An approach to the impaired physician.

Identification and management of the impaired physician has been one of the neglected areas of peer review. Since the State of California in 1988 mandated hospitals to have physician aid committees, there has been little change in the numbers of physicians actively involved in the medical board diversion program.[1] While participating in the program, physicians can continue to practice (as long as they are not a threat to patients) without being exposed to disciplinary action by the medical board. Although other diversion programs exist, the lack of an increase at the state level signifies that many physicians are not being identified and/or are not being referred for diversion.

This situation is the result of nonexistent or poorly functioning committees that fail to identify or intervene with impaired physicians. The inaction is due to ignorance that the condition exists, confusion as to exactly what must be done, anxiety of confronting other physicians, and fear of sending fellow physicians for discipline or punishment (with possible retaliatory litigation).[2]

Anxiety over confronting other physicians must be balanced by the security of knowing that the individuals, their families, and patients will be better off in the long run. Fear of a retaliatory lawsuit is unfounded, as the risk of litigation is negligible. Likewise, the fear of instigating disciplinary action is unfounded, because the diversion program is not disciplinary. In fact, the diversion program is a protection from punishment. It is designed to encourage early identification, intervention, and self-referral by avoiding the threat of loss of licensure. The program protects anonymity, avoids embarrassment, and acts as an advocate for the physician. The Medical Board of California will only be notified if physicians are determined to be unsafe to themselves or the public.

Incidence of Impaired Physicians

Denying that impaired physicians exist ignores reality. Unless there is an effective physician aid committee, they are rarely identified. Substance abuse, psychiatric illness, and senility occur among physicians, just as they do in all aspects of society. Estimates of the percentage of impaired physicians from substance abuse varies from 10 percent, to 12-14 percent4 40 percent. The 40 percent figure has never been proven,[5] and the general consensus is that 10-12 percent is more reasonable. This range is based on license and disciplinary actions, known or registered addicts, mortality rates, hospital admissions, treatment populations, and surveys of selected groups of physicians. Because the discovery of impaired physicians using alcohol and drugs is not 100 percent and there are difficulties in interpreting the data, the exact prevalence of drug problems among physicians is not known.[5] These percentages do not account for the number of psychologically impaired and senile physicians, who are also categorized as impaired physicians.

The Impaired Physician Committee

Effective November 3, 1988, the California Administrative Code, Title 22, Sections 70703 and 71503, required medical staff bylaws, rules, and regulations in acute care and psychiatric facilities to provide assistance for the impaired physician.[6] The formation of a distinct physician aid committee--its composition and duties--was left to the discretion of individual medical staffs. Although the committee can be joined with other medical staff committees, it was recommended that it be separate. Members of the committee should not, to the extent possible, be on other committees that have review functions or authority over members of the medical staff (e.g., medical executive or judicial review committee). Dual membership tends to inhibit a physician seeking the services of the physician aid committee. When it is not feasible to maintain this separation, extra care should be taken to clarify the committee's policies concerning confidentiality.[7] The physician aid committee must meet at least quarterly.

Committee Composition

One of the major duties of the committee is to identify members of the medical staff who may be impaired. To this end, it is advisable to have broad representation of the medical staff. One member from each major department should be considered for membership. That will give some assurance that every member of the medical staff is known by at least one member of the committee. This is important for two reasons:

* Every member of the medical staff

will be observed by a member of

the committee.

* If a member of the medical staff

has to be confronted, it will be done

by someone familiar and therefore

will be less of a confrontation. Physicians from specialties that have high addiction rates should be members of the committee. For this reason, an anesthesiologist should be a member of the committee. Anesthesiologists are 5 percent of licensed physicians in the state of California, yet represent 17.4 percent of the physicians in the diversion program.1 Several factors contribute to the high incidence of substance abuse among anesthesiologists. Most of them relate to the availability of medications and the characteristics of their practices.[8] First, anesthesiologists constantly handle narcotics and other substances. Narcotic addiction primarily occurs on three conditions: a predisposing personality, the availability of narcotics, and a set of circumstances that brings these two factors together.9 Second, drugs are most used when they are most available.10 Third, the demands on anesthesiologists create a setting where technical performance is necessary, and the hours may be long and unusual. The need for a little "pick-me-upper," to get some sleep, invites drug use.

