By Tom Harbin, MD, MBA,* and Neil Baum, MD†
Nearly every physician has encountered a doctor who is causing problems in the practice or at the hospital. These include physicians who are impaired because of drug or alcohol abuse. Managing these physicians and helping them get back on track can be difficult and daunting. This article will discuss impaired physicians with suggestions for interacting with them and helping them become valuable members of the team.
Definition of “Impairment”
In 1973, the American Medical Association defined the impaired physician as one who is unable to fulfill professional and personal responsibilities because of a psychiatric illness, alcoholism, or drug dependency. The prevalence of substance abuse and chemical dependence among physicians is difficult to ascertain. Conservative estimates indicate that 8% to 12% of physicians will develop a substance abuse problem at some point in their careers.2 Within the medical specialties, anesthesiologists and emergency medicine doctors appear to be at highest risk. It is unclear whether it is the particular specialty that increases the risk of abuse, or that the already at-risk physician is more likely to choose that specialty.3
In addition, other mental illnesses, such as dementia, bipolar disorder, and personality disorders, or physical injuries can lead to an inability to safely perform one’s duties as a healthcare provider.
Recognizing the Impaired Physician
An early identifier of impairment is change in the behavior of a colleague. Physicians who are normally on-time for seeing patients or attending meetings become chronically late and make excuses that don’t hold water. Physical appearance can change. Clothing now covers the arms to hide evidence of needle tracks, or a doctor becomes sloppy in at- tire and personal hygiene. Such doctors may have changes in personality with more evidence of temper problems or outright abusive treatment of staff. They become upset and confrontational over trivial matters. The impaired physician may raise his or her voice at fellow physicians, or more commonly at staff members, over minor problems. Other signs of impairment include signs of depression or being easily distracted, withdrawn, or disengaged. If the doctor’s workplace provides access to drugs, he or she may work long hours to stay close to the source of the addiction.
Still other behaviors that signify a problem include unpredictable behavior to staff or patients, as well as lack of availability when on-call or making careless medical decisions. Some impaired physicians will isolate themselves— they close or lock their office door or make hospital rounds at odd hours.
Impaired physicians seeking employment may present with “red flags” on their resume, such as unexplained lapses between jobs, frequent job changes, multiple relocations, and vague letters of referral. Any letter of referral that is not glowing calls for a personal conversation with someone in the organization from which the letter came.
In some cases, substance abuse problems can remain undetected for years before coming to light. Impaired physicians can function at an adequate level until their problem becomes more advanced and their ability to care for patients deteriorates. In these cases, the family may recognize problems before colleagues. Marriages usually suffer, and impairment can lead to separation or divorce.
Healthcare providers and behavioral health professionals have made great efforts to characterize psychiatric illnesses such as addiction and depression as diseases rather than as moral failings. Nevertheless, physicians who suffer from such illnesses often have difficulty acknowledging that they are susceptible, while in fact addiction and depression are as common in healthcare providers as in the general population.4
For all these reasons, physicians in a group, and especially the group’s leaders, should be vigilant and have a low threshold for investigating suspicious behavior for substance abuse. Moreover, leaders need to have some knowledge of the other mental illnesses that can lead to impairment: dementia in the older doctor, bipolar disorder, decompensating schizophrenia, and the like.
Leaders of groups need to be sensitive to the natural reluctance of staff or colleagues to report problems and should pay attention to any hints of problems that surface. Even better, an anonymous way to report problems within an organization can lead to earlier detection.
WHY ARE PHYSICIANS AT RISK FOR IMPAIRMENT?
Doctors have a lengthy training schedule, work long hours, and have significant stress. As a result, they are ripe for ad- diction to alcohol or drugs. In addition, doctors have easier access to addicting drugs, enhancing the potential abuse of these substances by susceptible doctors.
Alcohol is the most commonly abused substance among physicians. Next most common is prescription drug abuse, particularly benzodiazepines and opioids.5 Although the drug of choice for anesthesia personnel entering treatment for substance abuse is usually an opioid, abuse of propofol, ketamine, sodium thiopental, lidocaine, nitrous oxide, and the potent volatile anesthetics has also been reported.6 These drugs lend themselves to self-treatment and are easily accessible. Anesthesiologists in particular are at risk for controlled substance abuse. Despite strict controls and accounting measures, it remains relatively easy to divert controlled substances for personal use. Some have cited the high stress environment in which anesthesiologists work as a contributing factor, and others have suggested that exposure to trace quantities to these agents in the workplace sensitizes the reward pathways in the brain and promotes substance abuse. Still others have proposed that individuals with novelty-seeking behavior traits may be both more likely to choose a career in anesthesia and more prone to the development of addiction.6
MANAGING THE PROBLEM DOCTOR
An impaired physician has deleterious effects on his or her patients, colleagues, and staff of both the practice group and hospital. Members of a practice, group, or hospital staff that recognize or suspect an impaired physician are morally and ethically responsible to take steps so that the appropriate leadership can investigate and, when neces- sary, help the impaired doctor receive treatment and, just as importantly, protect patients from receiving poor care.
