens), ongoing treatment, and the physician’s performance when the physician returns to practicing medicine

20. Summary • Alcohol and drug use among physicians is a significant problem that can lead to impairments in the ability of physicians to function both at work and at home. • Early detection and aggressive treatment are key aspects to dealing with this serious problem. • Texas PHR, plays a vital role in the advocacy and treatment of impaired physicians.

21. References • Picker, L.A. Saving Troubled Physicians. Unique Opportunities-the Physician’s Resource. 11/12 2004.16-26. • Martin A.R. Stress in residency a challenge to personal growth. J Gen Int Med. 1986. 1: 252-257. • Frank, E. & Dingle, A.D. Self reported depression and suicide attempts among U.S. women physicians. Am. J. Psychiatry, 1999.156.1887-1894. • Mansky PA. Physician health programs and the potentially impaired physician with a substance use disorder. Psychiatr Serv. 1996;47:465-467.

22. The end • Please continue to the post test • Download the post test • Complete the post test • Send the post test to Dr. Sandra Oliver • 407i TAMUII

23. Post Test Question One 1. The incidence of disciplinary decisions by the Texas State Board of Medical Examiners in 2004 was: • 6.00% • 0.60% • 0.06% • 0.006%

24. Post Test Question Two 2. Chemical dependency is the leading cause of physician impairment with a lifetime prevalence of which of the following A. Less than the general population B. Similar to that of the general population C. Greater than that of the general population

25. Post Test Question Three 3. Signs of substance abuse in the work place include all of the following except: A. Unusual rounding times B. Increased secrecy C. Incorrect charting or writing of prescriptions D. Increase in efficiency

26. Post Test Question Four • The most important safeguard for patients and a successful recovery process is which of the following: A. Self-referral by affected physician B. Establishment of validity of complaint C. Referral for diagnosis and treatment D. Adequate monitoring