Physician Impairment

1. Physician Impairment Part One: I Suspect My Colleague is Using Drugs: What Should I Do? -Karl Nibbelink, MD

2. Disclosure Financial relationships include …none

3. Goals • Understand the scope of the problem of addiction/alcoholism in medicine. • Identify warning signs of substance abuse. • Identify barriers to referral/treatment. • Develop an intervention/referral strategy.

4. Briefly… • …if you suspect a colleague is impaired—make a confidential referral to your state impaired professional program. • That’s it!

5. …so what’s left to talk about? • Survey of 2938 US physicians: • 1/3 felt unprepared to deal with impaired colleague • Of 17% who had contact with impaired colleague, 1/3 did nothing about it • 19% felt someone else would • 15% felt nothing would happen • 12% feared retribution • 10% felt punishment would be excessive • 8% didn’t know how to handle it -DesRoches 2011

6. October 10, 2010 Physician had 0.57 blood-alcohol level at medical center where she worked

7. William S. Halsted, MD “The proneness to seclusion, the slight peculiarities amounting to eccentricities at times … were the only outward traces of the daily battle through which this brave fellow lived for years. He had done so well and so energetically that it did not seem possible that he could take the drug and done so much” -William Osler, MD, 1892

8. Cases • 1) Well regarded resident with multiple unexplained absences. • 2) Attending with erratic behavior, frequently missing. • 3) Colleague who allegedly smells of alcohol.

9. Definitions • Now the AMA defines the impaired physician… as one unable to fulfill professional or personal responsibilities because of psychiatric illness, alcoholism, or drug dependency.

10. Definitions The Neurobiology of Addiction -Dopamine, memory, and value. “Because of the excessive dopamine signal in the prefrontal cortex drugs become overvalued… Rational goals such as self-care, working, parenting, and obeying the law are devalued. In addition, normal aspects of cognitive control weaken.” -Hyman 2007

11. Some language • Addiction/alcoholism is a disease. • AMA 1956 • Referral instead of report. • Think treatment instead of discipline.

12. Epidemiology Are doctors more at risk? • 6%-8% of physicians have substance use disorders, up to 14% have alcohol use disorder. • Overall these are similar rates as found in the general population. • Chemical dependence is the most frequent disabling illness among physicians. -Talbott 1987 -Bissel 1984, Regier 1990, Brewster 1986, and Niven 1984

13. Epidemiology • National Survey of EM Residents 1992… • Alcoholic or risk for alcoholism: 12.5% • Cocaine use 23% (ever); 1% (in last year) • Marijuana 52.3% (ever); 8.8% (in last year) • Heroin 0.9% (ever); none in last year -McNamara, 1994

14. Epidemiology • Follow-up Survey of EM Residents 2006… • Increasing rates of marijuana use (past-year use increased from 8.8% to 11.8%; past-month use from 2.5% to 4.0%) • Alcohol use is increasing: • Daily drinkers from 3.3% to 5.0% • More residents are reporting that their alcohol consumption is increasing during residency (from 4% to 12.6%) -McBeth, 2008

15. Epidemiology • Emergency medicine and psychiatry residents have the highest rates of substance abuse • EM residents had highest rates of last month (8%) and last year (14%) cocaine use, last year marijuana (29%) • Psych residents had highest rates of last year marijuana (34%) and benzodiazepine use (27%) -Hughes, 1992, 1999

16. Contributing Factors/Presentation • Long stressful work hours? • Easy access to drugs? • Surprisingly NOT. • High academic rank • Perfectionist behavior • Idealistic beliefs • All correlate with drug use in physicians and medical students. -Bissell 1976, McAuliff 1987

17. Contributing Factors/Presentation Signs and symptoms of substance abuse in the workplace ● Frequently absent from work without reasonable explanations ● Arriving late consistently ● Missing appointments with patients ● Inaccessibility to patients and staff ● Inappropriate behavior with colleagues, staff, and patients ● Conflicts with colleagues, staff, and patients ● Avoiding a supervisor or other colleagues ● Rounding on patients at odd hours ● Large quantities of drugs ordered ● Inappropriate orders and forgotten verbal orders ● A disorganized schedule and missed deadlines ● Heavy drinking at hospital functions ● Vague letters of reference ● Multiple prescriptions for family members ● Long lunches or unnecessary breaks ● Decreased chart and work performance -Talbott 1998

18. Diagnosis and Referral • Delayed diagnosis is the standard. Why? • Work affected as a late manifestation • The “conspiracy of silence” • “Physician, heal thyself” • Fear of loss of career • Denial,Denial, Denial!

19. Diagnosis and Referral • Obligation to “report”… • AMA and ACEP state physicians have a moral duty to report impaired, or suspected impaired, colleagues. • >20% of states have laws mandating reporting (liability for NOT reporting, and protection for)

20. Diagnosis and Referral • Who to refer to… • Institutional Impairment Program • Director • Chairperson • Chief of Staff • State Impaired Physician Program

21. Diagnosis and Referral • State Impaired Physician Program • Confidential • Assessment • Intervention • Plan • Goal both physician heal AND patient safety

22. Cases…follow up • Case 1: the learning curve… • Case 2: the hard way… • Case 3: best case scenario…

23. Questions?

24. Physician Impairment Part Two: My Colleague is Back From Rehab: How Should I Act? -Karl Nibbelink, MD

25. Disclosure Financial relationships include …none

26. Goals • Understand the treatment of addicted physicians. • Identify specific needs in the early return to work period. • Discuss aftercare and relapse. • Know the long term prognosis for physicians.