A family physician should be a member of the committee because 25.1 percent of the physicians in the diversion program are in general or family practice.[1] Access to drugs stored in their offices allows family practitioners to circumvent close control of drugs. The psychological stress of being a family practitioner make them good candidates for substance abuse. Family physicians are often viewed as the low person on the totem pole in the age of specialization. Their lack of respect in the medical community does not satisfy the competitiveness and overachiever personality that prompted them to go into medicine. The apparent usurpation of control, position, and rights of the primary care physician in the industrialization of medicine has led to frustration, loss of self-esteem, and disenchantment with the practice of medicine.

Other members of the committee could include anyone who has experience or expertise in substance abuse or psychiatric illness. A psychiatrist, a recovered abuser, a board-certified addiction medicine specialist, and anyone with knowledge or interest in substance abuse are excellent candidates for the committee.

The Need for Confidentiality

The size of the committee must be balanced with the need for confidentiality. A minimum of three members is recommended, but more than seven members risks loss of confidentiality. More than seven members may be necessary in a large medical staff.

The committee should be limited to physician members. Committee minutes should be brief, thus eliminating the need for an administrative medical staff secretary. Committee members should remain on the committee for many years. Regularly changing members of the committee will allow many members of the medical staff to become privy to information on impaired physicians.

Extensive files must be kept, containing records of complaints, interventions taken, the monitoring agreement, and monitoring reports. All must be kept in the strictest confidence. Information is only accessible to committee members. Release of information only occurs with the written consent of the impaired physician. When there is potential harm to the physician, staff, or patients, an exception for release of information is necessary. Under these circumstances, disciplinary intervention must be taken, and the information can be released to medical staff or hospital leadership.

Naming the Committee

The committee functions as an advocate for the physician and as advisor to the medical staff. The initial approach is to aid physicians before they can harm patients or themselves. The name of the committee should reflect this posture and not connote anything derogatory or disciplinary. Suggested names for the committee are Committee on Physician Health, Committee on the Well-Being of Physicians, Medical Staff Aid Committee, Physicians Advisory Committee, Physicians' Aid Committee, and Physicians' Well-Being Committee.

Getting Started

After the committee has been selected, the first goal is to identify impaired physicians. The committee must arrange educational programs for the medical staff, hospital personnel, and physician office staffs so they will be able to recognize characteristics of the impaired physician. They must be educated on clues to alcoholism or drug addiction in six areas of a physician's life (table above). Without this type of knowledge, suspicions regarding impaired physicians will never be aroused.

The committee is the point where information and concern regarding the health of a physician must be delivered for consideration and evaluation. Channels of communication should be defined to promote, and properly distribute, information about suspected impaired physicians--e.g., medical staff members report to chair of the physician aid committee; nurses report to a nurse administrator, who reports to the chair of the committee; office personal report to the hospital administrator, who reports to the chair of the committee. Again, confidentiality is stressed, and the fewer the links, the better.

Close Encounters of the First Kind

Once suspicion has been raised about a physician, the committee must seek corroboration and additional information. The persons who contacted the committee should receive a response assuring them that some action is being taken. The initial complaint and corroborating evidence must be weighed. If there is any chance of harm to patients or personnel, the advocacy posture of the committee must be put aside. The information must be forwarded to the chief of staff for formal disciplinary action. Usually, the first encounter with the impaired physician is not because of an egregious act that requires this type of intervention. The usual scenario is a hint of a problem. Denial and deceit, which are characteristic of substance abuse, tend to hide problems in the beginning of the disease.

