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Help for impaired physicians.

A physician is considered to be impaired when personal problems (e.g., chemical dependence, emotional disorders, physical disability) or professional difficulties (e.g., malpractice litigation stress, incompetence) begin to interfere with the ability to function in the profession and in personal life. In this article, the nature of the impairment problem is briefly described and the issues of prevention, early recognition, effective and humane treatment, and the recovery process are addressed.

most cases of physician impairment remain hidden until some catastrophe forces recognition of the problem, the prevalence of impairment is unknown, but it could be as high as 20 percent.1 Alcoholism and other drug addictions are the most common causes of impairment. Nationally, the frequency of causes is alcohol with other mood-altering drugs, 40 percent; alcohol alone, 35 percent; drugs alone, 10 percent; mental illness, 10 percent; and physical disability (including senile dementia), 5 percent.2 The information on treatment and recovery in this article apply most obviously to chemical impairment but, with appropriate modifications, can be implemented in a wide variety of impairment situations. Emotional illness ranks second to chemical dependence as a cause of impairment in physicians. Pfifferling estimates that 10 percent of physicians are affected by emotional illness. Nearly one-third of interns experience profound clinical depression in their first six months of house -staff training, and 15-20 percent of medical students experience emotional problems. The explosive increase in malpractice litigation in recent years has led to a newly recognized cause of emotional impairment.4 Malpractice stress syndrome is characterized by depressed mood, negative self-image, irritability, and insomnia. If not successfully treated, the syndrome can result in suicide. Neurological and other physical disabilities account for a minority of cases of physician impairment. Most commonly encountered is severe hearing loss. Alzheimer's or multiinfarct dementia may cause personality changes and progressive cognitive impairment. Accurate diagnosis of the cause of dementia is critical, because it may have a reversible cause. Natural History In cases of impairment by chemical abuse, problems are first seen in the physician's family life and then in community relations, in employment applications, in physical status, and finally in the hospital. Dependence on mood-altering chemicals is a progressive illness. It can result in death from medical complications, unintentional injury, or suicide. Although cognitive impairment may be severe, it is largely reversible with prolonged sobriety. Seventy to 90 percent of drug-dependent pendent physicians who have been treated in impaired physician programs are able to maintain sobriety and return to professional life.5,6 Much less is known about the course of emotional illness in physicians. The literature has almost exclusively addressed the endpoint of suicide. Unmarried female housestaff are a high-risk group for suicide. This population represents one appropriate target for preventive and early intervention strategies. Recognition Denial, widespread ignorance, and a misapplied sense of loyalty to faltering colleagues impede recognition of physician impairment. As a rule of thumb, if you think a colleague might be impaired, he or she probably is. (Talbott and Benson have provided a comprehensive list of signs of impairment.6) Physician impairment is costly in terms of decreased productivity, danger to patients, litigation, and the lengthy rehabilitation required. Primary prevention would be the ideal way to eliminate these costs, and programs for that purpose are being implemented by many hospitals and medical schools. Strategies for early treatment and rehabilitation can also play important roles in reducing mortality and morbidity due to physician impairment, but they require a willingness and ability to recognize impairment. Primary Prevention A hospital-based committee can be a vehicle for primary prevention of physician impairment. Such a committee is different from a formal "impaired physician committee," which is constituted according to medical staff and administrative bylaws and serves a legalistic due process function. An informal committee can gather and disseminate information on topics relevant to the well-being of professionals, such as stress management, burnout prevention, career development, counseling services, and treatment programs for addictive disorders. It may help in identifying organizational problems that contribute to stress on the medical staff. The committee may serve an educational function, providing in-service training on pertinent topics and sponsoring outside speakers for lectures or workshops on physician well-being and impairment. It may facilitate health promotion activities, such as athletics, recreation, and smoking cessation classes. As many specialties as possible should be represented on the committee, demonstrating that impairment prevention is important to all specialties. Spouse participation should be considered, because the professional's health and home life are intimately related. Having a physician who is recovering from chemical dependence on the committee can be very helpful. There are potential pitfalls awaiting a committee whose goal is prevention of impairment. Because of the tremendous denial by physicians that they are at risk of impairment, it may be difficult to generate interest in such a committee. Furthermore, the committee may be perceived as threatening by professionals who are