Impaired physicians in the ED: Don’t ignore the signs
Impaired physicians in the ED: Don’t ignore the signs
By Ronald M. Perkin, MD, MA
Professor and Chairman, Department of Pediatrics, Brody School of Medicine at East Carolina University; Chairman, Committee on Physician Health, Pitt County Memorial Hospital, Greenville, NC; and Jay Weaver, JD, EMT-P, Attorney, Private Practice; Adjunct Faculty, Northeastern University, Boston.
Editor’s note:
Impaired physicians: Too often, many colleagues turn a blind eye to the condition, and even make jokes about such situations. But today, the situation is all too real. The emergence of addiction medicine as a specialty only underscores the prevalence of addiction in society; and physicians and nurses are not immune. In fact, the practice of emergency medicine is high on the list of factors associated with substance abuse. Based upon some of the conservative estimates discussed in the following article, there could be seven active substance abusers on any medical staff of 100 physicians at any given time, possibly even your own staff. Considering only the professional responsibilities that these seven hypothetical impaired physicians have, the substantial consequences that may occur are overwhelming. In addition to their patient care, their relationships and careers also are in jeopardy. Impaired physicians face an increased potential for encountering licensure problems, malpractice suits, and domestic legal problems, to name only a few issues.
This month, we review some of the issues involved with the sometimes-overlooked problem of physician impairment — as well as some situations that you might not have identified as impairment; may readers remain vigilant to recognize this very real problem. — Richard Pawl, MD, JD, FACEP
Introduction
Physician impairment has become an increasingly recognized problem in medicine. A physician or other health care professional becomes impaired when one or more problems cause him or her to be dysfunctional, with recurring problems in the quality of patient care, other professional activities, education, or private life. Denial of the impairment by the physician, the physician’s family, and the community is common. All states now have programs to identify and help impaired physicians.
This article will focus on impairment caused by alcohol and drug addiction. The American Society of Addiction Medicine has defined addiction as "a disease process characterized by the continued use of a specific psychoactive substance despite physical, psychological, or social harm." Addiction is the cause of physician impairment in up to 85% of evaluated
cases.1
Unlike traditional definitions, which focused wrongly on cultural, moral, and legal issues, addiction today is considered to be a disease entity — an affliction, not a human foible. The terms "progressive" and "fatal" are entirely appropriate to emphasize its seriousness.
Substance Abuse Among Physicians
Most physicians do not realize that physicians themselves develop substance abuse problems at least as frequently — and perhaps more frequently — than the population in general.2 Stress and accessibility to drugs may be responsible for this higher prevalence. Medical schools, too, must shoulder some of the blame. Medical educators do not put enough emphasis on the biological causes of addiction, thereby inhibiting future doctors from viewing substance abuse as a disease.3 One recent study found that the average medical school devoted only 12 hours of curricular time to this type of disorder. Only a small minority of physicians believes that they possess adequate knowledge concerning the diagnosis and treatment of substance abuse.4 Physicians who lack a basic understanding of the physical effects and medical approaches to addictive disorders generally will not detect and treat them properly.5
Although the exact rate of substance abuse among physicians is unknown, the most conservative estimates suggest that 8-12% of physicians will develop a substance abuse problem sometime during their career.6 At any given time, as many as 7% of practicing physicians — roughly one of every 14 — actively engage in substance abuse.7 No group of physicians is immune; the numbers are similar for every region of the country, age range, in urban or rural areas, in academic medicine, and in private practice.
Substance abuse carries severe implications for the health care professional. Chemical impairment increases the likelihood of physical and psychological illness, imposes adverse effects on the substance abuser’s family, and represents a major risk factor for medical malpractice and negligence lawsuits.8 Left untreated, the mortality rate of substance abuse among physicians may be as high at 17% — the equivalent of one medical school class per year.9
Despite its high prevalence among physicians, the topic of substance abuse rarely is discussed at professional meetings. Physician impairment receives limited coverage in medical school curricula. In the majority of cases, physicians with substance abuse problems remain undetected by their colleagues for several years before any intervention
occurs.10
How does such an endemic problem remain so ignored? Part of the answer lies in the fact that physicians work hard to hide their drug and alcohol problems. The physician abuser often becomes a loner, avoiding colleagues and friends who might notice the effects of abuse. Suggestions that the person’s behavior and performance have changed provoke explanations, avoidance, or outright anger. The abusing physician often will leave a job, rather than risk being identified as impaired.
