Transcript The Impaired Resident - Welcome to Jackson Health System

The Impaired Resident
Presented by
Richard M. Steinbook, M.D.
Professor of Psychiatry & Behavioral
Sciences
And
Director of Psychiatric Residency Training
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Overview
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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
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The Impaired Resident
Part I
Definitions
and
The Context
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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
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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
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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
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The Impaired Resident
Part II Suicide
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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
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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
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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
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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
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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
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The Impaired Resident
Part III
Depression
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Depression Among Residents
• Prevalence of depressive symptoms has been
reported to be 29% among residents and 3335% 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
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Depression Among Residents
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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
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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
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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.
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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
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The Impaired Resident
Part IV
Alcohol and Drug
Use/Abuse/Dependence
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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
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Alcohol and Drug Abuse
• National Survey of 3,000 3rd year residents
drawn from the AMA physician master file; 60%
response rate (n=1785)
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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
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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.
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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
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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
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Alcohol and Drug Abuse
• Risk factors
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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
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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.
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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.
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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.
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The Impaired Resident
Part V
Sexual Harassment
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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
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Yudovich, Violence & Victims 1996 11: 175-180
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Sexual Harassment
• 2.2% reported sexual assault during residency
• 32% of respondents reporting sexual
harassment experienced negative effects
including
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Poor self esteem
Depression
Psychological sequelae requiring therapy
In some cases transferring training programs
• Maintain an open attitude toward the reporting
of sexual harassment
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The Impaired Resident
Part VI
Fatigue and Burnout
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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
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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 suboptimal patient care at least monthly (53% vs 21%)
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Thomas, JAMA 2004 292:2880:2889
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The Impaired Resident
Part VII
Psychological Health
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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
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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
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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
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The Impaired Resident
Part VIII
Healthy Approaches to Physician Stress
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Healthy Approaches to Physician
Stress
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Interpersonal relationships
Health diet
Adequate sleep
Physical activity/exercise
Personal time
Play/recreational activities
Religious/spiritual connection
Vacation
Effective prioritization/time management
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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
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The Impaired Resident
Recommendations
Conclusions
Assignment
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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
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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.
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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
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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
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Recommendations
• Encourage mentorship with seasoned,
thoughtful mentors
• Remind residents of the opportunity for
confidential access to psychotherapy or
interventions for depression or substance abuse
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Assignment
• Locate and review your institution’s policy
on counseling and support services.
• When a resident needs private counseling or
professional assistance to address an issue which
may effect his/her ability to live or work
productively, assistance is available through:
– Employee Assistance Program
– Health Office
– Direct call to UMBH 305-243-7270
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Reporting Impaired, Incompetent or
Unethical Colleagues
• Physicians responsibities to colleagues who are
impaired by a condition that interferes with their
ability to engage safely in professional activities
include timely intervention to ensure that those
colleagues cease practicing and receive
appropriate assistance from a physician health
program…the duty to report…stems from
physicians’ obligation to protect patients from
harm…
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Recommendations
• Florida statute requires that you report ANY health
care professional that you think is IMPAIRED
• Internal: MEC, Department Chair, Managing Partner
• Professionals Resource Network (800-888-8776)
ANONYMOUS
• Florida Board of Medicine (850-245-4131)
• Department of Health, Consumer Services (888-4193456)
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