Pebble Kranz, Ivone Kim, Ashlynne Harris Brown Medical School

1. An impairment policy for medical students: an essential ingredient for the growth of tomorrow’s physicians Pebble Kranz, Ivone Kim, Ashlynne Harris Brown Medical School

2. Presentation Outline • Overview of issues in medical student distress and impairment • Brown’s Student Health Council • The case for an impairment policy for medical students • The path to a new policy at Brown • Questions and Comments

3. Disclosures • None of the authors/presenters have any relevant financial arrangements to disclose • This presentation has been supported by the RI Medical Society, Brown Medical School, and the Charles F. Carpenter Grant

4. “Disciplinary action by medical boards was strongly associated with prior unprofessional behavior in medical school.” Papdakis, MA et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med 2005; 353; 2673-82. Teherani A et al. Domains of unprofessional behavior during medical school associated with future discliplinary action by a state medical board. Acad Med. 2005; 80(10 suppl):S12-S20 Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279:1889-1893

5. Causes of Distress ?

6. High Stakes Exams Ethical Conflicts Long Hours Exposure to Death Personal Life Events Unstructured Learning Debt Personality Factors Dissection

7. Unproductive coping mechanisms Leading to… Burnout Impaired academic performance Cynicism Academic dishonesty Substance abuse Depression Lack of attention to balancing personal needs What does medical student distress look like?

8. Reports in 13 to 24% of medical student population Overall, studies indicate more depressive symptoms and psychological distress than age-matched peers Depression peaks in the 2nd year and tends to coincide with Step 1 board exams Depression Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002; 77(9):918-921. Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005; 53(5):219-224. Dahlin M et al. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005; 39(6):594-604

9. Substance Abuse • Problems with self-report mechanisms • Rates similar to general population: 13-26% • Increased use of benzodiazepines • Habits carry over from undergraduate years • Trends in medical school substance use follow undergraduate patterns Croen LG et al. A longitudinal study of substance use and abuse in a single class of medical students. Acad Med. 1997; 72(5):376-381. Keller S et al. Binge drinking and health behavior in medical students. Addictive Behaviors. 2006. IN PRESS Boland M et al. Trends in medcial student use of tobacco, alcohol, and drugs in an Irish university, 1973-2002. Drug and Alcohol Dependence. 2006; 85:123-128. Newbury-Birch D et al. Drink and drugs: from medical students to doctors. Drug and Alcohol Dependence. 2001; 64: 265-270.

10. Student Health Council (SHC)

11. Program for Liberal Medical Education (PLME) • High school students accepted into Brown University and Brown Medical School • 60 students accepted • PLME students are joined by approximately 40 other students in medical school

12. Student Health Council (SHC) • Mission: Promote healthy functioning of Brown PLME and medical students within their social and professional communities

13. SHC Goals • Education • Awareness and Discussion • Provide Resources • Support • Confidential Peer Counseling • Resource connection • Advocacy for students on school issues • Patient Safety

14. SHC Structure • Referral • Establish Contact • Evaluation • Contract • Advocacy and support

15. SHC Referrals

16. SHC: Referral Routes

17. Number of Cases Where Issue Has Been Important

18. PHC Scope of Cases • Sexual boundaries • Behavior • Psychiatric Health • Physical Health

19. PHC Scope of Cases

20. SHC Effectiveness • Anecdotal evidence of successes • Advocacy at Deans’ hearings

21. SHC Structure • Referral • Establish Contact • Evaluation • Contract • Advocacy and support

22. SHC: Barriers to Utilization • Stigma • Lack of defined policies on standards of professional behavior for students

23. Case Description Part One: 2003 • Junior PLME • Self-referral • No academic issues • Polysubstance abuse • Depression and suicidality • Treatment successes and setbacks

24. Case Description Part Two: 2006 • 2nd year medical student • Still no academic issues • Continued substance use • Unable to comply with random drug testing • Beginning to have contact with patients…

25. Our Dilemma • 2004 • Do we report him to the deans? • 2006 • Patient safety at stake • Self-referral mechanism does not allow for reporting • No clear consequences without academic issues • How do we get this student to comply with treatment? And protect patients?

26. Beyond Brown Impairment policies in other medical schools

27. Survey Methods • Non-scientific • Limited to Northeast schools • Connecticut – Rhode Island • Massachussetts – New Hampshire • Vermont – New York • Sources: student affairs office, student handbook

28. Survey Questions • Does the school have an impairment policy or equivalent • How is impairment defined • To whom does the policy apply • Protocol • Consequences

29. Schools with Impairment Policies • Schools contacted 19 • Schools responded 18 _________________________________ • Schools with no impairment 2 policies • Schools with official statements 16 on impairment

30. Definition of Impairment Broad Definition Narrow Definition

31. Scope of Policy

32. General Protocols Specific Protocols Disciplinary Protocols

33. Consequences • Physicians • Medical license • Medical Student • Probation • Notation on academic record/ Dean’s Letter • Referral to PHC in state of residency • Expulsion

