Transcript The Impaired Medical Staff Member

Recognizing and Intervening for the
Impaired Physician
Stephanie Andrews, LSCSW, LCSW
Debby Brookstein, LCSW, LSCSW
Michele Kilo, MD
Section of Developmental & Behavioral Sciences
The Impaired Fellow
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III.
What does it mean to be “impaired”
How does impairment present in
fellowship or the workplace
What to do if you are concerned, about
yourself or a friend/co-fellow
Definition of Impaired Physician
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The American Medical Association Council
on Mental Health published a report defining
physician impairment as “the inability to
practice medicine with reasonable skill and
safety to patients by reason of physical or
mental illness, including alcoholism and drug
dependence.”
Potential Forms of Impairment
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Classic – Substance Use & Abuse
Mental Illness – Axis I & Axis II
Disruptive Behavior
Medical Illness
Risk Factors unique to physicians
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Physical and professional demands of residency
and/or medical practice – long work hours, fatigue,
social isolation, making life and death decisions,
delivering bad news to families
Inherent personality traits of those who enter
medicine – obsessive and workaholic tendencies
Ready access to prescription drugs, self-medication,
the belief of personal invulnerability to addiction or
mental illness
Risk Factors unique to physicians,
cont’d.
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“Conspiracy of Silence” and loyalty of friends,
family, co-workers who enable problem
behaviors to go unchecked, fear of loss of
career
Unrealistic expectations of physicians (by
both ourselves and others) and a belief in
their ability to deal with anything that comes
along and remain untouched – “God
complex”
Classic Form of Impairment
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Substance Use and Abuse:
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The prevalence of substance use disorders in
healthcare professionals is equal to that in the
general population (8-14%).
However, successful and sustained recovery
greater in physicians, 80 – 90% whereas 50% in
general population. Believed to be due to the
substantial “investment” in career.
Classic Form of Impairment
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Substance Use and Abuse by Medical
Specialty – highest use:
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Anesthesiology- due to access to drugs with high
potential for abuse and addiction
Emergency Medicine – higher prevalence in most
studies – higher prevalence of marijuana and
cocaine use
Psychiatry – higher prevalence in most studies –
benzodiazepine use.
Classic Form of Impairment
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Substance Use and Abuse by Medical
Specialty – lowest use:
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OB/Gynecology
Pathology
Radiology
Pediatrics 
Symptoms of Abuse/Addiction:
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Physical signs –
Behavioral signs - changes in personality
Performance changes – productivity,
attendance
Compliance – difficulty meeting timeframes,
charts, billing
Mental Illness
A multiaxial diagnostic system involves an
assessment on several axes, each of which
refers to a different domain of information
that may help the clinician plan treatment
and predict outcome. There are five axes
included in the DSM-IV multi-axial
classification:
Mental Illness
Axis I
Axis II
Axis III
Axis IV
Axis V
Clinical Disorders
Other Conditions That May Be a
Focus of Clinical Attention
Personality Disorders
Mental Retardation
General Medical Conditions
Psychosocial and Environmental
Problems
Global Assessment of Functioning
Mental Illness
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Axis I disorder symptoms are commonly
seen in residency and fellowship and include
anxiety, depression and obsessive
compulsive disorder.
Axis I disorders typically respond to
outpatient or inpatient treatments, including
psychotherapy, medication or treatment
programs.
Mental Illness
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Axis II disorders include personality disorders
(narcissistic, histrionic, borderline, paranoid,
schizoid and antisocial).
Axis II disorders are VERY difficult to treat
and are EXTREMELY disruptive to the
individuals around the person with this type
of disorder.
Mental Illness
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Personality disorders develop over a period
of many years and are characterized by
persistent difficulty in interpersonal
relationships.
Individuals with this type of disorder view the
problems they encounter as SOMEONE
ELSE’S fault.
