Transcript Saving Troubled Physicians - Scott & White Memorial Hospital

Saving Troubled Physicians
Lester A Picker
Edited Dr. Sandra Oliver
Impaired physicians

AMA definition: Any physical, mental, or
behavioral disorder that interferes with
the ability to engage safely in
professional activities.
TBME grounds for denial or
disciplinary action
164:051 (4): unable to practice medicine with
reasonable skill and safety to patients because
of: (A) illness; (B) drunkenness;(C) excessive
use of drugs, narcotics, chemicals, or another
substance; or (D) a mental or physical
condition;
164:052 (4) uses alcohol or drugs in an
intemperate manner that, in the board’s
opinion, could endanger a patient’s life;
National Incidence
(ama-assn.org)
“Punitive actions against physicians by
medical board, including license suspensions,
revocations, and probations, increased by
35% over the past decade.” In 2002 there
were 4,875 medical board disciplinary actions
for all causes
 The percentage of impaired physicians is at
10-15 percent of all working physicians.

Texas Statistics
(TSBME.Texas.State.Tx.Us)
TSMBE issued a total of 256 disciplinary
decisions in 2004
 40,373 physicians are in active practice
in the state in 2004

Roots of the problem

Prescribing over the Internet and the wide
availability of recreational drugs have
contributed to problems of some
physicians.
 Chemical dependency is the leading
cause of physician impairment with a
lifetime prevalence of approximately 1015%, which is similar to that of the general
population.
Roots of the problem
Rates of clinical depression among
medical interns are reportedly between
27 and 30%. (Martin,1986)
 Frank and Dingle (1999) reported that
19.5% of 4501 practicing U.S. female
physicians admit to history of depression

Roots of the problem

The very personality factors that enable
a physician to endure the rigors of
medical training may also work against
the physician once an impairment
begins. Strong egos, issues of control
and fears of being wrong or
embarrassed propel impaired physicians
toward the brink of self destruction
before seeking help.
Roots of the problem

Mansky (1996) found that anesthesiologists
and emergency room doctors are 3 times
more likely to abuse substances than the
general population of physicians. Both fields
entail high-risk situations and performance
under pressure. Hence, both tend to attract
physicians who are more likely to engage in
high-risk behaviors in their personal lives.
Signs of Substance Use Disorder
Work-related symptoms:
 Late to appointments; increased absences; unknown
whereabouts
 Unusual rounding times, either very early or very late
 Increase in patient complaints
 Increased secrecy
 Decrease in quality of care; careless medical decisions
 Incorrect charting or writing of prescriptions
 Decrease in productivity or efficiency
 Increased conflicts with colleagues
 Increased irritability and aggression
 Smell of alcohol; overt intoxication; needle marks
 Erratic job history
http://www.ama-assn.org/ama/pub/category/11711.html
Signs of Substance Use Disorder
Problems at home:
 Withdrawal from family, friends, and community
 Legal trouble (ie, driving while under the influence)
 Increase in accidents
 Increase in medical problems and number of doctor’s
visits
 Increased aggression, agitation, and overt conflict
 Financial difficulties
 Deterioration of personal hygiene
 Emotional disturbances such as depression, anxiety,
and mood instability
http://www.ama-assn.org/ama/pub/category/11711.html
Intervention

Contact a Physicians Health Program, in Texas:
Committee on Physician Health and Rehabilitation at
TMA.
 If an impaired physician voluntarily seeks treatment
and monitoring, the PHP can then advocate for the
physician before the state medical board. If, however,
physicians are initially reported to the state medical
board before any involvement with a PHP, they are
then required to have a formal disciplinary relationship
with the board and are in greater danger of license
suspension and revocation.
http://www.ama-assn.org/ama/pub/category/11711.html
TMA Committee on Physician
Health and Rehabilitation

PHR promotes the health and well being of physicians as well as the
treatment and rehabilitation of those who have become impaired for
whatever reason. It is the responsibility of all members of the medical
profession to ensure that the practice of medicine is conducted using the
highest moral, ethical and scientific standards.

The function of the PHR committee is two-fold: 1) to ensure safe patient
care by identifying physicians whose practice is impaired and 2) to
advocate for the physician while maintaining confidentiality and the
highest ethical standards.

As advocates, the committee helps with intervention, referral for
evaluation and treatment, if necessary, monitoring upon return from
treatment, and education for physicians, family members and support
staff regarding possible impairments.