34. Our Criteria for Strong Impairment Policies • Broadly defines impairment • Specific to medical students • Narrowly defined protocols for assisting impaired students • Clearly delineates consequences for policy violations Based on these standards… 4 schools’ impairment policies met criteria

35. Lengthy internal discussion on problem cases Preliminary research: How do we define impairment? Convene group of faculty and students Group Retreat Team of students and faculty developed a draft Meeting with administrative policy makers Creating a Policy

36. Honesty Cheating on examinations, falsifying applications or data on medical records and other forms of intellectual dishonesty are wrong not only because such behavior violates intrinsic academic honesty, but also because such behavior may be deleterious to patients. Standards of Professional Behavior

37. Health Specific illnesses that impair performance include, but are not limited to, active drug and/or alcohol addiction, severe depression and other psychiatric illnesses and, occasionally, physical illnesses. It is not permissable for students to interact with patients while impaired by these conditions. It is the policy of the medical school toencourage recognition of illness which leads to impairment in medical students and to support treatment so that those students may continue their education successfully and without stigma. Standards of Professional Behavior

38. Boundary violations with patients It is never appropriate to have a sexual relationship with a current patient. Knowledge acquired during the doctor-patient relationship should never be used for any purpose other than therapeutic. A romantic relationship based on this information is always inappropriate. Standards of Professional Behavior

39. Criminal activities These include, but are not limited to, selling or dealing drugs, child abuse, possession of child pornography and sexual activities resulting in legal discrimination as a registered sex offender. Such behavior is incompatible with medical professionalism. Standards of Professional Behavior

40. Reporting violations There is an ethical imperative to report medical students and physicians in violation of these standards. Reports may be made to the Associate Dean for Medical Education Reports of health issues may be made to the Student Health Council Reports about faculty or other physicians may be made to the medical school or to the RI Physician Health Committee Standards of Professional Behavior

41. Communication • First-year orientation presentation with case discussions • Online Student Affairs policy handbook • Communication with individual SHC cases • Will make reporting parameters a part of each new SHC contract

42. What would have happened? • If this policy had been in place when our difficult case arose… • Clear from the outset that the behavior was problematic despite lack of academic difficulties • Collaboration with the administration • Compliance with random drug testing as a condition of enrollment • Medical leave of absence for in-patient treatment when necessary • Arrangements clear about reporting to the PHC in the student’s state of residency

43. Hopes for Medical Students at Brown • Clearer expectations of appropriate behavior • Increased interventions for problem behavior • Obligation to report/confront colleagues with problem behaviors • Improved treatment contract compliance and treatment outcomes

44. Hopes for the Profession • Consensus on standards of professionalism for physicians • Uniform policies at medical schools • Clear communication with students about consequences of untreated or under-treated impairment • A culture that values awareness and remediation of impairment and where students and physicians who are successfully engaged in the recovery process are free from stigma

45. Contact Information • Brown’s Student Health Council • Pebble Kranz (Pebble_Kranz@brown.edu) • Ivone Kim (Ivone_Kim@brown.edu) • Ashlynne Harris (Ashlynne@brown.edu) • RI Medical Society Rosemary Maher, Program Director (rmaher@rimed.org)

46. Acknowledgements • Dr. Herb Rakatansky • Rosemary Maher • Sarah Wakeman • SHC Members • Medical Schools surveyed • RI Medical Society • RI Medical Society Insurance Brokerage Corporation • Brown Medical School • Charles F. Carpenter Grant

47. Papdakis, MA et al. Disciplinary action by medical boards and prior behavior in medical school. N Engl J Med. 2005; 353; 2673-82. • Teherani A, Hodgson CS, Banach M, and Papadakis MA. Domains of unprofessional behavior during medical school associated with future discliplinary action by a state medical board. Acad Med. 2005; 80(10 suppl):S12-S20 • Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998;279:1889-1893. • ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine;European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002 Feb 5;136(3):243-6. • Givens JL, Tjia J. Depressed medical students' use of mental health services and barriers to use. Acad Med. 2002; 77(9):918-921. • Tjia J, Givens JL, Shea JA. Factors associated with undertreatment of medical student depression. J Am Coll Health. 2005; 53(5):219-224. • Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005; 39(6):594-604. • Croen LG, Woesner M, Herman M, Reichgott M. A longitudinal study of substance use and abuse in a single class of medical students. Acad Med. 1997; 72(5):376-381. • Keller S, Maddock JE, Laforge RG, Velicer WF, Basler HD. Binge drinking and health behavior in medical students. Addictive Behaviors. 2006. IN PRESS • Boland M et al. Trends in medcial student use of tobacco, alcohol, and drugs in an Irish university, 1973-2002. Drug and Alcohol Dependence. 2006; 85:123-128. • Newbury-Birch D, Wlashaw D, Kamali F. Drink and drugs: from medical students to doctors. Drug and Alcohol Dependence. 2001; 64: 265-270. • DyrbyeLN et al. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med. 2006;81:354-373. • Dyrbye et al. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006;81:374-384. • Dyrbye et al. Medical student distress: causes, consequences, and proposed solutions. Mayo Clin Proc. 2005;80(12):1613-1622. References