Physician Impairment

1. Physician Impairment John Schorling, M.D.

2. Physician Wellness • Overall physician health status • Burnout and its causes • Physician impairment • Healthy approaches to stress

3. Physician Well-Being • Leading a life that’s balanced in body, mind and spirit

4. Physicians’ Health Status • Overall mortality rates are half that of age-matched general population • Lower rates are due to decreased rates of cardiovascular disease, lung cancer and other diseases related to smoking

5. Smoking Prevalence in the U.S.: 30 Year Trends

6. Some of the factors involved in our becoming doctors contribute to a lack of balance • Family of origin issues • Compulsive personality traits • Psychology of postponement

7. “ Engrossed late and soon in professional cares you may find, too late, with hearts given way, that there is no place in your habit-stricken souls for those gentler influences which make life worth living.” William Osler, Address to medical students, 1899

9. Physician Burnout • Marked by emotional exhaustion, cynicism, depersonalization • Seems to be increasing- affects up to 65% of residents

10. Factors Leading to Burnout • Family of origin issues • Work stress- lack of control • Personality factors- compulsive traits • Doubt • Guilt feelings • Exaggerated sense of self-importance • Family stressors (Spickard et al, JAMA 2002;288:1447)

11. Physician Use of Opiates and Sedatives • Depending on age and gender, 6-23% of physicians had used non-prescribed opiates or sedatives in the past year • These substances were used by 1-4% of the general population • Most use of these substances by physicians was for self-treatment of symptoms

12. Substance Use by Physicians • Physicians less likely to use cigarettes and illicit substances than the general public • Physicians more likely to use alcohol • Physicians much more likely to use minor opiates and benzodiazepines • Overall, 8% of physicians reported ever having a substance abuse or dependence problem (Hughes, et al. JAMA 1992;267:2333)

13. Clinical Case A 41 yo male MD had a long history of self prescribing sedatives to treat anxiety and insomnia. His drug use gradually escalated to the point it was interfering with his work and home life. He tried repeatedly to control his use on his own, but without success. He began seeing a psychiatrist who felt he had a mood disorder, and did not directly address the substance abuse.

14. Clinical Case- Continued He began to feel his life was intolerable and discussed suicide with his wife, although he did not disclose a plan. He subsequently died in a “hunting accident” of a self-inflicted gunshot wound to the head.

15. Physician Suicide • Male physicians appear to commit suicide at about the rate of the general population, while the rate among female physicians may be two to four times higher • The rate of suicide attempts among women physicians is lower than the general population- are physicians who attempt suicide more likely to be successful? (JAMA 1987;257:2949, Frank and Dingle. Am J Psych 1999;156:12)

16. Potential Factors Leading to Impairment • Personality traits of physicians: “If I only work harder, I will be loved” • Difficulty expressing emotions • Difficulty seeking and accepting help • Work stress / harassment • Family history / family of origin issues • Depression • Self-medication

17. Clues to Physician Impairment • Self-prescribing of controlled drugs • Use of large quantities of alcohol • Driving under the influence • Domestic difficulties • Neglect of responsibilities • Outbursts of anger • Depressed mood

18. Drugs of Choice Among Impaired Physicians in Virginia 1998-2000 (n=151)

19. Approach to Impaired Physicians • Formal interventions may be required with referral to specialized treatment centers • We may not act due to concerns about the potential impact on the impaired person- failure to intervene is likely to have greater consequences • In Virginia, the Health Practitioner Intervention Program should be involved http://www.dhp.state.va.us/levelone/hpip.htm or 1 - 866 - 206-4747

20. Health Practitioner Intervention Program • Established by Virginia General Assembly in 1997 (Code of Virginia 54.1-2515) • Available to all licensed, certified, or registered health care practitioners • Practitioners who are impaired by mental or physical illness or by substance abuse problems may participate

21. Health Practitioner Intervention Program Disciplinary action may be stayed if: • There is no violation of law except diversion for personal use • The practitioner entered with a written contract • Disciplinary action has not previously been stayed • The practitioner remains in compliance • The Program has consulted with the appropriate regulatory board

22. Treatment of Chemical Dependency among Physicians • Most are referred to specialized treatment programs • Costs are often not covered by insurance • Initial treatment- 28-96 days • Evaluation and stabilization • Intensive outpatient treatment • Mirror image placement

23. Extended Aftercare Treatment and Monitoring • Assigned to staff person to coordinate care • Establish contract - usually for 5 years • Must have a primary care physician • Required 12-step program and Caduceus attendance • Worksite monitor • Random drug screens

24. Outcomes of Substance Abuse Treatment among Physicians • In general, treatment outcomes are better for physicians than others • Treatment usually includes long-term monitoring • On average, 70-80% of physicians completing initial treatment and signing long-term contracts maintain abstinence • Most physicians are able to reenter practice

25. Approach to Impaired Medical Students at UVA • Voluntary referral to Student Health can lead to medical leave of absence • Individuals with suspected problems can be discussed with Dean Pearson or Dr. Turner • Referral for further assessment may be required to continue in school • Individuals determined to be impaired can be mandated to seek treatment and participate in aftercare

26. The Rest of the Story

27. "You got to be careful if you don't know where you're going, because you might not get there. " - Yogi Berra

28. Healthy Approaches to Physician Stress • Increase self-awareness • Spiritual pursuits- religion, meditation • Psychotherapy • Share feelings and responsibilities • Protect time with family and friends • Participate in group social activities outside of medicine • Participate in formal experiential groups (Quill and Williamson. Arch Intern Med 1990;150:1857)

29. Healthy Approaches - II • Promote self-care • Attention to work scheduling • Express feelings • Pursue interests outside of medicine • Regular exercise • Develop a personal philosophy • Develop realistic short and long-term goals • Prioritize goals • Develop a time management system

30. “Physicians need to accept responsibility for much of the stress they perceive. Our own achievement orientation, our drive to excel, and our exaggerated sense of responsibility and self importance may lead us to think that we are helpless victims of awesome and uncontrollable stresses, the only solution for which is the comfort and refuge of alcohol or drugs. We as physicians need to cultivate a life that is not only “dedicated” but also balanced and healthy in mind, body, and spirit.” Collins. Cleveland Clinic J Med 1998;65:106.