The first encounter can be collegial, best done by a friend or someone who knows the physician, in order to advise the physician that there are some concerns regarding his or her health and to recommend that assistance be sought. If the physician begins a substance abuse program and/or seeks psychiatric care, the committee has jumped its biggest hurdle. The hardest step is making impaired physicians realize that they have a problem and seek help. Once treatment has begun, the committee monitors the physician's progress. The committee does not provide treatment. When the physician fails to cooperate, a different approach must be taken. The committee must arrange for an intervention--a meeting to confront the physician. All the information obtainable will be presented to the physician. Office staff and family members can be asked to participate. Participants should be made aware that the intervention is not punitive, but is intended to help a colleague in need and patients. At least two physicians should be present, preferably one who is close to the physician, and an experienced intervenor. The intervention should be rehearsed in order to handle excuses and to discuss options. The meeting should be scheduled so that it catches the alcoholic (drug abuser) by surprise and when he or she is sober (drug free). Early morning is often the best time.

During the meeting, those close to the physician state their concerns and personal interest. Evidence supporting their position should be based on facts to make it meaningful and less refutable. The intervenor acts as facilitator and coordinator. Emotions (guilt and anger, to name a few) and finger pointing frequently lead to getting side tracked. Everyone must stay focused and emphasize there is a problem that requires immediate attention. The physician is urged to seek treatment. It is important to try to have the physician make a call for help right there; procrastination usually leads to further inaction. If the physician refuses, options must be played out; each person present must inform the physician of the consequences. In a drastic situation, a partner would state, "I am leaving the practice," a spouse would state, "I am leaving the house," and the office staff would state, "We are quitting." These are only possible consequences. Options must be based on the severity of the situation. It can even be decided beforehand that one option will simply be to try again.

The Aftermath of the Intervention

Once the physician has made a commitment to enroll in a diversion program, the committee must make a formal contract with the physician detailing the obligations of each party, including what type of action will take place should there be a "slip." As part of the agreement, the committee must have the physician sign a written release of information so that the committee can receive information from all those providing evaluation and/or treatment. The physician must give permission for the committee to act as a monitor. Under some circumstances, the physician must agree to take a leave of absence, with the understanding that return to patient care will be under preestablished conditions.

The elements of the monitoring program must be spelled out in the agreement. Typically, the agreement calls for successful completion of a primary treatment program (in- or outpatient treatment is acceptable). This is followed by continued treatment at regular meetings in a recovery program and periodic drug screening for no less than two years. Periodic communication from the program director and results of drug screens must be forwarded to the committee. Monthly reports for the first year and quarterly reports for subsequent years are recommended. Usually, one member of the committee will be assigned to receive information. As long as the reports are favorable, detailed discussions in the committee are not necessary. Alterations in the monitoring program are acceptable as the situation changes.

When the committee is satisfied that the physician is able to safely practice, the physician may resume patient care. Direct observation is necessary once practice begins to ensure that there has not been a "slip." Contacts should come at various unscheduled times. This observation can take the form of proctoring. Formal observation can be discontinued when the physician is drug free and maintains a sober life-style for a predetermined period. The parties must agree on the type of drug screening, who is going to pay for the tests, who is going to observe collection of specimens, and who will receive the results of the teats. It must be understood that collections will be random.

Handling the "Slip"

Drug screening and direct observation of the physician are the basic elements of the monitoring program. As part of the initial contract, the parties must agree on what is to be done should the physician fail any part of the monitoring program. Relapse or resumption of the use of drugs or alcohol (a "slip") is not uncommon, especially in the early phases of recovery. The initial response to a "slip" should be evaluation by an experienced and knowledgeable evaluator (someone experienced in recovery). A determination should be made as to what effect the "slip" has on the recovery program and on patient care. Customarily, it is acceptable to merely intensify monitoring. If patient care is compromised, suspension of privileges or a leave of absence is in order.