Medical students and physicians may be intimidated by efforts to educate and train them about such disorders. Having to study, diagnose, and treat substance abuse problems sometimes forces physicians to confront identical disorders of their own. As a result, they may view this type of instruction as accusatory and threatening. For similar reasons, medical students, trainees, and physicians may resist diagnosing and treating these disorders in their patients.11
The inability or unwillingness of physicians to recognize the signs and symptoms of substance abuse in their colleagues often contributes to the delay in identifying the physician with a substance abuse problem. Colleagues may delay reporting in an effort to protect an impaired practitioner from adverse consequences (e.g., shame, social stigmatization, income loss, and licensure actions), or they fear retaliation.12
Intervention and treatment of addictive disorders in physicians must involve a caring rather than punitive manner. Specialized treatment, family and peer support, involvement of the state medical society, contingency contracts, and treatment of psychiatric issues can enhance recovery rates.13 To reduce the negative impact of physicians’ addictions on patients, medical schools, residencies, hospitals, and physician organizations must adopt a proactive approach in preventing and addressing such problems.14
| TABLE 1 |
Physician-Specific Factors Associated
with Substance Abuse
|
Risk Factors for Substance Abuse
Most of the risk factors for physician substance abuse parallel those of the general public. Although not absolute, a family history of substance abuse and the presence of psychological or psychiatric illness appear to be the greatest risk factors in the development of a substance abuse problem.
The familial association apparently represents both a genetic predisposition and the influence of environmental factors. Cocaine, opiates, and alcohol have a unique effect on the central nervous system of substance abusers.15 At the same time, substance abusers tend to come from dysfunctional homes and to have suffered physical or emotional abuse or family disruption during childhood.
A link also seems to exist between substance abuse and psychiatric disorders. Many substance abusers have an individual or family history of depressive illness, bipolar illness, or anxiety disorder. Personality disorders also occur more frequently in substance abusers than in the general population.16 It is not clear, however, whether the psychiatric illness predisposes to substance abuse, results from substance abuse, or whether both the substance abuse and the concurrent psychiatric diagnosis represent different manifestations of an underlying pathology. In all likelihood, each of these possibilities exists in various cases.
Some risk factors have an especially significant effect on physicians17 (see Table 1). The practice of emergency medicine is a factor associated with substance abuse. Easy or regular access to controlled substances, self-treatment with prescription medications, and high stress or long hours of practice all increase the likelihood of substance abuse.18 However, these risk factors are relative. Physicians with no apparent risk factors do develop substance abuse problems. Conversely, a physician with every possible risk factor might never develop such a problem.
Diagnosing Substance Abuse in Physicians
Diagnosing substance abuse in a physician poses a greater challenge than diagnosing the problem in the general population. Most physician substance abusers continue to function well until the problem becomes advanced. Because they must rely on their work either for access to drugs or for the income with which to purchase drugs, physicians often protect their reputation and appearance in the workplace until the disease has reached a critical stage. The duration of this period depends upon the substances involved. Alcohol-addicted people often remain sober during working hours for many years, even though they drink large quantities at night and on weekends. Intravenous opiate or cocaine abusers, on the other hand, may go from experimentation to collapse within a matter of weeks or months.19
Nevertheless, signs of substance abuse eventually become obvious to the objective evaluator, and certain risk factors for the problem become easily recognized. Given that up to 12% of all physicians develop a substance abuse problem during their careers, every health care professional has an obligation to identify the relevant signs and symptoms in colleagues, and to know how to contact the appropriate support groups to arrange treatment and aftercare to the physician when needed.
Unfortunately, the public and many physicians continue to think of substance abuse as a bad habit or a moral weakness, rather than as a disease.20 All modern medical authorities, however, consider substance abuse as a neurological or psychiatric illness influenced by genetic, social, emotional, and psychological problems.21 Individuals who suffer from true substance abuse disorders have as little success in controlling their untreated disease as severely depressed people have in feeling happy through sheer willpower.
Alcohol- and drug-addicted physicians exhibit unique characteristics. Because they know that they risk the loss of their medical license if detected, they exhibit a particularly high level of denial. Frequently those people around an addicted physician enable the physician, which allows the disease to continue longer than in nonphysicians. This conspiracy of silence has accounted for many deaths of addicted physicians.
| Table 2 |
Personality Changes
in Chemically Dependent Physicians
Physical Changes in Chemically Dependent Physicians
Performance Changes in Chemically Dependent Physicians
|
These problems make identification of alcohol and drug addiction in physicians difficult. The earliest signs of potential chemical dependence are changes in personality (see Table 2, at right). While most physicians may exhibit some of these behaviors at times, addicted physicians will show a definite change from their previous behavior with a worsening of these negative behaviors. As the disease process continues, impaired physicians will begin to show physical signs of their addiction (Table 2). These changes may become particularly evident early in the week after the physician has had a weekend off or after returning from a vacation. The last thing to be affected in addicted physicians is job performance. Most physicians are able to function satisfactorily until the impairment becomes quite severe.
The most critical concept to remember when trying to identify an impaired physician is that if you are suspicious, there is almost always a problem. Although most physicians are able to hide their addiction, they will almost always have slips in which telltale changes surface. When this happens, a caring, confidential process needs to begin, to confirm whether the physician has a drug or alcohol problem.
