Physician Fitness to Work

1. Physician Fitness to Work Michael Wills MD,FRCPC May 15, 2013

2. Learning Objectives • Describe models of physician health • Discuss issues of function in clinical setting (fitness to practise) • Review resources to provide help and information

3. Approaches to Physician Health • Impairment • Wellness • Peer Review • Occupational Medicine • Demographic and Resource Planning University of Chicago Psychiatry Grand Rounds on the Internet, March 12, 2001 Physician Wellness: An Overview Larry S. Goldman, MD/

4. Physician “Impairment” • Drink • Drugs • Depression • Divorce • . . .

5. AMA Guide: Impairment Definition • “… a loss, loss of use, or derangement of any body part, organ system, or organ function … • “An impairment may lead to a functional limitation or the inability to perform activities of daily living.” AMA Guide, 5th Edition

6. Physician “Impairment” “The general perception that rates of substance abuse are higher among physicians than among the general public appears to be based more on folklore than on fact. Prevalence data concerning substance abuse among physicians are generally lacking, and most of the published data are based on descriptive studies that use convenience samples unsuitable for comparison with other populations.” Weir, E; CMAJ June 13, 2000; 162(12)

7. Physician “Impairment” “The prevalence of alcoholism and illicit drug use among physicians is likely similar to that in the general population, at about 9%.” Weir, E; CMAJ June 13,2000;162(12)

8. Peer Assessment with the CPSO • The CPSOhas made no attempt at medical certification of fitness because of the difficulties involved in the breadth of task definition. • Random selection: The most common reason for peer assessment is that a physician is randomly chosen from the College’s register to participate in the program. Physicians who have been in independent practice for at least five years and who are under the age of 70 are eligible for random selection. • Age-related assessment: Once a physician turns age 70, s/he will be selected for peer assessment (if the physician has not been randomly selected in the previous five years). These physicians are then assessed every five years thereafter.

9. Demographics 2006 • 12 percent of all practising Canadian physicians are 65 years of age or older. • Within 10 years, 22 percent of Canada’s physicians will reach the retirement age of 65. Canadian Medical Association [CMA]: Percent Distribution of Physicians by Specialty and Age, Canada, 2006.

10. Aging and Clinical Competence • Senses • Motor • Age-related illness • Progression of pre-existing illness • Cognition http://www.texmed.org/Template.aspx?id=4435

11. Aging and Cognition • Inability to focus attention • Poor concentration over long periods of time • Difficulty in multi-factorial tasking • Difficulty learning unfamiliar material in short periods of time • Decline in immediate memory and recall • Decline in IQ • Decline in output • Difficulty selecting important out of many

12. Physician Health Studies • Doctors avoid formal consultations • Self diagnosis and corridor consultations common • Culture of stoicism and self denial • Fear of stigmatization and career repercussions • Inflexible medical career pathways

13. Physician Health Prevalence data concerning physician health are generally lacking, and most of the published data are based on descriptive studies that use convenience samples unsuitable for comparison with other populations.

14. Physician Impairment A Descriptive Study of Impaired Older Physicians Carmelle Peisah, MBBS (Hons), MD, FRANZCP Sydney, Australia Presented Dec.2, 2006 AMA/CMA Physician Health Conference Ottawa

15. Physician Impairment Consecutive case records of notifications of doctors >60 from January 2000-2006 to the Impaired Registrants Program of the New South Wales Medical Board, Australia; n = 41

16. Physician Impairment • cognitive impairment (55%) • substance abuse (29%) • depression (21%) with some co-morbidity • frank dementia (15%)

17. Physician Impairment • There were two work patterns: the “workhorse” and the “dabbler”. • A culture of postponed retirement due to a sense of obligation and working "until you drop" predominated.

18. Aging and Clinical Competence • Senses • Motor • Age-related illness • Progression of pre-existing illness • Cognition http://www.texmed.org/Template.aspx?id=4435

19. Issues • Concerns about demographics • Dementia needs a denominator • Is there a need for a fitness-to-practise medical assessment? • Should CMA and provincial medical associations shift some focus from “impairment” (traditional 4 Ds) to broader issues of impairment (AMA definition)?

20. Occupational Health • Define essential job activities • Define job demands • Match functional capacity of the worker to demands of essential work activity

21. Essential Duties of a Physician • To cure sometimes • To relieve often • To comfort always Hippocrates: Aphorisms

22. An Analogy:Medical Fitness to Drive • little scientific evidence, consensus opinion of an expert panel (Level V evidence) • recommendations are empirical and “impose no more than common sense restrictions on drivers with medical disabilities”

24. Future Directions Any decision to decline an applicant a place in medical school on the basis of impairment should be based on expert advice on what effect an applicant's impairment might have on their ability to study and practise medicine. Where this isn't available, the GMC and the MSC must ensure that those making the decision are appropriately trained in making such decisions.  Dr Vivienne Nathanson Disability Equality in the Medical ProfessionBMA: June 2007

25. Regulatory Trends • UK: Disability Discrimination Act (DDA) (1995) • USA: Americans with Disabilities Act (ADA) (1990) The ADA is a civil rights law that prohibits discrimination based on disability. It is similar to the Civil Rights Act (1964). Disability is defined by the ADA as "...a physical or mental impairment that substantially limits a major life activity."  

26. Accessibility for Ontarians with Disabilities Act (AODA) (2005; implementation 2011-2025) The five accessibility standards under the AODA include: • Customer Service Standard • Information and Communications Standard • Employment Standard • Transportation Standard • Built Environment Standard U of T Human Resources and Equity

27. Additional Sources • www.capd.ca • www.hrandequity.utoronto.ca • www.hope4medics.co.uk/homepage.php

28. Canadian Association for Physicians with Disabilities • To provide a national forum for discussion of issues of mutual interest and concern to physicians with disabilities • To open avenues for exchange of ideas and information, particularly as these apply to clinical practice