The physician must agree that recurrent "slips" will result in loss of medical staff membership without a hearing. The number of acceptable failures, and the time frame for accepting them, must be part of the agreement. "Three strikes and you're out" is a good approach. This finality motivates the physician in the recovery process; the threat of loss of practice increases the chance for success. Without this threat, the physician may continue to make excuses, escape reality, and live in denial, during which time the program can actually worsen the disease process. It is important that the system not become codependent to the physician. This occurs when the system's inadequacies enable the physician to continue in the disease process. The lack of effective intervention allows the physician to justify certain detrimental behavior. The physician must be made responsible for his or her actions.

"Slips may be considered the rule rather than the exception. More than 40 percent of the physicians in the diversion program will have relapses during the first year. More than 57 percent of the physicians in the diversion program have been in treatment programs at least once.[1] This emphasizes the need for long-term monitoring; the best recovery is developed over several years. Relapses after 'successfully" completing monitoring should be handled as initial interventions.

Horses of a Different Color

There are three types of impairment: substance abuse (approximately 92 percent), psychiatric illness and behavior problems (approximately 5.9 percent), and senility (approximately 2 percent).[1,11] Dealing with a senile physician is merely a matter of convincing him or her it is time to retire. Rehabilitation is out of the question. When there is adequate documentation that there is substandard patient care, corrective action must be instituted in the form of reduction of privileges, mandating coadmission with another physician, or other corrective action that will adequately protect patients.

The principles, policies, and procedures for managing the psychiatrically impaired physician are the same as those used to treat the substance-abusing physician. A major difference is that monitoring is done by a psychiatrist. Also, defining and identifying the psychiatrically impaired physician is a more difficult task. It is rare to encounter overt schizophrenia, where it is obvious that patient safety is jeopardized. Depression, anxiety, and personality disorders that result in subtle changes in behavior are much more common.

Identifying the psychiatrically impaired physician begins with education of the medical staff, hospital staff, and office staffs (the same process as in substance abuse). They must be informed as to what is acceptable behavior.

Although there are many forms of psychiatric illness and behavior problems, one area is extremely important because such behavior problems are a violation of law. When disruptive behavior takes the form of sexual harassment, it violates the Civil Rights Act of 1964. The easy part of dealing with this problem is that the language in the law provides a basis to define a problem physician. The courts view sexual harassment as falling into one of two types:

* Quid pro quo, when tangible job

benefits are conditioned on an

employee's submission to conduct

of a sexual nature and adverse job

consequences result from the

employee's refusal to submit to the

conduct.

* A hostile environment that creates

an offensive environment that seriously

affects the victim's psychological

well-being. Under the Civil Rights Act of 1991, victims of sex discrimination or harassment may demand jury trials and punitive damages. The publicity and costs can be severely damaging.

Medical staff and hospital personnel must be made aware of what is considered acceptable behavior. Behavior that adversely affects employees' rights will not be tolerated. Employees must be made aware that the physician aid committee stands ready to receive complaints. When, an employee comes forward with a complaint, the committee should investigate thoroughly. If the complaint is corroborated, corrective action must be taken. Only by taking action can the medical staff and the institution avoid the appearance of condoning unlawful behavior. Failure to intervene can result in additional liability.

Behavioral problems usually have two sides. Usually, there are no witnesses or other evidence to substantiate the complaint. When the complaint cannot be verified, the complaining party should be made aware of the difficulty in taking action, that the complaint will be kept in a file, and that, over time, there may be enough complaints to build a solid case against the physician. Once a case has been made against a physician, whether based on a single verified complaint or a series of complaints, some type of corrective action must be taken. The initial contact is a concerned, collegial approach and acts as a warning. It must be emphasized that retribution against a plaintiff or continued behavior may result in immediate suspension or termination of privileges or membership. If the problem persists, continued counseling is recommended. However, reduction or suspension of privileges or membership is in order if it can be documented that behavior directly or indirectly jeopardizes patient care.

Other forms of disruptive behavior must be clearly defined in the rules and regulations of the medical staff. Tirades in the operating room, throwing equipment, foul language directed at other persons, obstreperous conduct, abusive treatment of employees or patients, or disruption of meetings must be corrected on a formal level.