Profound consequences, such as death from accidental overdose, criminal charges from self-prescribing or driving while intoxicated, loss of hospital privileges, malpractice suits from practicing while impaired, and suicide from severe depression, often represent the first clear sign that a physician might have a substance abuse problem.22 Therefore, every physician must remember that ignoring the subtle symptoms in a friend and colleague actually will prevent that person from getting help and ultimately may have tragic consequences. Only a miniscule percentage of substance abusers will quit for more than a few months without treatment and aftercare.
The frequency of substance abuse in physicians varies between the genders even more significantly than in the general population. Although nearly one-third of American physicians are female, nearly 90% of physicians referred for substance abuse treatment are male.23 Compared with their male counterparts, female physicians who develop substance abuse problems are significantly more likely to suffer major depressive illness, but are less likely to have a personality disorder or to experience criminal consequences of their abuse.24 Among physicians who undergo treatment, females tend to manifest much greater permanent physical damage from their substance abuse than their male counterparts.25
Female physicians have a greater tendency than male physicians to initiate substance abuse after a traumatic life event. They also tend to have a shorter course between the onset of abuse and the initiation of treatment.26 Conversely, some reports indicate that whereas female physicians are less likely to use illicit substances or to be treated for substance abuse, they are far more likely to take prescribed tranquilizers and opioids than are male physicians.27 Although taking prescribed medication does not represent substance abuse, the use of such medications while practicing may have significant medicolegal implications in the event of an adverse outcome or malpractice litigation.
Action
The most important concept in helping addicted physicians is not to ignore the problem. Other physicians tend to become some of the strongest enablers for colleagues suffering impairment.28 Enabling actions delay an impaired physician from getting help and frequently lead to potentially serious consequences for patients. Many states have laws requiring physicians to report other physicians suspected of being impaired. The earlier an impaired physician receives help, the greater the likelihood of a successful recovery.
Physicians should seek help for impaired colleagues even if state law does not expressly require them to do so. Both the current opinion of the American Medical Association’s Council on Ethical and Judicial Affairs and traditional principles of medical ethics require physicians to report a peer who appears to be impaired or has a behavioral problem that may adversely affect his or her patients or the practice of
medicine.29 These reports should go to the hospital’s committee on physician health (COPH), hospital administration, or the external physician assistance program of the state licensing board or medical association. Behavior that poses an immediate threat to the health or safety of a patient should be reported directly to the state licensing
authority.30
Each hospital should have a committee on physician health. Known in some areas as a "well-being committee" or "impaired physician committee," these entities promote rehabilitation and encourage physicians to seek help. As the following case illustrates, these committees rely on confidentiality for their effectiveness.
Case # 1. Bay Medical Center v. Sapp31
In 1988, Edward Sapp initiated a malpractice action against a Florida physician, Dr. John Gooding, and the hospital in which Dr. Gooding practiced. Mr. Sapp alleged in his complaint that Dr. Gooding had caused the death of his son by providing treatment while intoxicated. Mr. Sapp also alleged that Bay Medical Center had acted negligently in allowing Dr. Gooding to practice after learning of the doctor’s alcoholism.
Before trial, Mr. Sapp learned that Dr. Gooding had admitted to being an alcoholic when he joined Bay Medical Center, and that hospital administrators had known that Dr. Gooding kept alcoholic beverages in his hospital office. On advice of counsel, Dr. Gooding refused to discuss with Mr. Sapp’s attorney whether he had ever performed medical procedures under the influence of alcohol.
Mr. Sapp filed with the court a request for the production of documents relating to Dr. Gooding’s activities. Specifically, he sought Dr. Gooding’s personnel file, committee reports and minutes, investigative reports and analyses, personnel and patient complaints against Dr. Gooding, disciplinary reports, and impaired physician reports. The trial court denied the request.
Mr. Sapp appealed the trial court’s decision. The Florida Supreme Court found in favor of the defendant hospital, on grounds that the state legislature had conferred privilege on the activities of hospital peer review committees. These kinds of committees require confidentiality, the court found, to encourage "full, frank medical review and evaluation." Since Dr. Gooding’s alcoholism fell within the purview of the hospital’s governing board and its various committees in determining whether to grant or continue Dr. Gooding’s staff membership, and since Mr. Sapp would not endure "undue hardship" in proving his case through other forms of evidence, the court held that Bay Medical Center did not have to turn over the requested materials.
Discussion
Early reporting may provide protection for the physician suspected of having a substance abuse problem. As Sapp demonstrates, resulting investigations usually remain confidential. If the problem goes unreported until legal issues or questions of competence are raised, however, the physician may lose this right of confidentiality, and the problem may become a matter of public record. Public awareness of the physician’s problem, in turn, may result in license suspension or revocation, withholding of future hospital privileges, and rejection of provider status by third-party payers. More importantly, word of such behavior can destroy the image of a medical professional in the eyes of a jury. A doctor whose substance abuse problem becomes a matter of public knowledge faces an uphill battle during a malpractice trial, no matter what the facts of the case tend to show.
