Ethics and Professionalism The Integrity of Medicine Impaired Physicians

2. Ethics and ProfessionalismThe Integrity of MedicineImpaired Physicians Richard L. Elliott, MD, PhD, FAPA Professor and Director, Medical Ethics Mercer University School of Medicine Adjunct Professor Mercer University School of Law

3. Goals • Week one • Review first year ethics • Research and ethics • “The purpose of Community Medicine II is to introduce the concept of evidence-based medicine” • Tuskegee, IRBs, Pharmaceutical industry • Small group discussions (exam material!) • Week two • Medical student abuse • Impaired colleagues • Exam (10 – 12 multiple choice questions, not all USMLE format) • Course evaluation – What can we do differently?

4. Resources • http://medicine.mercer.edu/Academics/Degree%20Programs/Doctor%20of%20Medicine/medicalethicsprogram • Second year and research subsections • PowerPoint to be loaded on Blackboard • Blackboard • Change in readings: Only required reading is Studdert for malpractice

6. Ethics and ProfessionalismThe Integrity of MedicineThe Impaired Physician Richard L. Elliott, MD, PhD, FAPA Professor and Director, Medical Ethics Mercer University School of Medicine Adjunct Professor Mercer University School of Law

7. Dr. Wells’ case – the missed phone call • System issue • Forgetting patient • Answering machine • No call from lab • No “bad apple”

8. Definitions of Impaired Physician • “unable to practice medicine with reasonable skill and safety to patients because of physical or mental illness, including deterioration through the aging process or loss of motor skill, or excessive use or abuse of drugs including alcohol.” (AMA) • “inability to exercise prudent medical judgment and the ability to practice with reasonable skill and safety without jeopardy to patient care” (AAFP)

9. Examples of Impairment • Substance abuse • Mental Illness • Cognitive • Personality traits • Boundary violations • Physical condition • Motor • Visual

10. Impaired Physician - Epidemiology • Overall • 10-15% lifetime risk of becoming impaired • Substance abuse – 90% of impaired physicians • 8-10% lifetime risk • 2% current • Mental Illness – 8% of impaired physicians • No greater than general population except 30-100 times greater risk of narcotic addiction

11. Impaired Physician - Trainees • Medical students: 11% with excessive alcohol use during at least one 6-month period, 18% with alcohol abuse during first two years • 30% residents report depression with suicidal ideation in previous two weeks • 14% students reported suicidal thoughts in previous year • Only 22% of depressed students received treatment

12. Medical Student Impairment • N Engl J Med 353;25 December 22, 2005 2673 • 235 physicians disciplined by medical boards matched with 469 physicians who graduated from the same school and year • Students who were described as having unprofessional conduct during medical school were 3 times more likely to be disciplined, with a risk of 26%. • Risk factors during medical school for future disciplinary action included irresponsibility (lack of accountability) and lack of capacity for self-improvement

13. Impaired Physician – Risk Factors • Problem behaviors, low test scores, drug use in medical school predict problems in residency and later • Sensation seeking and paternal history predict substance abuse in students • Sleep – drugs to sleep or stay awake • Access – narcotics • Stress – school, family, burnout • Specialty – anesthesia, ER – x3 • Pharmacological optimism, reliance on intellect, strong willed, high “T”

14. Impaired Physician - Recognizing • Personality changes • Patient and staff complaints • Sleep problems • Erratic performance and behavior • Burn out – 50% of physicians • Absences, odd hours • Errors and unusual practices • Irritability, moodiness

16. Physician Mortality • 1261 physicians, graduated 1948-1964, studied through 1998 • Overall mortality 56% lower in men, 26% lower in women • Suicide 82% greater in men, 395% greater in women • DM Torre et al. Suicide compared to other causes of mortality in physicians. Suicide and Life-Threatening Behavior. 2005;35:146-53

17. Aid for the Impaired Medical Student (AIMS) • MUSM Medical Student Handbook • Provide assistance before irreversible harm • Protect rights of students to receive treatment in confidence • To ensure recovered students can continue education without stigma or penalty • To protect others affected by impaired students • Prevent future cases of impairment

18. Aid for the Impaired Medical Student (AIMS) II • Administered by AIMS Council (8 students, 4 professionals) • Referral to AIMS student representative • Class representatives and professional member review circumstances, interview student, recommend action • Professional member monitors follow-up

19. Impaired Physician - Interventions • Key is recognition – colleagues must overcome denial, reluctance, desire to be “discrete” • Personal vs. formal intervention • Thorough assessment – high co-morbidity • Physician-focused treatment (e.g., Ridgeway, Caduceus) • Anticipate relapse and determine consequences • Long term monitoring • Address specific issues – (e.g., burnout)

20. Impaired Physician - Reporting • AMA “Physicians have an ethical obligation to report impaired, incompetent, and/or unethical colleagues in accordance with the legal requirements in each state” • August 29, 2005, AMA E-9.031 • Reporting not mandatory in Georgia

21. Attitudes to Reporting Impaired or Incompetent Colleague • JAMA 2010;304(2):187-193 • 17% MDs had direct knowledge of impaired or incompetent colleague in preceding year • 2/3 reported • Most common reason for not reporting: • Someone else will • Nothing will happen • Less likely to report in high malpractice risk areas

22. Impaired Physician – Outcomes • Risk of relapse related to family history, opioid use, co-morbid psychiatric disorder • California – 73% drug free more than two years • Missouri Physician Health Program –90% recovery • Anesthesia – 56% success, 40% entered another specialty, 5% mortality within several years