27. Briefly… • …treat your returning recovering colleague as you would anyone returning from a medical leave. • That’s it!

28. Treatment “The purpose of the process [of identifying and treating impaired physicians] is assistance and rehabilitation rather than discipline, to aid a physician in retaining optimal professional functioning, consistent with protection of patients.” -The Joint Commission, 2001

29. Treatment • Talbott Model • Evaluation by addiction specialist • Substance abuse, medical, and neuro-psychiatric evaluation • Residential vs. outpatient treatment • Therapy (family, individual, group) • Medication • Drug screening • 12 Step recovery programs

30. Return to Work • Recovery Monitoring Contract • Therapy • 12 Step Program • Drug/Alcohol screening • Monthly/Quarterly reports • Documented progress • Return to work assessment

31. Return to Work • Early return to work period • Schedule • Hours • Isolation • Access

32. Prognosis • Recovery rates for physicians much higher than the general population. • At 10 yrs 75%-85% of physicians maintained abstinence while 15%-20% relapsed within 1-2 yrs of initiation of treatment. • Higher rates of sustained abstinence for those continually involved in a recovery program (AA,NA). -Gallegos 1992, Alpern 1992, Morse 1984

33. Prognosis • The Pennsylvania experience: • Retrospective study of 308 physician/clients of the PHP in 2003 • 75% had continuous sobriety for 10-12 yrs. • 25% had experienced a relapse • 92% had >5 yrs sober -Gable (2010 personal comm.)

34. Cases…follow up • Case 1: the learning curve...and the long road back. • Case 2: the hard way…is sometimes the only way. • Case 3: best case scenario…gets better.

35. Summary • “Timely identification, treatment, and follow-up care will allow impaired providers the opportunity to heal and to be successful in their clinical careers and personal lives.” -Baldisseri 2007

36. References 1. Baldisseri M: Impaired Healthcare Professional Critical Care Medicine 2007; 35 supp2:106-116 2. Osler W: The Principles and Practice of Medicine.New York, D. Appleton, 1892, pp1005–1006 3. Bissel L, Haberman P: Alcoholism in the Professions. New York, Oxford University Press, 1984 4. Regier DA, Farmer ME, Rae DS, et al: Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990; 268:1012–1014 5. Brewster JM: Prevalence of alcohol and other drug problems among physicians. JAMA 1986; 255:1913–1920 6. Niven RG, Hurt RD, Morse RM, et al: Alcoholism in physicians. Mayo Clin Proc 1984;59:12–16 7. Talbott G, Wright C: Chemical dependency in healthcare professionals. Occup Med 1987;2:581–591 8. McNamara R, Sanders A, Ling L, et al: Substance use and alcohol abuse in emergency medicine training programs, by resident report Academic Emergency Medicine. 1994; 1:47-53 9. McBeth B, Ankel F, Ling L, et al: Substance use in emergency medicine training programs Academic Emergency Medicine 2008: 15:45-53 10. Hughes PH, Brandenburg N, Baldwin DC, et al: Prevalence of substance abuse among U.S. physicians. JAMA 1992; 267:2333–2339 11. Hughes P, Storr C, Brandenburg N, et al: Physician substance use by medical specialty J Addict Dis, 1999; 18:23-37 12. Bissell L, Jones RW: The alcoholic physician: A survey. Am J Psychiatry 1976; 133:1142–1146

37. References 13. McAuliffe WE, Santangelo S, Magnuson E, et al: Risk factors of drug impairment in random samples of physicians and medical students. Int J Addict 1987; 22:825–841 14. Talbot GD, Gallegos KV, Angres DH: Impairment and recovery in physicians and other health professionals. In: Principles of Addiction Medicine. Second Edition. Graham AW, Schultz TK (Eds). Chevy Chase, MD, American Society of Addiction Medicine, 1998, pp 1263–1279 15. Alpern F, Correnti CE, Dolan TE, et al: A survey of recovering Maryland physicians. Md Med J 1992; 41:301–303 16. Gallegos KV, Lubin BH, Bowers C, et al: Relapse and recovery: Five to ten year follow-up study of chemically dependent physicians. The Georgia experience. Md Med J 1992; 41:315–319 17. Morse RM, Martin MA, Swenson WM, et al: Prognosis of physicians treated for alcoholism and drug dependence. JAMA 1984; 251: 743–746 18. Talbott GD, Martin CA: Relapse and recovery: Special issues for chemically dependent physicians. J Med Assoc Ga 1984; 73:763–769 19. Gable G: Personal communication of doctoral research 2010 20. Hyman, S: The Neurobiology of Addiction: Implications for Voluntary Control of Behavior The American Journal of Bioethics 2007 7:8-11 21. DesRoches CM, Rao SR, Fromson JA, et al: Physicians’ Perceptions, Preparedness for Reporting, and Experiences Related to Impaired and Incompetent Coleagues. JAMA 2011; 304: 187-93 Special thanks to: Herb Malinoff, MD FACP, FASAM, Marie Baldisseri, MD, FCCM, Brian McBeth, MD, FAAEM, who’s work generously contributed to this presentation.

38. Questions?