A hospital’s COPH proves most successful when it interacts with impaired physicians before substantial performance failure has occurred or the need for disciplinary action has arisen. The committee therefore must operate in a manner that permits and encourages confidential reports of physician behavior, even from outside the hospital. The hospital’s governing body should authorize the COPH to receive information from anyone who chooses to bring it forward. Nurses, particularly, have an opportunity to observe physician behavior, but other hospital professional personnel or a physician’s family members also can provide useful observations.
A COPH chair should agree, for example, to listen to an observation that a member of the medical staff was seen going down a ski slope while drunk. Al-though these events occurred outside the hospital, the fact that the physician would engage in irresponsible activity while intoxicated or would fail to meet obligations regarding punctuality or coverage raises serious questions about his or her health. On the basis of either observation or upon receiving a report that the physician was seen drinking to excess socially, the committee chair would have cause to initiate a confidential discussion with the doctor.
The discussion need not stop at a confidential encounter where evidence exists of potential patient danger. Committee policy should require consultation with the chief of staff whenever any of the following occur: arrest, blackouts, serious traffic accidents, violent behavior outside of the hospital, serious memory or judgment lapses in a social setting, or reports of professional problems in other practice venues.
Reaction by the chief of staff in these circumstances should focus on patient welfare. Consultation between the impaired physician, the committee chair and the chief of staff also should occur whenever a practitioner presents himself to the well-being committee after an adverse event associated with potential or actual patient injury. Self-referral under these kinds of circumstances poses a problem, however, in that the practitioner, perceiving that he or she faces trouble over a performance or outcome issue, seeks protection by becoming a ward of the well-being committee. Only in instances of early referral — prior to professional decline or the occurrence of patient injury — should the physician receive immunity from hospital discipline.
The hospital’s COPH needs to act as an advocate for the suspected physician. It should not have a disciplinary function. Physicians unwilling to accept the committee’s recommendations should be turned over to the executive committee.
States have three basic methods of assisting addicted physicians.32 Every state medical society has a program or committee dedicated to the identification, treatment, and support of physicians with substance abuse problems. These programs go under various names, such as "physicians’ wellness committee," "physicians’ health program," "diversion program," and "impaired physician program." These organizations, which can be located through the relevant state medical society, usually are empowered by the state medical board to intervene with, and to direct treatment and aftercare of, physicians with substance abuse problems. Typically, as long as the physician remains in compliance with the wellness committee, the state medical board takes no action, and the interaction remains protected by confidentiality laws.
The hospital’s COPH often refers physicians to a state diversion program, which monitors their recovery. This action demonstrates that the hospital has taken a major step to protect patients. Diversion case managers maintain contact with a hospital monitor and a member of the COPH to update them on the participant’s progress. In this way, the state diversion program provides a benefit to hospitals by monitoring physicians for them. Also, by following this path, if a peer investigation reveals evidence of a substance abuse problem, involvement of the state medical board or law enforcement agencies rarely becomes necessary.33
Some states have informal groups of physicians who confront impaired physicians and attempt to coax them into treatment programs.34 The third type of state program is similar to a hospital’s physician health committee, except that it is administered by the state’s medical licensing board. A major problem with this type of program is that public disclosure may be required, which may lead to the physicians’ names appearing in the media. This, in turn, may deter physicians from seeking help. To locate available programs in your state, contact the state medical association. If it does not have a program, it will refer you to the appropriate resource.
Intervention
Physicians have an ethical obligation to assist colleagues in need. An opinion recently released by the American Medical Association’s Council on Ethical and Judicial Affairs calls for physicians to:
- Promote health and wellness among colleagues.
- Support peers in identifying physicians in need of help.
- Intervene promptly when the health of a colleague appears to have been compromised, and to offer encouragement, coverage, or referral to a physician health program.
- Establish physician health programs that provide a supportive environment.
- Establish mechanisms to ensure that impaired colleagues promptly cease practice.
- Assist recovering colleagues when they resume clinical practice.
- Report to appropriate bodies, including licensing authorities when appropriate, impaired colleagues who continue to practice despite reasonable offers of assistance.35
Of all the methods used to conquer denial among impaired physicians, a tactic known as intervention probably has proven the most successful. The Johnson Institute in Minnesota developed this technique and has used it to help thousands of addicted physicians. The purpose of an intervention is to motivate the addicted physician to accept help. Interventions should be undertaken with care and concern by someone with specific training in the technique. Five key elements exist for successful interventions:
1. Gather together people who are very meaningful to the chemically dependent person and who have concern about his or her substance use.