24-Hour Hotline [(800) 880-1640]
Process of PHR

If after the initial investigation the evidence
indicates that the physician is impaired,
referral should be made to an outside
provider/agency for evaluation, diagnosis and
treatment.
 It is important to note that the PHR is in no
position to make the diagnosis and require
treatment of this physician. It’s role is purely
facilitation of such evaluation, diagnosis and
treatment by competent, outside
providers/agencies.
Case study
http://www.texmed.org/cme/phn/jcaho/jcaho_course.htm

A surgery resident was taken to his hospital emergency room unconscious. Medical
and neurologic workup found no basis for this lapse of consciousness. In fact, the
resident had experimented with Fentanyl, overdosed and was found by his wife who
arranged the transfer to the emergency department.

Approximately three years later, the same physician was under suspicion at the
hospital for possible drug abuse. Urine drug screens were being obtained although
no psychiatric/substance abuse evaluation had been arranged. A positive urine for
stimulants was quickly explained away by the physician and accepted by the
hospital. No formal physicians health committee existed in this
hospital. Subsequently, a serious, adverse patient event occurred while this
physician was on duty and a suspension and more rigorous investigation indicated a
high probability of ongoing drug abuse. The physician agreed to an intensive
inpatient substance abuse program where his denial was effectively resolved and a
successful recovery ensued.

This case illustrates the importance of having an organized process to thoroughly
evaluate, assess, and refer any physician who presents with a possible substance
abuse problem. The incident of unconsciousness during his residency was not
appropriately investigated and could have cost the physician his life, but did lead to
further impairment and adverse clinical results.
Intervention
Impaired physicians are far more likely to
commit suicide than their peers.
 Intervening early and rigorously following
up is essential to rehabilitation and may
even save the physician’s life.

Goal of Treatment
Abstinence is always the final goal if the
physician hopes to return to
practicing medicine.
 No other option is suitable in light of the
physician’s level of responsibility for the
lives of his or her patients

http://www.ama-assn.org/ama/pub/category/11711.html
Treatment
http://www.ama-assn.org/ama/pub/category/11711.html

Treatment of an impaired physician might consist of any or all of
the following options:

Detoxification/medical stabilization: This is for patients in active
withdrawal or who have concurrent medical issues.

Inpatient residential setting: These programs typically specialize
in treating impaired physicians. Maximum confidentiality and
privacy are the standards.

Rehabilitation: This occurs in an outpatient setting. Ongoing
treatment includes group psychotherapy, individual
psychotherapy, 12-step programs such as Alcoholics Anonymous
(AA) or Narcotics Anonymous (NA), relapse prevention,
psychotropic stabilization, and alternative therapies such as yoga,
meditation, relaxation training, and exercise
Monitor

Perhaps the most important safeguard for
patients and a successful recovery process is
adequate monitoring.
 Most PHRs monitor addicted physicians for 5
years.
 Elements of aftercare plan may include the
monitoring of bodily fluids (ie, toxicology
screens), ongoing treatment, and the
physician’s performance when the physician
returns to practicing medicine
Summary

Alcohol and drug use among physicians is a
significant problem that can lead to
impairments in the ability of physicians to
function both at work and at home.
 Early detection and aggressive treatment are
key aspects to dealing with this serious
problem.
 Texas PHR, plays a vital role in the advocacy
and treatment of impaired physicians.
References

Picker, L.A. Saving Troubled Physicians. Unique
Opportunities-the Physician’s Resource. 11/12
2004.16-26.
 Martin A.R. Stress in residency a challenge to
personal growth. J Gen Int Med. 1986. 1: 252-257.
 Frank, E. & Dingle, A.D. Self reported depression and
suicide attempts among U.S. women physicians. Am.
J. Psychiatry, 1999.156.1887-1894.
 Mansky PA. Physician health programs and the
potentially impaired physician with a substance use
disorder. Psychiatr Serv. 1996;47:465-467.
The end
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

407i TAMUII
Post Test Question One
1. The incidence of disciplinary decisions
by the Texas State Board of Medical
Examiners in 2004 was:
A. 6.00%
B. 0.60%
C. 0.06%
D. 0.006%
Post Test Question Two
2.
A.
B.
C.
Chemical dependency is the leading
cause of physician impairment with a
lifetime prevalence of which of the
following
Less than the general population
Similar to that of the general
population
Greater than that of the general
population
Post Test Question Three
3. Signs of substance abuse in the work
place include all of the following except:
A. Unusual rounding times
B. Increased secrecy
C. Incorrect charting or writing of
prescriptions
D. Increase in efficiency
Post Test Question Four
4.
A.
B.
C.
D.
The most important safeguard for
patients and a successful recovery
process is which of the following:
Self-referral by affected physician
Establishment of validity of complaint
Referral for diagnosis and treatment
Adequate monitoring