Courts have held that hospitals have a duty to take action when physicians' conduct disrupts the operation of the hospital, affects the ability of others to get their jobs done, creates a "hostile work environment" for hospital employees or for other physicians, or begins to interfere with the physician's own ability to practice competently.

Management of abusive physicians follows the same principles previously described:

* Define the problem.

* Educate and provide awareness of

the problem.

* Indicate where to take complaints.

* Develop policies for handling complaints,

including how adequate

documentation will be maintained

to demonstrate a pattern of conduct.

* Describe when and what type of

corrective action will be taken. The

type of corrective action and the

number of chances given will

depend on the seriousness of the

conduct. Dangerous or unlawful

conduct should result in immediate

action, with the proviso of "just one

more chance, and that is final." People observing or experiencing adverse conduct should be encouraged to report. Although the reporting person should remain anonymous, the physician can usually determine who filed the report because of the circumstances surrounding the incident. To protect the person filing the report, the policy must state that "Any retribution or continued behavior directed at the reporting person will lead to more stringent controls on behavior, including loss of membership from the medical staff."

It Pays to Act

Intervention and monitoring permits success for approximately 96 percent of physicians. Those without drug screen monitoring have a 64 percent success rate.[16] The Medical Board of California Diversionary Program had 1,110 participants from 1980 to 1991; 73 percent have successfully completed the program, remaining sober and drug free for more than two years, and have a life-style that supports ongoing sobriety.[1]

Physicians are highly treatable because they are highly motivated, well educated, and high achievers and have a great deal to lose from an abridged practice. Loss of esteem, prestige, and money are factors that weigh heavily on success. Peer and family pressure provide further impetus to succeed. With early identification and effective intervention, the impaired physician can usually continue to work or can return to work fairly quickly.[10]

Making it All Succeed

The composition, frequency of meetings, policies, and procedures of the physician aid committee must be part of the bylaws, rules, and regulations of the medical staff. They must be approved by the hospital board. Policies regarding confidentiality and flow of information are necessary to protect the physician and the institution.

Conclusion

In summary, the program starts with a standing committee that meets at least quarterly and that educates the medical, hospital, and office staffs. Once educated, these people will be able to recognize the impaired physician. When suspicions are aroused, the impaired physician can be identified and referred to the committee. After verifying the information, the committee can proceed to informal, collegial discussions and counseling. If these actions are ineffective, a formal intervention takes place. The physician signs a written agreement incorporating a commitment to enter a recovery program and plans for surveillance (monitoring with drug screening and personal observation), relapses (including termination from medical staff without ability to reapply, or to reapply with terms and conditions), and reentering practice. Early recognition and effective intervention is highly successful. Denial and delay until damage is done unnecessarily jeopardizes the recovery process for impaired physicians, their relationships with others, and their patients.

HEALTH CARE QUALITY

Clues to Alcoholism or Drug Addiction in Six Areas of a Physician's Life(*)[4]

Community

* Isolation and withdrawal from community activities, leisure

activities and hobbies, church, friends, peers.

* Embarrassing behavior at club or parties.

* Arrests for driving while intoxicated, legal problems.

* Unreliability and unpredictability in community and social

activities.

* Unpredictable behavior, e.g., inappropriate spending, excessive

involvement in political activities.

Family

* Withdrawal from family activities, unexplained absences

from home.

* Fights; child abuse.

* Development in spouse of disease of "spousaholism."

* Abnormal, antisocial, illegal behavior by children.

* Sexual problems--impotence, extramarital affairs, contra-cultural

sexual behavior.

* Assumption of surrogate role by spouse and children.

* Institution of geographic separation or divorce proceedings

by spouse.

Employment

* Numerous job changes in past five years.

* Frequent geographic relocations for unexplained reasons.

* Frequent hospitalizations.[dagger]

* Complicated and elaborate medical history.[dagger]

* Unexplained intervals between jobs.