These people must have firsthand knowledge of incidents and behavior related to the person’s chemical use, such as blackouts, driving while intoxicated, loss of behavioral control, accidents, personal threats, or injury to self or others.
2. Have these people make written lists of specific data about the person’s substance use, its effects, and their emotional responses.
This must consist of firsthand knowledge about incidents and behavior; avoid gossip and secondhand information.
3. Have the concerned persons decide on a specific treatment plan that they expect the chemically dependent person to accept.
They must decide beforehand what type of help they want the person to get. The intervention will succeed only if the chemically dependent person accepts the help
he or she needs, and accepts this help immediately upon conclusion of the intervention session.
4. Have the concerned persons decide beforehand what they will do if the chemically dependent person rejects all forms of help.
5. Have the group present the relevant data and recommendations to the chemically dependent person in an objective, caring, nonjudgmental manner.
This is crucial to the intervention process. Those concerned persons who cannot control their anger at the time of the intervention should not participate.
A carefully planned or even rehearsed intervention will protect patients and may save the life of an impaired physician. Interventions generally should begin in the morning, when the physician is least likely to be under the influence of drugs. The purpose of such an intervention is not to punish the individual; a properly executed intervention will convince the physician to decide voluntarily to enter a residential treatment facility for detoxification and medical evaluation. Residential outpatient treatment will follow, typically for several months.
When these steps are followed, approximately 90% of interventions lead to the addicted physician’s accepting help.36 Participants must agree upon a definite plan before the intervention begins. After the intervention, suicide precautions should be taken. If an addicted physician refuses to get help, the participants need to report the individual to the hospital executive committee or the state medical licensing board. This rarely becomes necessary if the technique is used in a caring way and with empathy.
Despite our many medical societies and fellowships, individual physicians often lead lonely lives. They carry secrets, both personal and professional, for which they have no ready outlet. A better understanding of the types of stress involved in medical training and practice and the nature of the dangerous emotions it can produce, along with a willingness to teach and talk openly about the disease of addiction are helpful attitudes. Many physician suicides occur as a result of drug abuse. The corporate health of the medical profession is dependent upon how well physicians care for their patients, but also how well they care for themselves.
The Americans with Disabilities Act
When Congress enacted the Americans with Disabilities Act (ADA)37 in 1990, the substance abuse treatment community had reason to be pleased. This legislation established a "clear and comprehensive mandate for the elimination of discrimination against individuals with disabilities,"38 including those suffering from drug and alcohol addiction.
The ADA defined three distinct ways to qualify for a disability:
- • having a physical or mental impairment that subsequently limits one or more major life activities;
- • having a record of such an impairment;
- • being regarded as having such impairment.39
Because drug addiction and alcoholism can produce each of these criteria, a physician who abuses these substances may qualify for ADA protection. Requesting accommodation under the ADA gives the impaired physician an opportunity to accept counseling or some other form of treatment in lieu of discipline. The physician must seek help before the problem becomes too severe, however, for an alcoholic or addicted physician cannot hide behind the ADA after harming a patient in order to avoid punishment.40
The inclusion of alcoholism and drug addiction under the ADA does not preempt the employer’s right to require employees to conform to the Drug-Free Workplace Act of 1988.41 While the use of alcohol outside of the workplace, by itself, cannot serve as a basis for discipline, an employer does have the right to discipline any employee who poses a threat to the safety of others or breaks workplace rules against the use of alcohol. Employers may ask potential employees if they currently drink or use illegal drugs, but they may not inquire as to whether an applicant is an alcoholic or drug addict or has engaged in alcohol or drug rehabilitation.42
Drug abusers have a more difficult time qualifying for ADA protection than alcoholics do. Current drug use — in other words, drug use that has "occurred recently enough to indicate that the individual is actively engaged in such conduct"43 — receives no protection under the ADA, whether occurring on or off the job. Drug use need not occur on the day that an employer takes action against an employee in order to qualify as "current." To the contrary, an employer may take action against an employee for "current use" even where the drug use occurred several months earlier.
Drug addicts qualify for ADA protection, however, if they:
- Have successfully completed a supervised drug rehabilitation program and no longer engage in the illegal use of drugs or have been otherwise successfully rehabilitated;
- Are participating in a supervised rehabilitation program and no longer use drugs;
- Are mistakenly regarded as using drugs.44
The presence of mental illness, too, may qualify a physician for ADA protection. As the following case illustrates, however, a mentally impaired physician — like an alcoholic or drug-addicted physician — must seek help early, before any harm occurs, in order for the ADA to apply.
Case #2. Kirbens v. Wyoming State Board of Medicine45
Drew Kirbens held a license as a physician in Wyoming. On Jan. 2, 1997, after receiving a number of complaints that Dr. Kirbens had performed inappropriate or unnecessary surgeries, and after learning that two hospitals had suspended Dr. Kirbens’ privileges because of incompetence or misconduct, the state board of medicine notified him that it intended to convene a disciplinary hearing. Dr. Kirbens forestalled this hearing by voluntarily abstaining from the performance of invasive procedures, and on Dec. 15, 1997, he entered the Physicians in Crisis Program at the Menninger Clinic in Topeka, KS. There he was diagnosed with bipolar and narcissistic disorders.
