The Impaired Resident

1. The Impaired Resident Presented by Richard M. Steinbook, M.D. Professor of Psychiatry & Behavioral Sciences And Director of Psychiatric Residency Training

2. Overview • Definitions and the context • Suicide • Depression • Alcohol and Drug Use/Abuse/Dependence • Sexual Harassment • The Problem Resident • Fatigue and Burnout • Psychological Health • Health Approaches to Physician Stress • Conclusion/Recommendations/Assignment

3. The Impaired Resident Part I Definitions and The Context

4. Who is the “Impaired Resident” • AMA Council on Mental Health (1973): physician impairment is “the inability to practice medicine adequately by reason of physical or mental illness, including alcoholism or drug dependence” • Although most residents experience high levels of stress during training, about 10% will become seriously impaired • Potentially remediable physician problems may lead to less than optimal patient care

5. The Context: Residency Training • Sleep deprivation and fatigue • Limited time for family/friends and social/recreational activities • Common obsessive-compulsive style of the house officer • Emphasis on professional development at the expense of personal growth • Financial pressures/medical school debts • Assumption of the responsibilities of marriage and parenting

6. The Context: Residency Training • Geographical relocation with loss of friendships and the support of close family • Transition from the student role to that of physician (responsibility for patient care) • Difficulty asking for help • Access to addictive substances

8. The Impaired Resident Part II Suicide

9. Suicide Among Physicians • Suicide rates among physicians may be twice that of the general population • Scarce data on suicide among residents • Suicide rate among male physicians in the US is similar to that for all white males >25 years • Female physicians commit suicide at 3-5 times the rate of the white female population>25 years • Kirsling & Kocher, Psychological Reports 1989 64:951-959

10. Suicide Among Physicians • Very similar suicide rates for male and female physicians (approx 40/100,000) • Suicide rates may increase with age for male physicians but decrease with age for female physicians • 20% of physician suicides are associated with drug abuse • 40% are associated with alcohol abuse

11. Suicide Among Physicians • Aggregate suicide rate ratio for male physicians compared to the general population 1.41 (1.21, 1.65) • For female physicians, the ratio was 2.27 (1.90, 2.73) • Schernhammer & Colditz Am J Psychiatry 2004 151: 2295-2302

12. Suicide Among Physicians AMA/APA profile of the suicide-prone physician (1987) • Prior suicide attempt • Suicidal verbalization • Self-prescribed psychoactive drugs • Financial losses • History of treatment for emotional or psychiatric problems • Depression • Social problems related to alcohol abuse • Difficult childhood

13. Suicide Among Physicians • The most frequent precursor to suicide is depression (>75% of all physician suicides may be attributable to depression and/or alcoholism) • Potential preventive measures: • Be vigilant for depressive symptoms and alcohol/drug abuse among residents • Maintain an open and supportive attitude for residents who may need referral for evaluation and treatment • Work closely with the residency program director

14. The Impaired Resident Part III Depression

15. Depression Among Residents • Prevalence of depressive symptoms has been reported to be 29% among residents and 33-35% among interns specifically • Be familiar with depressive signs and symptoms • Depressed mood/feeling sad or empty/tearfulness • Diminished interest or pleasure in activities • Change in appetite/weight loss or gain

16. Depression Among Residents • Insomnia or hypersomnia • Psychomotor retardation or agitation • Fatigue or loss of energy • Feelings of worthlessness/excessive or inappropriate guilt • Diminished ability to think or concentrate/indecisiveness • Thoughts of death or suicidal ideation

17. Depression Among Residents • Early clinical and behavioral signs may be difficult to recognize, especially given the context of residency training • Depression is a highly treatable illness • The aim of treatment is complete remission

18. Depression & Suicide in Physicians • Consensus recommendation • Transform professional attitudes • Change institutional policies to encourage physicians to seek help • As physicians remove barriers and confront depression and suicidality in their peers, they are more likely to recognize and treat these conditions in patients • Support any resident who seeks help.

19. Depression and Suicide in Physicians • Chief of Service or his/her representative may request Physical and Psychiatric/Psychological examination(s) • Seek help from Employee Assistance Program (EAP) or the JMH Health Office • Physicians on the JMH Health Plan may call UMBH to arrange a private and confidential appointment with a psychiatrist or psychologist (on campus or off campus available)305-355-7270

20. The Impaired Resident Part IV Alcohol and Drug Use/Abuse/Dependence

21. Alcohol & Drug Abuse • Complex social, behavioral, psychological and biological dimensions • Product of heredity and environment • Stress has been documented to be an important contributory factor • Commonly characterized by denial or failure to recognize the problem

22. Alcohol and Drug Abuse • National Survey of 3,000 3rd year residents drawn from the AMA physician master file; 60% response rate (n=1785) • 5% reported daily alcohol use • 7% reported marijuana use in the past month • 3.7% reported benzo use in the past month • 1.4% reported cocaine use in the past month • Hughes et al JAMA 1991 2069-2073

23. Alcohol and Drug Abuse • 80% of substance users began use in college, high school or earlier • Only benzo and opiate use were initiated during residency by a sizable portion of users (31.4% and 23.1%, respectively) • Self treatment for medical purposes (to relieve tension or to relax)was the primary use of prescription drugs, amphetamines were used to improve performance and alertness.