showing signs of impairment. The goal of impairment prevention may seem foreign to professionals who are oriented toward curing rather than preventing disease. Political infighting or conflicts of interest can also hinder the work of the committee. Inadequate library materials, resources, or staff will reduce the ability of the committee to fulfill its mission. To be a force for beneficial change, the committee must keep a high profile in the hospital. Publicity can be sought in the hospital newsletter and the medical staff letter. Members may offer to give grand rounds on pertinent topics. Having the committee serve more than one hospital may allow for more efficient use of funding and other resources. Secondary Prevention An informal hospital committee can be a valuable resource for secondary prevention, acting to identify, make appropriate referrals, and give support to physicians experiencing problems. Few institutional programs have the funding, the resources, and the monitoring capabilities for state-of-the-art treatment of impairment, so it is generally advisable to draw on the resources of state professional advocacy programs. The committee should not be obligated to report its activities to regulatory agencies, but should be able to refer an impaired professional to a formal disciplinary body if the physician refuses necessary treatment and poses a potential danger to patients. Many states have laws that require peers and colleagues who know of an untreated impaired physician to report him or her to the state Board of Medical Licensure. This is distasteful to collagues and distressing to the impaired professional, and may bring adverse publicity to the institution with which the impaired physician is associated. Hospitals and other health care facilities are required by state laws to notify the state medical board when suspending or curtailing a physician's employment, association, or privileges when the action is being taken because of ongoing impairmen% incompetence, or misconduct. Thus the most appropriate, helpful and nonpunitive first step to take on behalf of a physician showing signs of impairment is to notify the impaired physician program of the state medical society before the impairment becomes severe enough to be labeled as such, and thus becomes reportable. A member of the hospital's impairment prevention committee could act as a liaison between the hospital and the state program for facilitation of treatment, rehabilitation, and monitoring of recovery cry, and could act as an advocate for the recovering professional when he or she returns to the workplace. intervention All 50 state medical societies now have impaired physician programs. Referrals to the programs are accepted from colleagues, hospital and office staff, insurance carriers, licensure boards, and any other person who is genuinely concerned about the well-being of a physician or the physician's patients. It is not true that a chemically addicted person needs to "hit bottom" in order to begin recovery, or even that he or she needs to want help. On the contrary, intervention should take

e to the physician's career and patients has occurred. Allegations of impairment must be investigated tactfully and discreetly. This may be done by the chairman of the hospital's impaired physician committee or by the medical director of the state medical society's impaired physician program. Having the medical director of the state program carry out the investigation avoids questions of conflict of interest or loyalties. If the existence of impairment is confirmed, the medical director assigns an intervenor or intervention team to the case. Intervention is usually carried out by a team of two or more persons, which may include a respected peer, a physician recovering from a similar impairment, and a representative of the state medical society's impaired physician program. It is essential that the team members be specially trained for this delicate task. Intervention team members should be nonjudgmental and should emphasize advocacy. They should contact the physician and present specific, documented evidence of impairment. Denial, and even hostility, is to be expected from the impaired physician. The intervention team should have carefully prepared options for treatment and be able to implement the agreed-upon plan quickly. If the physician agrees to undergo treatment, he or she is asked to sign an agreement with the institution and the state program specifying the nature and terms of the treatment, rehabilitation, after care, and return to practice. However, if the impaired physician refuses diagnosis or treatment, the team should explain the coercive measures that will be used (e.g., notification of the state board of medicine or action on hospital privileges) and should follow through on them. Treatment The treatment program should be acceptable to the hospital's Impaired Physician Committee as well as to the state impaired physician program. Progress in treatment must be monitored to ensure its adequacy and continuity. Monitoring by the hospital authority is subject to numerous pitfalls, such as the impaired physician becoming lost to follow-up because of relocation (the so-called geographical cure"). State impaired physician programs are generally in a better position to provide ongoing monitoring than are hospital-based programs, and will report on the physician's progress in treatment to the appropriate person at the physician's workplace. Hospitals should consider making loans available to cover any treatment costs not covered by insurance or to provide for the impaired physician's family while he or she is not working. Health insurance with the best possible