The hearing took place one month later. Dr. Kirbens asked the board for permission to relinquish his medical license voluntarily, but instead the board revoked his license and fined him $5,000.
In appealing his license revocation before the Wyo-ming Supreme Court, Dr. Kirbens admitted that he no longer could practice medicine safely. He argued that the board’s action had violated the ADA, however, in that he had a disability for which the board had punished him. He again sought permission to surrender his license voluntarily, or alternatively, a court order mandating the board to provide a program for the assistance of mentally impaired physicians similar to the one operated by the board for doctors suffering from drug and alcohol dependence.
Observing that "the ADA will not protect a disabled individual whose disability constitutes a direct safety threat to the public," the Wyoming Supreme Court found that the board had not violated the ADA in revoking the doctor’s license. "Although persons with disabilities are generally entitled to the protection [of the ADA]," the court wrote in its decision, quoting the federal regulation that governs the administration of the ADA, "a person who poses a significant risk to others will not be qualified, if reasonable modifications to the public entity’s policies, practices, or procedures will not eliminate that risk." Because Dr. Kirbens had admitted that his continued practice of medicine would "constitute a significant risk to the health or safety of the public," the supreme court upheld the board’s order and allowed the license revocation to stand.
Discussion
Kirbens contains two important lessons for medical practitioners. First, an impaired physician must seek help early. Whether the impairment occurs as a result of alcoholism, drug abuse, or mental illness, the physician must seek help before harming any patients. By the time a physician commits malpractice, the opportunity to claim protection under the ADA already has passed.
The second lesson illustrated by Kirbens pertains to the obligations of an employer such as a hospital. As Dr. Kirbens learned, the ADA requires "reasonable accommodations," but it does not mandate the hiring or retention of an employee who for health reasons cannot safely perform the job in
question.46 The ADA does not require an employer to adopt lower performance standards, disruptive or cost-prohibitive accommodations, or to maintain a stress-free environment. It protects employees from discrimination on the basis of disability, but the extent of that protection does have limits.
Some authorities have called into question the effectiveness of the ADA with respect to employment. In a review of judicial decisions involving addicted employees, Westreich concluded that "a widespread aversion to extending ADA protection to addicted people seems clear."47 Westreich documented the manner in which case law has shaped the application of the ADA in addiction cases. ADA protection may be expected, for example, where addiction has a close tie to the employee’s aberrant behavior. Where the link between addiction and behavior is less obvious, however, society tends to overlook addiction as the cause of the behavior. Westreich observed that in the case of an employee who failed to show up for work, the employee’s absence for ADA purposes was attributed to the employee’s inability to make bail, rather than to his detention for an alcohol-related offense. In reaching this conclusion, the court clearly minimized the role of alcoholism.
Several courts even have gone so far as to rule that alcoholism is not a disability per se warranting protection under the ADA. In one case, a federal court denied ADA protection to an executive who was fired while in rehabilitation for alcoholism. In the eyes of the court, there existed insufficient evidence that alcoholism had substantially limited any of the executive’s major life activities. The judge viewed the executive’s hangovers and dulled reactions merely as "temporary impairments."48
The hope that addicted individuals will receive ADA protection when appropriate is not consistently being fulfilled.49 Quite possibly this disappointing development reflects the judicial struggle between the role of personal responsibility and the biopsychosocial forces that propel the development of addiction.50
Physician Depression
The scope of major depressive disorder in the United States recently has been identified. More than 16% of American adults suffer from major depression at least once during their lifetimes, and the likelihood that an American adult will suffer from major depression in any given year is 6.6%.51 These episodes of depression usually involve severe manifestation of symptoms and role impairment. One survey of patients treated for depression within the preceding year revealed that 57% of the respondents with major depressive disorder had received some form of treatment, but that fewer than 25% of those respondents had received treatment meeting criteria deemed at least minimally adequate.52
Researchers have documented the staggering economic costs of untreated or undertreated depression. Some of the productive time lost by workers with depression was due to absenteeism, but the majority of the cost resulted from diminished performance while at work, known as "presenteeism."53
Depression exists as commonly among physicians as it does in the general population.54 Physicians have a greater tendency to commit suicide than nonphysicians, however.55 In the general population, males commit suicide four times as often as females; whereas among physicians, the female suicide rate is just as high as the male rate.56
Suicide results from a complex interplay of risk and protective factors that are biological, psychological, and social in nature.57 Substance use disorders and mental disorders constitute the two primary risk factors. More than 90% of those who die by suicide have at least one of these disorders, most frequently depression (in the form of major depressive disorder or bipolar disorder) or alcohol abuse.58 The risk increases dramatically when both exist simultaneously. Because most people with these disorders do not die by suicide, additional risk factors come into play, including stressful events and predisposing factors. Protective factors include effective treatment for mental and physical disorders, social and family support, resilience and coping skills, religious faith, and restricted access to lethal means.59
Risk factors for completed suicide typically become apparent through psychological autopsy, a process that reconstructs factors that contributed to the suicide via semistructured interviews with key informants. Few psychological autopsy studies have been undertaken for physician suicides. In the United States, the last psychological autopsy study of physicians occurred approximately 20 years ago.60 In addition to mood and substance use problems, the study found a greater likelihood of personal and professional losses, financial problems, a tendency to overwork, and career dissatisfaction.61 Anecdotal evidence suggests that even if physicians are treated for suicide risk, the quality of treatment, paradoxically, may be compromised because of collegial relationships and deference from the treating clinician who may give more freedom to the physician-patient to control the focus of therapy and to self-medicate.