23. Physician Health Program • Physicians Well-Being ProgramMedical Association of Georgia • 339 Tenth Street, NWAtlanta, GA 30318-5681 • (404) 875-1061 • Fax (404) 875-3084 • email AAGM8888@aol.com • George D. Miller, MD, Medical Director • Types of disease, illness, or conditions monitored: • Chemical dependency • Mental health • Behavioral health problems • Sexual misconduct and/or boundary violations • Physical illness

24. Georgia PHP – Chemical Dependency • Length of contract: 5 years • Random urine drug screen frequency: • Year 1: 1 time per week • Year 2: 1 time per month • Year 3: 1 time per month • Year 4: 1 time per month • Year 5: 1 time per month • Support (self help) group requirements: • AA,,NA, Caduceus, Other: IDAA • Support (self help) group frequency: • Year 1: 3 times per week • Year 2: 3 times per week • To completion: 2 times per week • Therapy or treatment requirement: peer group required, other Tx as directed by provider • Work or practice monitor requirement: once weekly contact (minimum) • Other provisions: monthly monitoring meeting with program representative

25. Georgia PHP – Mental Health • Length of contract: 5 years • Support (self help) group requirements: professionally facilitated • Support (self help) group frequency: as directed by participant's psychiatrist of record • Therapy or treatment requirement: as directed by participant's psychiatrist of record • Work or practice monitor requirement: weekly contact • Other provisions: as needed • Other monitoring services provided: as needed, committee monitor (quarterly), worksite monitor, therapeutic monitoring groups, hair analysis, naltrexone

28. Slides from this point on were not part of the presentations

29. USMLE #3 • A 95-year-old woman in a nursing home has had advanced vascular dementia, severe dysphagia, and a 9-kg (20-lb) weight loss over the past 2 months. Her four children are divided regarding the decision to provide artificial feeding through a gastrostomy tube. There is no living will. The oldest son approaches the physician after a family meeting and says, “You should simply decide what is best for her and tell the others that’s what we should do.” Assuming the physician proceeds in this manner, which of the following best describes the physician’s action?

30. Best Interest Standard • Paternalism • Preserving fairness in use of resources • Protecting patient autonomy • Rationing care • Truth-telling

31. USMLE #4 • You are a psychiatrist and Mr. Moore is your patient. Mr. Moore has been talking to you for some time about his neighbor who, he believes, has it in for him. He tells you that he plans to get his revenge. He tells you he plans to kill his neighbor.

32. Tarasoff – Duty to Protect • Which is the best course of action? • Inform the police of this threat. • Inform the patient’s neighbor • Inform both the police and the patient’s neighbor • Inform no one but focus on treating the underlying illness

33. USMLE #6 • You are preparing a clinical trial of different doses of a certain medication. This medication has already been proven to be clinically effective and is already approved by the FDA. You are only studying to see whether a higher dose of the medication will lead to enhanced benefit.

34. Tuskegee • The Tuskegee Study of Untreated Syphilis in the Negro Male • Do whites and blacks differ in disease course? • Treatment planned, cut due to cost • Participation of Tuskegee Institute, black nurse eased fears among men • Macon County Medical Society, mostly black physicians, agreed to deny treatment • Treatment – arsenic, mercury, ASA, iron, spinal taps – perceived as far superior medical care than usually received • Later, men denied free care for syphilis at PHS clinics • Study continued after Nuremberg and Declaration of Helsinki (1964) • Expose 1972 ended the study • $10 million settlement • IRBs established • Legacy of mistrust between blacks and whites in research

35. Where is Tuskegee Today? • Vulnerable populations and research • AIDS in Africa • Is use of a placebo ethical? • Children • Proxy consents

36. Mortality and Vioxx • Data submitted to FDA concluded no significant risk • Intent-to-treat deaths in RCTs for Alzheimer’s • Subjects 34/1069 • Placebo 12/1078 • Hazard ratio 2.99 • JAMA 2008;299:1813

37. Policy on the rights of patients in medical education (BMJ) • For educational activities not part of clinical care: • Patients must understand that medical students are not qualified doctors (and not "young doctors," "my colleagues," or "assistants"). • What about interns? Unlicensed physicians? Non-board certified physicians? Do all patients understand the distinctions? • Clinical teachers and students must obtain consent from patients before students take their case histories or physically examine them, making sure they understand the primarily educational purpose of their participation. • What is “primarily educational?” Students are valuable history takers, examiners, etc.

38. BMJ Patients’ Rights II • Never perform examinations or present cases that are potentially embarrassing for primarily educational purposes without the patient's consent. When individual students are conducting such examinations a chaperone should usually be present. • Students should never perform examinations on patients under general anesthetia for primarily educational purposes without patients' consent. Patients who are unconscious or incompetent must be involved in primarily educational activity only with the explicit agreement of their responsible clinician and after consent from parents (children) or consultation with relatives (adults).

39. The Art of Pimping • To pimp: verb. To ask a series of progressively arcane and distantly related questions. The purpose is to establish or confirm power. • Historical, anatomical, physiological, clinical, eponomical, characterological, hierarchical • Responses: bluffing, feigned erudition • Brancati FL. The art of pimping. JAMA. 1989;262(1):89-90. • Detsky AS. The art of pimping. JAMA 2009;301:1379-81