* Indefinite or inappropriate references.

* Working in job inappropriate for qualifications.

* Reluctance of job applicant to let spouse and children be

interviewed.

* Reluctance to undergo immediate preemployment physical

examination.

Physical Status

* Deterioration in personal hygiene.

* Deterioration in clothing and dressing habits.

* Multiple physical signs and complaints.

* Numerous prescriptions and drugs.

* Frequent hospitalizations.

* Frequent visits to physicians and dentists.

* Accidents.

* Emotional crises.

Office

* Disruption of appointment schedule.

* Hostile, withdrawn, unreasonable behavior to staff and

patients.

* "Locked-door syndrome."

* Excessive ordering of supplies of drugs from local druggists

or by mail.

* Complaints by patients to staff about doctor's behavior.

* Absence from office--unexplained or due to frequent illness.

Hospital

* Making rounds late or inappropriately, abnormal behavior

during rounds.

* Decreasing quality of performance, e.g., in staff presentations,

writing in chart.

* Inappropriate orders or overprescription of medications.

* Reports of behavioral changes from hospital personnel

"hospital gossip" .

* Involvement in malpractice suits and legal sanctions

against hospital.

* Reports from emergency department staff of unavailability

or inappropriate responses to telephone calls. (*) Areas are usually involved sequentially, although two or three may seem to be involved simultane [dagger] Information obtained from employment applications.

References

[1.] Data from the Medical Board of the California Diversion Program. [2.] Chappel, J. "Physician Attitudes toward Distressed Physicians." Western Journal of Medicine 134(2):175-80, Feb. 1981. [3.] Bloom, M. "Impaired Physicians: Medicine Bites the Bullet. Medical World News 19(15):40-1,46,50-1, July 24, 1978, p.40 [4.] Talbott, G., and Benson, E. "Impaired Physicians." Postgraduate Medicine 68(6):56-64, Dec. 1980. [5.] Brewster, J. "Prevalence of Alcohol and Other Drug Problems among Physicians." JAMA 255(14):1913-20, April 11, 1986. [6.] Physician Impairment. California Medical Association. Medical Staff Advocate, Nov./Dec. 1988, p. 2. [7.] California Medical Association "Guidelines for Physician Aid Committees of Hospital Medical Staffs," March 4, 1988. [8.] Pelton, C., and Ikeda, R. "The California Physicians Diversion Program's Experience with Recovering Anesthesiologists." Journal of Psychoactive Drugs 23(4):427-31, Oct.-Dec. 1991. [9.] "The Sick Physician. Impairment by Psychiatric Disorders, Including Alcoholism and Drug Dependence." JAMA 223(6):684-7, Feb. 5, 1973 [10.] Levy, B. "The Impaired Physician." HMS Health Letter, March 1987, p. 5. [11.] Talbott, G., and others. "The Medical Association of Georgia. Impaired Physician Program." JAMA 257:2927, 1987. [12.] Leach v. Jefferson Parish Hospital District No. 2, 870 F. 2d 300 (5th Cir. 1989). [13.] Shone, J. "The Oregon Experience with Impaired Physicians on Probation. An Eight-Year Follow-Up." JAMA 257(21):2931-4, June 5, 1987.

Further Reading

"Statewide Physician Health Program Procedures." Wisconsin Medical Journal 92(9):539-42, Sept.1993. Pelton, C., and others. "Physician Diversion Program Experience with Successful Graduates." Journal of Psychoactive Drugs 25(2):159-64, April-June 1993. Blondell, R. "Impaired Physicians." Primary Care 20(l):209-19, March 1993. Arshem, E. "Dealing with Substance Abuse in the Medical Workplace," Medical Group Management Journal 40(2):46-51, March-April 1993. White, R., and others. "Hospital-based Professional Assistance Committees: Literature Review and Guidelines." Maryland Medical Journal 41(4):305-9, April 1992.

William J. Mandell, DO, JD, is a practicing physician and attorney in Simi Valley, Calif.