Staff and colleagues should take action sooner rather than later. Failure to take prompt action may put the of- fending doctor at risk of permanent damage to his or her reputation and can also put patients at risk for injury or improper treatments.
Practice leaders that hear a complaint about a fellow colleague by the staff or another member of the practice must take such complaints seriously. Begin by getting all of the facts. Remember there are always two sides to every story. No matter how egregious or damning one side of the story is, you should keep an open mind until you’ve heard the other side and have all of the details. Get as many facts as you can from as many people as you can, and make certain that there really is a problem.
Some large practices and almost all hospitals have a committee specifically set up to manage the impaired physician. This is the avenue for reporting suspicions for practices that belong to such an organization. Many states have a legal requirement to report any physician that may be practicing while impaired. It may seem tempting to privately question or confront the physician about the possibility of a problem, but this often results in denial and can cause more harm than good. Once the physician becomes aware that others may know of the problem, there is the potential for self-harm.
Virtually all state medical societies and licensing boards have a Physician Health Program (PHP) for dealing with impaired physicians. Nine states have legislated impaired physician programs administered by state medical boards, independent agencies, or medical societies through con- tracts with medical boards. All other state programs are administered by medical societies.7 The Federation of State Physician Health Programs is a nonprofit organization that serves as a forum for information exchange among these various state programs.
All shared information is treated confidentially and can be divulged without fear of retaliation. It may seem difficult to report a colleague, but failing to do so puts the patients of the impaired physician at risk. The PHP can serve as an advocate for the physician before the medical board. The potential consequences of licensure suspension and revocation for the physician are greater if the physician is reported to the board without involvement with the PHP.
After the initial contact is made with the PHP, it will arrange for a comprehensive assessment of the physician to help identify a substance abuse problem or psychiatric ill- ness. If the PHP determines that an intervention is needed, a small group consisting of representatives for the PHP or local physician wellness committee and, sometimes, col- leagues will meet with the physician and recommend a formal evaluation be done to determine if any treatment is necessary. The physician can voluntarily follow the recommendations of the committee. If the physician chooses not to, he or she could be reported to the state board and face serious consequences.
Treatment of physicians with substance abuse problems is different than that of the general public. Short-term out- patient therapy relapse rates are greater than 60%, which is unfavorable, considering physicians will be returning to a workplace where judgment must not be compromised.
Extended treatment that lasts three to four months and takes place in a center with other impaired physicians has a better success rate.8
Treatment usually begins in a hospital setting in order to focus on the physical consequences of withdrawal and overcoming initial drug cravings. This may take a few days to a couple of weeks. During this time, psychological therapy, behavior modification, and education are initiated. The intermediate and late phases take place in a recovery setting where physicians can gain insight by interacting with others that are further along in their recovery.
A nine-year study of physicians in the New Jersey PHP reported a recovery rate of 83.8%, with no relapses at the end of two years. Including those who had one relapse (13.8%), the success rate was 97.6%. Most relapses occur during the first two years after treatment. A structured aftercare program can increase the success rate and help identify a relapse. Typical monitoring is usually done for the following five years, but longer periods may be chosen.9
Bottom Line: Most of us will encounter an impaired physician during our medical lifetime. It is imperative to help the impaired physician and not ignore the problem thinking that it will get better by itself. Disruptive behavior
due to impairment seldom gets better without intervention. With compassionate hand-holding and effective treatment, the disruptive behavior goes away, the impaired physician keeps his or her job and often his or her family stays intact, and the practice is happier and avoids the problems associated with firing a colleague or taking away his or her medical privileges. Y
- The sick physician. Impairment by psychiatric disorders, including alcoholism and drug dependence. JAMA. 1973;223:684-687.
- Brewster JM. Prevalence of alcohol and other drug problems among physicians. JAMA. 1986;255:1913-1920.
- Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci. 2001;322:31-36.
- Yancey JR, McKinnon HD. Reaching out to an impaired physician. Fam Pract Manag. 2010;17:27-31.
- Karp D. Dealing with an impaired colleague. Med Econ. 2007;84:30.
- Bryson EO, Hamza H. The drug seeking anesthesia care provider. International Anesthesiology Clinics. 2011;49:157-171.
- Ikeda R, Pelton C. Diversion programs for impaired physicians. West J Med. 1990;152:617-621.
- Bohigian GM, Croughan JL, Sanders K, Evans ML, Bondurant R, Platt C. Substance abuse and dependence in physicians: the Missouri Physicians’ Health Program. South Med J. 1996;89:1078-1080.
- Reading EG. Nine years experience with chemically dependent physicians: the New Jersey experience. Md Med J. 1992;41:325-329.