coverage for treatment of alcohol and drug abuse and mental illness should be sought and made available to the hospital staff. Most insurance plans treat these disorders as "stepchildren," leaving patients to pay a considerable part of their treatment expenses themselves. The hospital should also offer disability insurance and/or encourage staff to purchase individual noncancellable policies that will provide income if they are disabled by physical or mental illness. Unfortunately, few physicians recognize the importance of this type of insurance coverage. Monitoring After initial treatment, the state medical society's impaired physician program assists in formulating after care plans, monitors compliance with the terms of the plan (including attendance at support group meetings and urine monitoring for abuse of drugs, in the case of chemical dependence), and maintains communication with the treating physician, with the therapist, with the person monitoring the recovering physician's clinical performance, and, when necessary, with regulatory agencies. The program acts as the recovering physician's advocate by documenting progress in recovery, assisting him or her to maintain or gain employment, and helping the physician's family to become part of the recovery process. The monitoring plan must be reevaluated at some point to ensure that it is adequate and to eliminate, over time, unnecessary elements. Information about a physician's recovery status should be limited to persons responsible for monitoring his or her progress, as long as no relapse occurs that necessitates disciplinary action. Reinstatement of Privileges The burden of proof of readiness to resume practice lies with the recovering physician, who should be prepared to furnish the hospital medical board with evidence of completion of treatment and a plan of structured after care, which is usually three months in duration. Recommendation to return to practice must be given by the physician who oversaw the treatment. A report should also be given by the physician who will be providing the recovering physician's ongoing medical care. If the recovering physician is in psychotherapy, a report regarding mental fitness to resume practice should be obtained from the therapist. Requiring this documentation can prevent a premature resumption of clinical duties that would set the physician up for failure and relapse. For physicians recovering from addictive disorders, participation in Alcoholics Anonymous or a similar program should be required and documented. Participation in an impaired physician group is desirable. There is a national support group for physically handicapped physicians (the American Society of Handicapped Physicians, 137 Main St., Grambling, La. 71245), and there are support groups for physicians suffering from the stress of malpractice litigation. Ordering of Schedule II and III drugs by physicians recovering from chemical dependence should be monitored by the designated clinical supervisor. The recovering physician should refrain from prescribing any controlled drugs until privileges are fully reinstated. The physician should agree not to use such drugs unless they are prescribed by another physician for a legitimate reason and to notify the monitoring physician of this drug use. Physical, neuropsychiatric, and/or laboratory examination of the recovering physician should be carried out at specified intervals and in cases of suspected relapse. In cases of chemical addiction, urine specimens must be obtained under direct observation on both a regularly scheduled and random basis. This protects the recovering physician by documenting that the recovery is sustained and by permitting early identification of relapse. The physician applying for reinstatement of medical staff privileges should be thoroughly warned in advance that violations of any of the conditions for reinstatement win result in immediate revocation of staff reappointment. Although a solitary, brief relapse occurs during the recovery of many addicted physicians, forgiveness of anything more than that is likely to amount to enabling" the addiction. The applicant should be informed of the circumstances under which relapse will be reported to a licensing board. He or she should be assured that fun reinstatement will take place after two years of satisfactory performance and uninterrupted sobriety (or a shorter time in the case of early stage impairment). In some case, such as the physician impaired by, a senile dementia or the surgeon with failing eyesight, retirement or a change in specialty or career is necessary. The hospital can be helpful by assisting the physician in locating vocational and financial counseling. A good place to start is the state medical society's impaired physician program, which will have more experience with such cases than the individual hospital medical director. Prognosis The prognosis for impaired physicians who obtain treatment is excellent, particularly when the problem is one of chemical dependence. The prognosis for those whose impairments are ignored is poorer. The recovering physician can be a great asset as an advocate for other physicians in the recovery process, as an intervenor in cases of impairment, as a source of encouragement to troubled colleagues, as a monitor for physicians resuming practice after treatment for impairment, and as an educational resource for the medical community.
COPYRIGHT 1989 American College of Physician Executives
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1989, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Author:Samkoff, J.
Publication:Physician Executive
Date:Jan 1, 1989
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