Symptoms of Anxiety:
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Excessive anxiety and worry
Difficulty controlling worry
Restlessness, feeling keyed up or on edge
Fatigued easily
Difficulty concentrating or mind going blank
Irritability
Symptoms of Anxiety (continued):
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Sleep disturbance - falling or staying asleep
or restless unsatisfying sleep
Symptoms not due to medical condition –
racing heart, chest pain
Symptoms cause clinically significant distress
or impairment in social functioning - isolation
Symptoms of Depression:
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Depressed mood
Marked diminished interest or pleasure in
previously enjoyed activities
Significant weight loss when not dieting or
weight gain (5% variance)
Insomnia or hypersomnia
Psychomotor agitation or retardation
Symptoms of Depression (cont’d):
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Fatigue, loss of energy
Feelings of worthlessness
Excessive or inappropriate guilt
Diminished ability to think or concentrate,
indecisiveness
Thoughts of suicide
Causes clinically significant distress or
impairment
Symptoms of OCD:
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Intrusive or inappropriate persistent thoughts
Repetitive behaviors, physical (handwashing) versus mental (thought loop)
Symptoms are time-consuming (> than 1
hour per day), cause marked distress and
anxiety, and significantly interfere with
person’s normal routine
Disruptive Behavior
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May often be associated with a combination of
above-mentioned forms of impairment.
Overt or subtle intimidating behavior including:
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Verbal, physical, emotional, undermining, degrading,
demeaning, negative
Can include boundary violations such as sexual and
professional boundaries
Other staff refusing to work with this person
Can be extremely subtle
Medical Illness
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Importance of attending to observed
impairment in a timely manner
If impairment is a newly observed behavior,
may be medically induced….diabetes…a
reaction to medication, sleep disturbance
Greater chance, for all impaired behavior, for
a successful recovery the sooner intervention
takes place.
Response to Impairment
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By Impaired Medical Staff:
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Fear of consequences
Loss of identity as physician/potential loss of
career
Feelings of “I can take care of myself”
Strong tendency to self-diagnose and treat
Disease understanding does not equal disease
acceptance
Shame & embarrassment
Response to Impairment
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By Staff:
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Fear of intimidation by impaired medical staff
member
Fear of loss of job if known as whistle blower
Peer pressure to keep “Conspiracy of Silence”
After reporting concerns, lack of follow through,
feelings of vulnerability
Concern about being wrong
Process of Reporting Impairment
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Ethical obligation to report a physician who
may be endangering the lives of others
through impairment – result of the 1972 AMA
House of Delegates
State Impaired Physicians Programs, also
known as Physicians Health Programs, are
present in all 50 states, as a result of The
Disables Doctors Act of 1974.
Process of Reporting Impairment
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The Missouri State Medical Association established
the Missouri Physician Health Program (MPHP) in
1985.
The MPHP is legally and financially independent of
licensure and regulatory agencies, such as the
Board of Healing Arts, BNDD and DEA. It has no
reporting requirements to the National Practitioner
Data Bank.
Process of Reporting Impairment
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MPHP maintains a confidential hotline
Physicians who volunteer to participate in the
program have the opportunity to arrest the
progression of their disease and check their
impairment before public exposure,
disciplinary action of licensing boards or loss
of family relationships, financial resources
and clinical privileges occurs.
Process of Reporting Impairment
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As of January 2001, the Joint Commission on
Accreditation of Healthcare Organizations
has required that all JCAHO accredited
hospitals establish a “process to identify and
manage matters of individual physician
health that is separate from the medical staff
disciplinary function.”
CMH Process of Reporting
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Potential Route of Reporting:
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Person themselves, to express your concerns
Section Chief
Department Chair
Any chosen confidant in a position of authority
Anyone and everyone can make an anonymous and
confidential referral
*Please remember this is a fully confidential
process and program
Your responsibility:
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Monitor yourself
Monitor your friends
Monitor your colleagues
Monitor your staff
Our responsibility:
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Provide whatever assistance, support and
guidance needed to help you through a
difficult time in your life.
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Children’s Mercy Hospital values you!
Our shared responsibility:
 DO
SOMETHING ABOUT IT
 IT COULD SAVE A CAREER
 IT
COULD SAVE A LIFE . . .
MAYBE EVEN YOURS OR
SOMEONE YOU CARE FOR
Conclusion:
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Physicians helping Physicians
Not meant to be a punitive process
Goal is for early identification and
intervention for greatest opportunity for
recovery and return to practice.