Personal, professional, and financial stresses add to the risk of physician suicide. More recent studies have found that physicians experience stress with a changing set of problems — paperwork and administrative annoyances, in particular — loss of autonomy, and excessive professional
demands.62
Physicians’ dissatisfaction with the practice of medicine may have public health implications beyond the obvious problems of recruiting new members into a troubled
profession.63 Data suggest that dissatisfaction on the part of physicians breeds poor clinical management, as well as dissatisfaction and treatment noncompliance among patients, and that the rapid turnover of unhappy doctors in offices and hospitals may lead to discontinuous, substandard medical
care.64 In this regard, promoting physician health and well-being represents a key to quality improvement in hospitals.
The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians in seeking help often take a punitive form, including discrimination in medical licensing, hospital privileges, and professional advancement. A key to breaking down these barriers are changes in professional attitudes and institutional policies to encourage physicians with mental health problems to seek help. Then, physicians may confront depression and suicide risk among their peers and may become more likely to recognize and treat these conditions in patients, including colleagues and medical students.
Disruptive Physician or Impaired Physician?
Who or what is a disruptive physician? "Disruptive" behavior may be defined as: Aberrant behavior manifested through personal interaction with physicians, hospital personnel, health care professionals, patients, family members, or others, which interferes with patient care or could reasonably be expected to interfere with the process of delivering quality care to
patients.65
Medical staffs occasionally must deal with a physician whose practice pattern or personality traits seem likely to compromise the quality of care provided to patients. These physicians typically do not have identified substance abuse or psychiatric disorders. Medical staffs traditionally have tolerated a wide range of behavioral characteristics when deciding to hire or retain a physician — and this is appropriate, as no single set of personality attributes is perfect for all patients or clinical circumstances. Nevertheless, some personality patterns interfere with effective clinical performance, and as a result, retaining the wrong physician may place patient safety at risk. When this occurs, the medical staff has an obligation to abandon traditional levels of tolerance.
The disruptive physician typically exhibits a pattern of behavior characterized by one or more of the following actions:
- Profane or disrespectful language
- Demeaning or intimidating behavior
- Sexual comments or innuendo
- Inappropriate touching, sexual or otherwise
- Racial or ethnic jokes
- Outburst of rage or violent temper
- Throwing instruments, charts, or other objects
- Inappropriately criticizing health care professionals in front of patients or other staff
- Boundary violations with staff, patients, surrogates, or key third parties
- Comments that undermine a patient’s trust in a physician or hospital
- Inappropriate chart notes
- Unethical or dishonest behavior
- Difficulty working collaboratively with others
- Repeated failure to respond to calls
- Inappropriate arguments with patients, family, staff, and other physicians
- Resistance to recommended corrective action
- Poor hygiene, slovenliness
Often this behavior occurs because of an underlying pathology that includes addiction, stress, affective disorders, personality disorders, or an underlying medical problem such as sleep deprivation or dementia. Behavior involving any underlying disorder should receive an appropriate evaluation; effective treatments may exist. Character disorders may be resistant to treatment but should be evaluated nevertheless before they are labeled as chronic.
Regardless of the cause or manifestation, any behavior that might potentially undermine patient care or the patient care environment should be considered "disruptive." Well-intentioned medical staff leaders can jeopardize patients and increase the likelihood of consequential litigation by mislabeling disruptive behavior as "impairment." Medical staffs must distinguish these concepts and refuse to tolerate disruptive or abusive physician behavior.
Conclusion
Untreated addiction to alcohol or drugs is a devastating, chronic, and often fatal disease. In physicians, the disease of addiction almost always reaches an advanced state before signs and symptoms become obvious in the workplace. Timely identification, diagnosis, and intervention — along with coercion, when necessary — can save a physician’s career and even his or her life. The worst thing you can do for an addicted person — or for yourself — is to ignore the problem. Spontaneous insight from an addicted person almost never occurs.