24. Alcohol and Drug Abuse • Compared to adults of similar age, residents were less likely to use 8 of 11 substances surveyed. • Higher past month rates of alcohol and benzodiazepine use

25. Alcohol and Drug Abuse • The early clinical and behavioral signs may be difficult to recognize, especially when use is intermittent and the resident is not yet dependent or impaired • In addition to overt manifestations (e.g. smell of alcohol on breath) clues may include behavioral changes, deterioration in performance, tardiness, irresponsibility • Anesthesiology, emergency medicine and psychiatry residents may have higher rates of substance use

26. Alcohol and Drug Abuse • Risk factors • Family history of addiction • Access to psychoactive drugs • domestic breakdown or relationship problems • Unusual stresses at work • Programs for physicians impaired by alcohol/drugs provide accessible early intervention and treatment that is not punitive and that advocate rehabilitation for continuing medical practice

27. Alcohol and Drug Abuse • “It is a physician’s ethical responsibility to take cognizance of a colleague’s inability to practice medicine adequately by reason of physical or mental illness, including alcoholism and drug dependence.” (AMA 1972) • The profession has a responsibility to preserve society’s trust by monitoring itself and helping impaired colleagues.

28. Alcohol and Drug Abuse • The PHT and CIR recognize that employee substance and alcohol abuse can have an adverse impact on the Public Health Trust’s operations, the image of employees and the general health , welfare and safety of the employees and the general public.

29. Alcohol and Drug Abuse • Employees reasonably believed to suffer from substance abuse may be referred at the Trust’s chief of Service’s discretion to the Employee Assistance Program and submit to toxicology and alcohol testing designed to detect the presence of any controlled substance, narcotic drug or alcohol. The Physicians Recovery Network (PRN), is a primary resource for confidential housestaff post-treatment monitoring. Initial confidential evaluations and treatment will be coordinated by the resident’s health insurance plan.

30. The Impaired Resident Part V Sexual Harassment

31. Sexual Harassment • 1.802 U.S. family practice female resident phys9cians surveyed; 51% responded • 32% reported unwanted sexual advances • 48% reported use of sexist teaching materials • 66% reported favoritism based on gender • 36% reported poor evaluation based on gender • 37 reported malicious gossip • 5. 3% reported punitive measures based on gender • Yudovich, Violence & Victims 1996 11: 175-180

32. Sexual Harassment • 2.2% reported sexual assault during residency • 32% of respondents reporting sexual harassment experienced negative effects including • Poor self esteem • Depression • Psychological sequelae requiring therapy • In some cases transferring training programs • Maintain an open attitude toward the reporting of sexual harassment

33. The Impaired Resident Part VI Fatigue and Burnout

34. Fatigue and Burnout • Burnout is a syndrome of emotional exhaustion and a sense of low personal accomplishment • Little is know about burnout in residents or its relationship to patient care

35. Fatigue and Burnout • Cross-sectional study using an anonymous mailed survey to Internal Medicine residents (n=115) at a university based residency program • 87/115 (76%) met the criteria for burnout • Compared with non-burnout residents, more likely to self report providing at least one type of sub-optimal patient care at least monthly (53% vs 21%) • Thomas, JAMA 2004 292:2880:2889

37. The Impaired Resident Part VII Psychological Health

38. Psychological Health • Physical and psychological health of 178 family practice residents in South Carolina • Excellent coping skills, with clinically significant psychological symptoms noted in only one • Despite the rigors of residency training, residents are likely have average physical health and better-than-average psychological health, according to age-adjusted population norms

39. Psychological Health • 350 Family Practice residents from seven programs in South Carolina • Reported less anxiety and anger across most dimensions compared with general adult populations Michaels et al, Academic Med 2003: 78:69-70

40. Psychological Health • Residents reported a higher frequency of hassles than did normal populations but they did not consider these hassles severe. • Social and emotional “in-house” support, attention to stress-management skills and personality characteristics of Family Practice residents may explain these encouraging findings

41. The Impaired Resident Part VIII Healthy Approaches to Physician Stress

42. Healthy Approaches to Physician Stress • Interpersonal relationships • Health diet • Adequate sleep • Physical activity/exercise • Personal time • Play/recreational activities • Religious/spiritual connection • Vacation • Effective prioritization/time management

43. Healthy Approaches to Physician Stress • Young physicians who sacrifice their personal lives during training believing that they will reap the rewards of a balanced life after graduation often find themselves without skills to clarify and prioritize values or to develop a personal philosophy that integrates professional, personal and spiritual domains

45. The Impaired Resident Recommendations Conclusions Assignment

46. Conclusions • Despite the rigors of residency training residents may have average physical health and better-than-average psychological health • Early remediation and program support during training may significantly reduce the potential for resident impairment

47. Conclusions • Be vigilant for depressive symptoms • Be vigilant for alcohol/drug abuse • Perceived sexual harassment may be a common occurrence among residents during training • Burnout is common among residents physicians and is associated with suboptimal patient care practices.

48. Recommendations • For problem residents, work closely with the Residency Director and rotation attendings; the resident should be involved in every step of the process • For problem residents: more frequent feedback sessions, assigning a mentor for structured supervision, probation, professional counseling, strict behavioral guidelines and remedial didactic curricula

49. Recommendations • Residents need vacation time. Don’t let your residents skip vacations • Residents need time not on-call. Don’t let your residents insist on covering calls for their patients when not on call • Actively promote help-seeking • Actively promote introspection/reflection. • Work closely with the Residency Program Director early in the course of a problem

50. Recommendations • Encourage mentorship with seasoned, thoughtful mentors • Remind residents of the opportunity for confidential access to psychotherapy or interventions for depression or substance abuse