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Dear Director,
One of our doctors has had issues with
attendance and weight loss. Now, he just got a DUI. I’m sure there is a substance abuse problem. What are my responsibilities in this situation? Any suggested resources?

Emergency physicians are well versed in handling substance abuse among their patients. But what about when the tables are turned and it’s a fellow white coat who is practicing under the influence?

Given that the prevalence of drug and alcohol abuse among physicians is similar to the general population, it’s actually surprising to me that more medical directors aren’t voicing similar concerns. About 15% of physicians will be impaired at some point in their careers. While physicians tend to drink alcohol less than the general population, it remains the drug of choice when it comes to abuse, followed by opioids and benzodiazepines. Not surprisingly, controlled substances are usually self-prescribed under the pretense of self treatment.

Let’s clarify the terminology. The term “impaired healthcare provider” goes back 40 years to a landmark article published by the American Medical Association titled “The Sick Physician.” The authors were recovering physicians who defined an “impaired physician” as one “who is unable, or potentially 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 skills, or the excessive use or abuse of drugs, including alcohol.” In this piece, the authors clearly point out how impairment implies progression of disease to the point where the physician can no longer perform specific activities.

Although we likely feel responsible for our colleague and want to protect them, the AMA clearly states that our obligation is to protect our patients, and therefore, we have the ethical responsibility to report our impaired colleagues. Some of us have worked side by side with a colleague and ignored warning signs only to then be “surprised” when our friend is arrested for a DUI or gets in a drunk driving accident. By ignoring warning signs, we could be leaving them more exposed since early intervention could prevent future criminal charges, malpractice litigation, or something else that could end a physician’s career.

Identification of the Impaired Physician
We all readily recognize substance abuse when we see it clinically, but studies have shown that physicians are more adept at covering up their addictions. In fact, alcohol dependence may exist for up to 15 years before progression of the illness leads to the point where the individual or their colleagues recognize the need for treatment. I suspect we’ve all worked with people who just seemed to call out sick a little more than everyone else or who had more than the occasional flare up with a nurse in the clinical arena. Taken alone, each sick day or negative interaction does not mean that the person has a dependence problem, but when a theme develops, we all need to consider the potential sources.

As substance abuse progresses, there are clear warning signs. Be on the lookout for: discord in relationships (separations, break ups, divorces), isolation, avoidance of peers, signs of depression, irritability, mood swings, and an inappropriate level of response to a stressful situation. Other signs to look out for include showing up to work with a disheveled, sloppy or sleepy appearance or deteriorating handwriting. Audits and chart reviews may reveal inappropriate orders or a higher than usual ordering of sample medications, particularly benzos and narcotics. I’ve worked in several EDs where routine audits caught nurses pilfering narcotics that were “ordered” as samples or “to go” meds for patients. Ultimately, impairment from substance abuse boils down to behavior that impacts social life, health, and finances. Fortunately, from a patient safety perspective, clinical performance is usually the last thing impaired.

As medical directors, we may have an opportunity to identify potential impairment from a data driven process. We are required to perform semi-annual, ongoing practice performance evaluations (OPPE) on all of our providers and one category that must be evaluated is disruptive physician behavior. There are many reasons to address each disruptive incident with the provider. In particular, there is value in comparing the number of incidents by provider within your group to help identify potentially troubling behavior. Having further discussion with the outliers about potential triggers may allow for earlier identification of an illness.

Interventions
Honestly, I’m not a very confrontational person, but after deciding that a physician may be impaired (and likely after other conversations about disruptive behaviors or absenteeism) an intervention needs to take place. As a medical director, it’s unlikely that you’re trained in doing this, but fortunately help is available. For starters, don’t confront the physician alone. Use colleagues, family, HR administrators, someone from your state’s Physician’s Health Program (PHP) or your company’s Employee Assistance Program to help you. It’s important to avoid arguing or negotiating with the person you’re confronting, but rather express positive regard for their abilities and how treatment will allow them to continue to use their skills as a physician. Before the intervention, set up a specific plan of action and clearly indicate to your physician the consequences of not following through with the action plan.

Physician Health Programs
Coordinated by your individual state, the PHP works in tandem with your state’s board of medicine. Nationally, each state board of medicine is affiliated with the Federation of State Medical Boards, which published their own policy on physician impairment in 2011. The state’s PHP goals are to diagnose, treat, rehabilitate and monitor impaired physicians while the board of medicine would likely restrict a physician’s practice until patient safety can be assured. The goal of these programs is to return the physician to work, which makes getting treatment less punitive. PHPs accomplish this through supporting physicians intervening on their colleagues, by helping the addicted physician accept the help they need to begin recovery, and by providing treatment and monitoring during reintegration to work.

Nearly all states have legal requirements that physicians report impaired colleagues to the board of medicine or to the PHP and allow for anonymous reporting of physicians. The PHP features intensive clinical management and professional support and may include frequent, random drug testing for five or more years.

Suspected Impairment
Although it may seem like a no-brainer, a situation that needs immediate attention is when someone working in the ED is suspicious that a practitioner is impaired. In this case, the medical director needs to set the wheels in motion to remove the practitioner from clinical responsibilities immediately (shift needs to be covered) and start a full investigation. This involves the medical director coming to the department to privately discuss the concerns with the doc and to outline the investigation. The practitioner should undergo mandatory drug and alcohol testing at the time of the incident and may also need to undergo a mental health evaluation performed within days to assess further treatment needs.

Some Tough Calls
Between tee-totaling and full-blown intervention, there is a large, somewhat nebulous middle territory. What about the doc who drinks a bottle of wine most nights, and has a drink during the day before a night shift? He’s edgy from his shift and needs a few shots to settle down. What happens if a doc gets arrested for a DUI but adamantly states that it was one “stupid mistake,” and he doesn’t drink regularly? Depending on the situation, a medical director may not know about this until the physician is getting recredentialed. In that case, the hospital would likely bring it to your attention. Hospitals may vary from being very strict and insisting on alcohol treatment to being more understanding of an explanation, and each state’s medical board may vary in their response as well. Some states may place the doc in a probationary period, while others will insist on monitoring. Some may even issue a summary suspension of a license until a full investigation has taken place. Lawyers have told me that a single DUI may not prevent a doc from getting credentialed, but the medical director and credentials committee needs to take a very close look at that doctor before allowing them to work in the hospital. In my mind, after following my state’s and hospital’s policies, I think it’s reasonable to have the physician undergo a fitness for duty exam by a worker’s comp professional or undergo an assessment by an addictions specialist to make further recommendations for treatment or no treatment.

Outcomes
Now for the good news. A study of 904 patients in a PHP found an overall return to work rate of 79% at 5 years. Fifteen percent stopped practicing and 11% lost their license. In other words, most physicians with impairment, when recognized and treated, don’t lose their jobs but are able to be rehabilitated and continue to contribute as physicians. Physicians need to want treatment and be compliant with treatment and subsequent follow up (which would likely include random drug and alcohol tests).

Conclusion
Physician impairment is common enough that medical directors have to expect to be in the same situation you’re in at some point in their career. While physicians may be able to hide some of the warning signs of abuse, they will eventually surface and will need to be addressed seriously. The good news is that our boards of medicine are more interested in rehabilitating physicians than punishing them and with good treatment, most doctors are able to return to work.


Michael Silverman, MD, is a partner at Emergency Medicine Associates and is chairman of emergency medicine at the Virginia Hospital Center. 

 

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