Endnotes
1. Schulz JE. "The Physician’s Role: Caring for Others, Caring for Self." In: Substance Abuse Report of the Second Ross Roundtable on Critical Issues in Family Medicine. Abbott Park, IL: Abbott Laboratories/Ross Products; 1994, pp. 105-115.
2. See Cicada RS. Substance abuse among physicians: What you need to know. 39 Hosp Physician 2003;39:39-46. See also Boisaubin EV, Levine RE. Identifying and assisting the impaired physician. Am J Med Sci 2001;322:31-36.
3. See Leshner AI. Addiction is a brain disease, and it matters. Science 1997;228:45-47.
4. See Miller NS, et al. Why physicians are unprepared to treat patients who have alcohol- and drug-related disorders. Acad Med 2001;76:410-418.
5. See Leshner, supra note 3; Brewster JM. Prevalence of alcohol and other drug problems among physicians. JAMA 1986;225:1913-1920.
6. See Cicada, supra note 2; Brewster, supra note 5.
7. See Cicada, supra note 2.
8. See Cicada, supra note 2.
9. See Schulz, supra note 1.
10. See Schulz, supra note 1; Cicada, supra note 2; Miller, supra note 4; McCall SV. Chemically dependent health professionals. W J Med 2001;174:50-54.
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13. See Miller, supra note 4.
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16. See Cicada, supra note 2.
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18. See Waterhouse, supra note 17.
19. See Cicada, supra note 2.
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22. See Brewster, supra note 5.
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25. See Nelson-Zlupko L, Kauffman E, Fore MM. Gender differences in drug addiction and treatment: Implications for social work intervention with substance-abusing women. 40 Soc Work 1995;40:45-53.
26. See Cicada, supra note 2; Leshner AI, Koob GF. Drugs of abuse and the brain. Proc Assoc Am Physicians 1999;111:99-108.
27. See Nelson-Zlupko, supra note 25.
28. See Svenson J. A physician’s dilemma. JAMA 1998;259:2749.
29. See American Medical Association Council on Ethical and Judicial Affairs, Op. E-9.031, Reporting Impaired, Incompetent, or Unethical Colleagues (June 2004) ("Physicians’ responsibilities 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 these colleagues cease practicing and receive appropriate assistance from a physician health program. Ethically and legally, it may be necessary to report an impaired physician who continues to practice despite reasonable offers of assistance and referral to a hospital or state physician health program. The duty to report such circumstances, which stems from physicians’ obligation to protect patients against harm, may entail reporting to the licensing authority.")
30. Id.
31. 535 So.2d 308 (Fla. 1988).
32. See Blondell, supra note 14.
33. See Morse RM. The definition of alcoholism. JAMA 1992;268:1012.
34. See Schulz, supra note 1.
35. See American Medical Association Council on Ethical and Judicial Affairs, Op. E-9.0305, Physician Health and Wellness (June 2004).
36. See Schulz, supra note 1.
37. 42 U.S.C. § 12102 et seq.
38. 42 U.S.C. 12101(b)(1).
39. 42 U.S.C. § 12101(2).
40. See, Kirbens v. Wyoming State Bd. of Med., 992 P.2d 1056 (Wyo. 1999). See also State ex. rel. Oklahoma Bar Assoc. v. Busch, 919 P.2d 1114 (Okla. 1996).
41. 41 U.S.C. § 701 et seq.
42. 42 U.S.C. § 12112(d)(2).
43. 29 CFR § 1630, App. 1630.31.
44. 42 U.S.C. § 12114(c).
45. 992 P.2d 1056 (Wyo. 1999).
46. 42 U.S.C. 12113(a).
47. See Westreich LM. Addiction and the American with Disabilities Act. J Am Acad Psychiatry Law 2003;30:355-363.
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56. See Center, supra note 54.
57. See Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med 2002;136:302-311.
58. See Center, supra note 54.
59. See Mann, supra note 57.
60. See American Medical Association Council on Scientific Affairs. Physician mortality and suicide: Results and implications of the AMA-APA Pilot Study. Conn Med 1986;50:37-43.
61. See Center, supra note 54; American Medical Association, supra note 60.
62. Id.
63. See Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004;350:69-75; Mechanic D. Physician discontent: Challenges and opportunities. JAMA 2003;290:941-946.
64. See Pathman DE, et al. Physician job satisfaction, dissatisfaction, and turnover. J Fam Pract 2002;51:593.
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By Ronald M. Perkin, MD, MA Professor and Chairman, Department of Pediatrics, Brody School of Medicine at East Carolina University; Chairman, Committee on Physician Health, Pitt County Memorial Hospital, Greenville, NC; and Jay Weaver, JD, EMT-P, Attorney, Private Practice; Adjunct Faculty, Northeastern University, Boston.Subscribe Now for Access
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